HOPPING ALLAH ACCEPT MY TRIAL TO HELP OTHERS
TO MY WIFE AND MY KIDS , AIMING TO LEAVE SOME GOOD THINKS IN THIS LIFE AND FOR OUR COUNTRY WHICH IS SCREAMING
MAGDI AWAD SASI
Different esophageal disorders are discussed in this lecture. The learning objectives are to understand:
The anatomy and physiology of the oesophagus and their relationship to disease.
The clinical features, investigations, and treatment of benign and malignant disease with particular reference to the common adult disorders.
Topics include: Surgical anatomy, Physiology, Symptoms, Investigations, Congenital lesions: TOF and Atresia, Benign tumours, Cancer of oesophagus, Foreign bodies,Oesophageal perforation, Gastro-oesophageal reflux diease, Hiatal hernia,
Oesophageal motility disorders: achalasia and diffuse spasm, Oesophgeal diverticula.
and Others.
Ischemic colitis is the most common form of intestinal ischemia. It manifests as a spectrum of injury from transient self-limited ischemia involving the mucosa and submucosa to acute fulminant ischemia with transmural infarction that may progress to necrosis and death. Although there are a variety of causes, the most common mechanism is an acute, self-limited compromise in intestinal blood flow.
Gallstones:
Most common biliary pathology
Asymptomatic in majority of cases (>80%)
Approx. 1–2% of asymptomatic patients develop symptoms requiring cholecystectomy per year.
Different esophageal disorders are discussed in this lecture. The learning objectives are to understand:
The anatomy and physiology of the oesophagus and their relationship to disease.
The clinical features, investigations, and treatment of benign and malignant disease with particular reference to the common adult disorders.
Topics include: Surgical anatomy, Physiology, Symptoms, Investigations, Congenital lesions: TOF and Atresia, Benign tumours, Cancer of oesophagus, Foreign bodies,Oesophageal perforation, Gastro-oesophageal reflux diease, Hiatal hernia,
Oesophageal motility disorders: achalasia and diffuse spasm, Oesophgeal diverticula.
and Others.
Ischemic colitis is the most common form of intestinal ischemia. It manifests as a spectrum of injury from transient self-limited ischemia involving the mucosa and submucosa to acute fulminant ischemia with transmural infarction that may progress to necrosis and death. Although there are a variety of causes, the most common mechanism is an acute, self-limited compromise in intestinal blood flow.
Gallstones:
Most common biliary pathology
Asymptomatic in majority of cases (>80%)
Approx. 1–2% of asymptomatic patients develop symptoms requiring cholecystectomy per year.
In general, the standard physical exam typically includes: Vital signs: blood pressure, breathing rate, pulse rate, temperature, height, and weight. Vision acuity: testing the sharpness or clarity of vision from a distance. Head, eyes, ears, nose and throat exam: inspection, palpation, and testing, as appropriate.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...
General rules of abdomenal examination
1. MAGDI AWAD SASI 2014 ABDOMENAL EXAMINATION
1 DR.MAGDI AWAD SASI ABDOMENAL EXAMINATION
2. MAGDI AWAD SASI 2014 ABDOMENAL EXAMINATION
2 DR.MAGDI AWAD SASI ABDOMENAL EXAMINATION
GENERAL RULES:
• Wash hands / warm them.
• Patient should be lying flat.
• Keep the room as warm as possible and make sure that the lighting is adequate.
• Proceed calmly / don’t make sudden moves.
• Approach from right side of the patient.
• Gather as much data as possible by observation first.
• Arms at side (behind head tightens abdomen) & legs straight.
• If the head is flexed, the abdominal musculature becomes tensed and the examination made
more difficult
• Bending knees may relax abdomen.
• Abdomen should be fully exposed. Patient needs to be exposed from above the
xiphoid process to the symphysis pubis. Exposure:---
1. Ask the patient to lie on a level examination table that is at a comfortable height for both of
you. At this point, the patient should be dressed in a gown and, if they wish, underwear.
2. Take a spare bed sheet and drape it over their lower body such that it just covers the upper
edge of their underwear (or so that it
crosses the top of the pubic region).
This will allow you to fully expose the
abdomen while at the same time
permitting the patient to remain
somewhat covered. The gown can then
be withdrawn so that the area
extending from just below the breasts
to the pelvic brim is entirely uncovered,
remembering that the superior margin
of the abdomen extends beneath the
rib cage.
Order of Examination
• Inspection
• Auscultation
• Percussion
• Palpation
3. MAGDI AWAD SASI 2014 ABDOMENAL EXAMINATION
3 DR.MAGDI AWAD SASI ABDOMENAL EXAMINATION
• Inspection : standing at the foot of the table and looking up towards the patient's
head
1. Abdominal contour(Appearance of the abdomen )-Shape=contour:
Is it flat? Distended? If enlarged, does this appear symmetric or are there
distinct protrusions, perhaps linked to underlying organomegaly? The
contours of the abdomen can be best appreciated by standing at the foot
of the table and looking up towards the patient's head. Global abdominal
enlargement is usually caused by air, fluid, or fat. It is frequently
impossible to distinguish between these entities on the basis of
observation alone, distended with full flanks. 5F are the causes of
abdominal distentión— fat, feces ,flatus ,feotus , fluid.
2. Abdominal skin --Scars , striae (purple or silver), dilated veins
around umbilicus in caput medusa veins radiating from the umbilicus &
its direction of flow: from below upward or vise versa ((portal
hypertension)) and veins in the lateral parts of abdomen (( inferior vena
cava obstruction)) ,rashes and lesions, Peristalsis (visible--Visible loops
of bowel) ,Pulsations (Aorta).
The abdomen is divided into 9 quadrants by two vertical midclavicular lines and two horizontal
lines—one through transpylorus and the other through the anterior iliac spine.
Common scars:
1. Right subcostal scar---- cholycestectomy scar
2. Mid –line long lapratomy scar---- acute abdomen of surgical unknown cause
4. MAGDI AWAD SASI 2014 ABDOMENAL EXAMINATION
4 DR.MAGDI AWAD SASI ABDOMENAL EXAMINATION
3. Right or Left lumbar scar---- kidney surgical intervention
4. Suprapubic scar---- Caesarean scar or prostate operation or pelvic operation.
5. Mid line supra umbilical scar—duodenal ulcers , pancreatic operations.
5. MAGDI AWAD SASI 2014 ABDOMENAL EXAMINATION
5 DR.MAGDI AWAD SASI ABDOMENAL EXAMINATION
3. Respiratory movement :
Male --- abdomino-thoracic-- manner of breathing is abdominal respiration.
Female –thoraco-abdominal-- the manner of breathing is thoracic respiration.
4. Umbilicus central or pushed down , inverted or flat or everted.
The flat umbilicus is a clue to the ascitis or organomegally due to increase intraabdominal presure.
Look for discoloration over the umbilicus:
1. Cullen’s Sign: discoloration over the umbilicus.
2. Grey Turner’s Sign: discoloration over the flanks.
These are both late signs suggesting intra-abdominal bleeding.
6. MAGDI AWAD SASI 2014 ABDOMENAL EXAMINATION
6 DR.MAGDI AWAD SASI ABDOMENAL EXAMINATION
SUMMARY:
INSPECTION
Shape of the abdomen and flanks
Skin –scar ,striae ,prominent veins ,umbilicus , visible peristalsis
Movements of abdominal wall with respiration
Ask the patient to cough and look for hernial orifices
Hernia is derived from the Latin for "rupture"
It is the protrusion of an organ or part of an organ through a defecte in the wall of the cavity
((peritoneal lining ))normally containing it.
Types of herniae:
Inguinal (( Indirect or indirect ))
Inguinal hernias can be direct which is herniation through an area of muscle weakness, in the
inguinal canal, and inguinal hernias indirect herniation through the inguinal ring. Indirect
hernias, the more common form, can develop at any age but are especially prevalent in
infants younger than age . This form is three times more common in males.
Femoral Herniation through the femoral canal .
Incisional Herniation ------- through an area weakened by a scar
Umbilical
Paraumbilical --------- Acquired defect above or below the umbilicus
Epigastric --- in the midline of abdomen above the umbilicus caused by a defect in linea alba.
If there is a visible mass or herniae , you have to asses the :
Size
Site
Surface
Shape
Affect of cough
7. MAGDI AWAD SASI 2014 ABDOMENAL EXAMINATION
7 DR.MAGDI AWAD SASI ABDOMENAL EXAMINATION
Palpation:
Kneel down
Ask about site of abdomenal pain
First warm your hands by rubbing them together before placing them on the patient.
The pads and tips (the most sensitive areas) of the index, middle, and ring fingers are
the examining surfaces used to locate the edges of the liver and spleen as well as the
deeper structures. You may use either your right hand alone or both hands, with the
left resting on top of the right.put the palm of your right hand over abdomen and
flexes your hand frequently at metacarpophalangeal and interphalangeal joints.
Apply slow, steady pressure, avoiding any rapid/sharp movements that are likely to
startle the patient or cause discomfort.
Examine each quadrant separately, imagining what structures lie beneath your hands
and what you might expect to feel.
A. SUPERFICIAL PALPATION:
Aim – to get confidence and assurance , to check temperature ,tenderness.
Palpate the abdomen to detect:
1. Tenderness 2.Muscular rigidity or Rigidity
3.Superficial organs and masses
Before you begin palpation, ask your patient if he has any pain or tenderness ,
and be away from the
area of the pain .
Palpate that area last,
using gentle pressure.
Start your palpation by
the palm of the right
hand from the right iliac
fossa and go anti-clock
wise .
From RIF to suprapubic – left iliac fossa –left lumbar---- left hypochondrial ---
epigastric -----right hypochondrial----right lumbar.. Press down around 1 cm
Light palpation by moving your hand slowly and just lifting it off the skin.
Watch for patient’s face for signs of discomfort.
Abdominal pain upon light palpation suggests peritoneal irritation or inflammation
8. MAGDI AWAD SASI 2014 ABDOMENAL EXAMINATION
8 DR.MAGDI AWAD SASI ABDOMENAL EXAMINATION
If rigidity or guarding while palpating, determine whether it is voluntary (patient
anticipates the pain) or involuntary (peritoneal inflammation)
Assess for rebound tenderness by pushing slowly and then releasing your hand
quickly off the tender area.
Watch for patient’s face for signs of discomfort.
Identify any masses and note:
Size,Location,Contour,Tenderness,Pulsations,Mobility
DEEP PALPATION:
For the organs and masses.
A deeper exam is performed with the right hand or two hands, one on top of the other again
flexing at the MCP & IPJ joints. You should still be looking at the patient’s face for them
flinching due to pain. Again, examine all 9 named segments of the abdomen.
Liver is located under right upper quadant and if the liver enlarged or pushed it
descend toward the right iliac fossa along the mid calvicular line.
In general, it is easier to detect abnormality if you start in an area that you're sure
is normal by comparison.
The right iliac fossa is the starting point for superficial and deep palpation.
Direction of enlargement of organs
Liver: Enlarges towards right lower quadrant
Spleen: Diagonally towards right lower quadrant
Reactions that may indicate pathology include:
Guarding, describing muscle contraction as pressure is applied.
Rigidity, indicating peritoneal inflammation.
9. MAGDI AWAD SASI 2014 ABDOMENAL EXAMINATION
9 DR.MAGDI AWAD SASI ABDOMENAL EXAMINATION
Rebound, pain on release
Hernial orifices if positive cough impulses.
Start by kneeling down to be on the same level of patients abdomen.
Start the deep palpation by putting your right hand (palm) over the abdomen of the patient.
start from right iliac fossa and ascend through mid clavicular line toward right hypochondrial area .
keep your palm in touch with the
patients abdomen.
One way…..Gently push down
(posterior) and towards the patient's
head with your hand oriented roughly
parallel to the rectus muscle or lower
right costal margin, allowing the
greatest number of fingers to be
involved in the exam as you try to feel
the edge of the liver. Advance your
hands a few cm cephelad and repeat
until ultimately you are at the bottom
margin of the ribs.
Pushing up and in while the patient
takes a deep breath may make it easier
to feel the liver edge as the downward
movement of the diaphragm will bring
the liver towards your hand.
The tip of the xyphoid process, the bony structure at the bottom end of the sternum, may be directed
outward or inward and can be mistaken for an abdominal mass. You should be able to distinguish it
by noting its location relative to the rib cage (i.e. in the mid-line where the right and left sides meet).
The two handed
method may be used.
Begin at the right lower
quadrant and examine the
entire abdomen gently by
deep palpation.
Lay one hand
over the abdomen and
push with the second
concentrating on the feel
of the bottom hand. Once
again, known tender areas
should be palpated last.
130-131: Palpation of Liver: Alternative Method
It is acceptable during palpation of the liver to
use both hands to palpate abdomen. You use
the fingers of one hand to palpate and the
other hand is used to apply pressure to the
dorsum of the other hand. Thus the hand you
are using to palpate does not need to be used
to apply pressure.
10. MAGDI AWAD SASI 2014 ABDOMENAL EXAMINATION
10 DR.MAGDI AWAD SASI ABDOMENAL EXAMINATION
Usual way-----
1.Start from right iliac fossa with
your hand( palm ) parallel to the
right costal margin
2.Ask the patient to take deep
breath while keeping your hand in
touch
3.Ask the patient to exhale ,
palpate deeply 4 cm in as the
abdomen become relaxed
4.Preeced toward the right costal
margin through midclavicular line
5. During expiration, palpate
deep. During inspiration, moves
toward RT costal margin till you
fell the liver margin where you
have to ask the patient to take
deep breath and go deeply with
your hand 4cm depth. This is
because the liver is
intraperitoneal and moves down
with inspiration.
For spleen:
The Palpation of the spleen is as for the liver but in the direction of the left hypochondrium. The
edge of the spleen which may be felt if distended is more nodular than the liver.
The normal spleen in not palpable. When enlarged, it tends to grow towards the pelvis and the
umbilicus (i.e. both down and across)
Another way to assess
for splenomegaly is to ask the
patient to lie on their right side.
Support the rib cage with your left
hand and again ask the patient to
take deep breaths in moving your
right hand up towards the left
hypochondrium.
Spleen (if not palpable, R lateral
decubitus)--- The edge, when
palpable, is soft, rounded, and
rather superficial
Palpation: Liver
Stand on the pt’s right side. Place your left hand behind the
patient’s R side under the 11th and 12th rib area. Press upward
with the L hand.
Place your R hand on the pt’s
abdomen well below where you
percussed the liver edge
11. MAGDI AWAD SASI 2014 ABDOMENAL EXAMINATION
11 DR.MAGDI AWAD SASI ABDOMENAL EXAMINATION
To feel for the kidneys you should
place one hand under the patient in the
flank region ((right hand at the inferior
and lateral border of the ribs))and the
other hand on top. ---pushing down
as you push up from behind with
your left hand.-----You should then
try to ballot the kidney between the two
hands. In the majority of people the
kidneys are not palpable, but they may
be in thin patients who have no renal
pathology.
Note:
If the liver is palpable , it may be pushed down or enlarged. Liver span is the next step to be done.
If the spleen is palpable , it is enlarged.
If the liver is palpable , it is important to detect the tenderness--- hepatitis or congestion, the
size below the costal margin(cm) ,consistency—firm or hard, edge ,surface regularity---nodular
/ irregular in malignancy or secondaries , pulsatile – tricuspid regurgitation .
You can also try to "hook" the edge of
the liver with your fingers. To utilize this
technique, flex the tips of the fingers of your
right hand (claw-like). Then push down in the
right upper quadrant and pull upwards
(towards the patient's head) as you try to
rake-up on the edge of the liver. This is a nice
way of confirming the presence of a palpable
liver edge felt during conventional
examination.
12. MAGDI AWAD SASI 2014 ABDOMENAL EXAMINATION
12 DR.MAGDI AWAD SASI ABDOMENAL EXAMINATION
Causes of hepatomegally:
1. Infections--- hepatitis – HAV , HBV ,HCV, EBV, CMV , TB abscess , malaria ,alcohol
2. Inflammtion ---- autoimmune hepatitis
3. Ischemia----- bubb chiari syndrome , congested liver ,hepatic vein thrombosis
4. Tumour ---- hepaoma , lymphoma , leukemia
5. Tumour 2ry--- metastases
6. TB------ abscess
7. Fatty liver
Causes of splenomegally ( huge):
4 fingers below costal margin 14cm
1. Malaria
2. Leishmaniasis
3. CML--- chronic myeloid leukemia
4. CLL----chronic lymphocytic leukemia
5. Portal hypertension---- liver cirrhosis is the commonest.
6. Myelofibrosis
Causes of mild splenomegally :
1. 1.Infection --- HAV ,glandular fever , EBV , CMV, infective endocarditis, malaria ,leishmaniasis
2. Inflammation---- SLE , Rhemtaoid arthritis , sarcoidosis
3. Ischemia----- portal vein thrombosis
4. Tumour---- lymphoma ,leukemia
5. Tuberculosis --- military
6. Portal hypertension
How can you differentiate splenomegally from enlarged kidney on the left side of abdomen?
For splenomegally ,
1. Direction of enlargement ----- toward the right iliac fossa toward the midline
2. Continuity of the dullness on percussion note
3. Movement with deep breathing as it is intraperitoneal
4. Splenic notch over the medial site
5. The examiner cant insert the fingers below the left costal margin
For the kidney,
1. Ballottement is the pathognomic sign
2. Area of resonance over the mass
PERCUSSION:
Helps to identify the amount & distribution of gas and to identify possible masses that are solid or
fluid filled.
Percussing the abdomen produces different sounds based on the underlying tissues.
Sounds help you detect excessive gas and solid or fluid-filled masses
Also help you determine the size and position of solid organs such as the liver and spleen.
13. MAGDI AWAD SASI 2014 ABDOMENAL EXAMINATION
13 DR.MAGDI AWAD SASI ABDOMENAL EXAMINATION
By Percussion , you are looking for areas of tympany and dullness
Expect to hear tympany in most of the abdomen
Expect dullness over the solid abdominal organs such as the liver and spleen
Can be used to assess size of liver and spleen
On the right, it is the liver dullness; on the left, dullness of the spleen, kidney ,colonic mass.
The liver span is estimated by percussion.
Remember that it is easier to hear the change from resonance to dullness – so proceed with percussion from
areas of resonance to areas of dullness.
1.upper border from 2
nd
intercostal
space through mid clavicular line,
start percussing on the chest
moving down towards the abdomen
about ½ to 1 cm at a time. Note
where the percussion notes change
from resonate to dull which is the
beginning of the liver
border((upper)).
2.lower border from right iliac fossa
though midclavicular line and
ascend toward costal margin till the
dullness note start which is the
beginning of the liver border((
lower)).
Liver span is normally 6 to 12 cm in
the midclavicular line which is the
distance between upper and lower
borders.
For spleen,
• When a spleen enlarges, it
expands downward and medially toward
the right iliac fossa and pushed the
umbilicus to be flat . Fullness in the left
hypochondrial may be the first clue of
spleenomegally. Spleen enlargement
replaces the tympany of the stomach
with the dullness of a solid organ
• Percussion cannot confirm
splenic enlargement, but it can raise
your suspicion.
• There are two techniques to
percuss splenic enlargement.
• Percuss the left lower anterior
chest wall between lung resonance (6 IC)
above & the costal margin (an area
termed Traube’s space)
• As you percuss laterally, note
the extent of the tympany; if tympany is prominent laterally, splenomegaly is unlikely.
• Can also check for a splenic percussion sign
• Percuss the lowest interspace in the left anterior axillary line; the area is usually tympanitic
• Then ask the patient to take a deep breath and percuss again
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14 DR.MAGDI AWAD SASI ABDOMENAL EXAMINATION
• When the spleen is normal, the space usually remains tympanitic
ASCITES
• Shifting Dullness
• Percuss centrally from the epigstrium to
umbilicus then to each flank
• Locate point of change on side
• Ask patient to roll towards you
• Wait….for a minute for fluid to move to other
side
• Percuss again ?area of dullness moved
• Fluid Thrill
– Use patients right hand in midline
– Flick one side and feel the other side
– This is done if the patient has huge abdomen which is tense and difficult to palpate
and there is no area of central resonance for comparison and for fluid to move from
side to another.
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15 DR.MAGDI AWAD SASI ABDOMENAL EXAMINATION
What are the causes of ascitis?
As apart of generalised cause (( with bilateral pitting pedal odema ))
1. Portal hypertesion—liver cirrhosis
2. Chronic renal failure
3. Nephrotic syndrome
4. Hypothyrodism
5. Congestive heart failure
6. Protein losing enteropathy
As a part of local abdomenal disease,
1. Tuberculosis
2. GIT tumours--- stomach ,colon , pancrease
3. Metastases to the peritoneum
4. Connective tissues diseases
5. Budd chiari syndrome
6. Acute pancreatitis
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16 DR.MAGDI AWAD SASI ABDOMENAL EXAMINATION
AUSCULTATION:
• Provides important information about bowel motility: decreased motility suggests
peritonitis; increased motility suggests obstruction
• Need to listen before percussion or palpation since these maneuvers may alter the
frequency of bowel sounds
• Can also appreciate BRUITS over the aorta or other arteries, suggesting narrowing
of the arteries from atherosclerosis
Bruits are high pitched sounds due to obstruction to flow due to narrowing
(stenosis) of arteries
Listen midline (bruit in aorta)
Right / left upper quadrant (renal artery bruits)
• Listen with diaphragm of stethoscope
• Normal sounds occurs every 5-10 seconds & consist of clicks and gurgles
• Need to listen for 2 minutes to declare no bowel sounds; since bowel sounds are
widely transmitted, need only to listen in one spot
• Occasionally hear borborygmi - long, prolonged gurgles of hyperperistalsis - the
familiar stomach growling
SUMMARY PONTS:
1. BOWEL SOUNDS
a. ABSENT
b. LOUD
2. VENOUS HUMS
a. B/W XIPHISTERNUM AND UMBILICUS
3. Renal Bruit
4. Hepatic Bruit
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17 DR.MAGDI AWAD SASI ABDOMENAL EXAMINATION
• Succussion Splash
• Puddle Sign
• Cover the patient up
• Turn to the examiner
“ I would like to complete my examination by examining the
external genitalia, performing a digital rectal examination
and dipstick the urine.”
You can ellicit succussion splash in normals following
ingestion of aerated drink. Whenever there is air and fluid inside a bowel you can ellicit this
sign.
NOTE:
Special manevures may also be performed, to elicit signs of specific diseases. These include
Gallbladder: Murphy's sign
It is performed by asking the patient to breathe out and then gently placing the hand below the costal margin on
the right side at the mid-clavicular line (the approximate location of the gallbladder). The patient is then
instructed to inspire (breathe in). Normally, during inspiration, the abdominal contents are pushed downward as
the diaphragm moves down. If the patient stops breathing in (as the gallbladder is tender and, in moving
downward, comes in contact with the examiner's fingers) and winces with a 'catch' in breath, the test is
considered positive. In the elderly the sensitivity is markedly lower; a negative Murphy's sign in an elderly
person is not useful for ruling out cholecystitis if other tests and the clinical history suggest the
diagnosis
• Courvoisier's law:
States that in the presence of an enlarged gallbladder which is non tender and accompanied with mild
jaundice, the cause is unlikely to be gallstones. Usually, the term is used to describe the physical
examination finding of the right-upper quadrant of the abdomen. This sign implicated possible malignancy of
the gall bladder or pancreas and the swelling is unlikely due to gallstones(( because gallstones are formed
over an extended period of time, resulting in a shrunken, fibrotic gall bladder which does not distend easily)).
This shrunken gallbladder is less likely to be palpable on exam. In contrast, the gallbladder is more often
enlarged (and more easily palpated) in pathologies that cause obstruction of the biliary tree over a shorter
period of time such as pancreatic malignancy leading to passive distention from back pressure. Note that a
palpable tender gallbladder may be seen in acute acalculous cholecystitis, which commonly follows trauma
or ischemia and causes acute inflammation of the gallbladder in the absence of gallstones.
The exceptions to the law are stones that dislodge and acutely jam the duct distally to the hepatic/cystic duct junction:
1. Gallstone falling and blocking the Ampulla of Vater
2. Gallstone falling and blocking the cystic/hepatic duct junction
.The psoas sign: is a medical sign that indicates irritation to the iliopsoas group of hip flexors in the abdomen, and
consequently indicates that the inflamed appendix is retrocaecal in orientation (as the iliopsoas muscle is retroperitoneal).
It is elicited by performing the psoas test by passively extending the thigh of a patient lying on his side with knees
extended, or asking the patient to actively flex his thigh at the hip. If abdominal pain results, it is a "positive psoas sign".
In particular, the right iliopsoas muscle lies under the appendix when the patient is supine, so a positive psoas sign on the
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18 DR.MAGDI AWAD SASI ABDOMENAL EXAMINATION
right may suggest appendicitis. A positive psoas sign may also be present in a patient with a psoas abscess. It may also
be positive with other sources of retroperitoneal irritation, e.g. as caused by hemorrhage of an iliac vessel.
.Blumberg's sign is a sign that is elicited during physical examination in medicine. It is indicative of peritonitis.
The abdominal wall is compressed slowly and then rapidly released. A positive sign is indicated by presence of
pain upon removal of pressure on the abdominal wall. It is very similar to rebound tenderness
Appendicitis or peritonitis:
Psoas sign - pain when tensing the psoas muscle
Obturator sign - pain when tensing the obturator muscle
Rovsing's sign - pain in the right iliac fossa on palpation of the left side of the abdomen
Carnett's sign - pain when tensing the abdominal wall muscles
Patafio's sign - pain when the patient is asked to cough whilst tensing the psoas muscle
Cough test - pain when the patient is asked to cough
Suspected Pyelonephritis: Murphy's punch sign
Hepatomegaly: Liver scratch test
Ascites: bulging flanks, fluid wave test, shifting dullness
IF THE PATIENT HAS A HUGE ASCITIS , WHAT IS THE COMMONEST CAUSE AND WHAT OTHER SIGNS YOU
HAVE TO LOOK FOR?
Liver cirrhosis with portal HTN is the commonest cause.
The signs that you have to look for are the stigmata of chronic liver disease.
They are:
Jaundice , spider neavi , Gyanecomastia in male & Breast atrophy in female , flapping tremors
,palmer erythema , muscle wasting , kilonychia ,leuchonychia , ecchymosis , pedal odema.
Those are mandatory to look for in any case of abdominal examination.
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HOPPING , IT WILL HELP AND ALLAH ACCEPT MY TRIAL TO HELP OTHERS