Abdominal Examination

ABDOMINAL EXAMINATION INGUINOSCROTAL EXAMINATION DR. HAZEM ZAKARIA

Contribution to Diagnosis

HISTORY EXAMINATION INVESTIGATION

Appendix Caecum Right Ovary Small bowel

Bladder Uterus Small bowel

Sigmoid colon Left ovary Small bowel

Descending colon Small bowel Aorta

Spleen Colon

Stomach Duodenum Tr colon Aorta Pancreas

Liver Gallbladder Duodenum

Ascending colon

Aorta Small bowel

ABDOMINAL EXAMINATION COMPLAINT • • • • • • • • • • • •

Abdominal swelling Abdominal pain Vomiting, Heart burn Dyspepsia Haematemsis Bleeding per rectum Bowel habbit changes Abdominal distension Loss of weight,Anorexia Easy fatigability Urinary complaint Gynacological symptoms

Purpose of examination

• To elicit physical signs • To aid formulation of a diagnoses • To comfort the patient

ABDOMINAL EXAMINATION/GENERAL

• General exam begins on first sight of the patient

• Examine the whole patient

Abdominal Examination/GENERAL • General observation – – – –

Comfort Position Colour Respiration

ABDOMINAL EXAMINATION/GENERAL

• General examination: Mental state: drowsiness,loss of conc. Posture:Leaning forward..Pancreatic lesion Facies: toxic,earthy in uraemia,liver failure Body built: Underweight, Cachexia,well Vital signs,Head, eyes, Mouth,

Abdominal Examination/GENERAL • Head and Neck – Eyes • Colour of sclera • Pallor of eyelids – Tongue • Hydration – Cervical and supra-clavicular lymph nodes

•Examine from the

patients right side

ABDOMINAL EXAMINATION Equipment Needed A Stethoscope

General Considerations

. The patient should have anempty bladder The patient should be lying supine on the .exam table and appropriately draped The examination roommust be quiet to perform adequate auscultation and .percussion

ABDOMINAL EXAMINATION .Starting the examination All examinations start in the same way. Firstly, the examinee introduces him or herself to the patient, and checks that the patient is comfortable and happy with the procedure. The patient is thenpositioned andexposed. The examiner should make sure that there is the best light available that is possible and that both the patient  .and the examiner are comfortable

ABDOMINAL EXAMINATION Watch the patient's face for signs of discomfort .during the examination Use the appropriate terminology to locate your :findings vertical lines,2 transverse 2 lines(subcostal,intertubercular plane (Right Upper Quadrant (RUQ (Right Lower Quadrant (RLQ (Left Upper Quadrant (LUQ (Left Lower Quadrant (LLQ :Midline Epigastric Periumbilical

INSPECTION • Expose abdomen from nipple to knee • Stand back: Symmetery Abdominal movement with respiration • Contour: from the foot of the patient • Subcostal angle: 90-110 widened.. Inc. Intra abdominal pressure Rising test: Contraction of Ant. Abd.wall muscle

INSPECTION • Umbilicus: site, shape, impulse on cough, discharge,sinus Dilated veins: Caput Medusae,IVC,SVC Pubic hair distribution Impulse at hernial orifices Scars of previous operation Back : scoliosis,Kyphosis,swelling Scrotum: mass, skin changes Swelling : site, Intra- or Extra- abdominal (test),size, shape,surface,skin overlying,pulsation,impulse

Abdominal Examination/Palpation

Clean hands & nails Warm hands Kneel down Inform patient of your plans -Ask about pain Begin with light palpation Examine the quadrants in an anticlockwise manner starting so that a painful quadrant is last Use one hand for palpation & one for positioning

Abdominal Examination/Palpation :Avoid guarding of abdominal Muscles Warm hand Ask patient to flex his knees Ask the patient to open his mouth and breath deeply in &out :Technique Start from region opposite to patient complaint affected region should be the last &

Abdominal Examination/Palpation Move hand gently and steadily from one quadrant to the next Look at the patients face as you are examining Deep palpation – follow the same course as for light palpation but with a little firmer pressure If a mass is palpated try to delineate it and note its consistency surface, movements and relations to surrounding structures

Abdominal Examination/Palpation Examine the liver Begin with the hand low in the (.abdomen ( level of Rt I F Deeply palpate with the edge of the examining hand as the patient inspires move towards the costal margin with successive inspirations Four steps should be enough Percuss the liver to delineate the size

Abdominal Examination/Palpation

• Alternate Method

• This method is useful when the patient is obese or when the examiner is small compared to the patient. • Stand by the patient's chest. • "Hook" your fingers just below the costal margin and press firmly. • Ask the patient to take a deep breath. • You may feel the edge of the liver press against your fingers.

Other methods for liver palpation 1-Bimanaual method: liver edge can be more prominent by putting Lf. Hand under lower ribs 2-Dipping method : in tense ascites

Abdominal Examination/Palpation Liver Span Percussdownward from the chest in theright midclavicular line until you detect the top edge .of liver dullness ,(tidal percussion).. fifth space Percussupward from the abdomen in the same line until you detect the bottom edge of liver .dullness Measure the liver span between these two points. This measurement should be 6-12 cm in a normal .adult

Abdominal Examination/Palpation

• Palpation of the Aorta • Press down deeply in the midline

above the umbilicus. • The aortic pulsation is easily felt on most individuals. • A well defined, pulsatile mass, greater than 3 cm across, suggests an aortic aneurysm.

AORTIC ANEURYSM

Abdominal Examination/Palpation Examine for the spleen

Normal: spleen not palpable (infant,2% in adults.. Could palpate with deep (inspiration Spleen must enlarge 1.5 time to be palpable Begin palpation for spleen in the RIF, move toward the LUQ stepwise with inspiration Six steps should be enough Recognize the notch Don’t be surprised if you can’t find it

Abdominal Examination/Palpation Splenic Dullness Percuss the lowest costal interspace in the left anterior axillary line. This area is .normally tympanitic Ask the patient to take a deep breath and percuss this area again. Dullness in this .area is a sign of splenic enlargement Other methods: Bimanual examination Hooking method

Examination of the Kidneys Normal kidney is not palpable In suspecting renal mass.. Look for renal angle fullness

Ballottement .. Bimanual examination

Place left hand on back below costal margin and palpate with right hand Murphy’s kidney punch.. Tender renal angle with thumb Again don’t be surprised if you can’t palpate the kidney

Examination of abdominal mass • Site, Intra- or Extra- abdominal • Temperature, tenderness • Size, shape, surface, skin, edge • Consistency, signs of inflammation • Pulsation, mobility in 2 directions

Percussion Percuss in all four quadrants using .proper technique A- Use the wrist B- Use middle finger of Rt hand opposite middle phalynx of oppsite middle finger Categorize what you hear as tympanitic or dull. Tympany is normally present over most of the abdomen in the supine position. Unusual dullness may be a clue to an

PERCUSSION • Percuss liver,spleen,kidney (renal angle normally resonant)

• Ascites : • Moderete(1500-3000) : shifting

dullness • Minimal( 500-1500) : Percuss umbilicus in knee elbow position • Massive : Fluid thrill

Traube’s area • Area of tympanic note in lower Lf. Part of

the front of the chest(gas of stomach). • Boundaries: LF. :ant. margin of spleen RT.: inf. Border of liver Superior: lower border of Lf. Lung Inf. : Lf. Costal margin Dull in : splenomegaly,hepatomegaly,pleural effusion,huge gastric mass

Auscultation • Place the diaphragm of your

stethoscope lightly on the abdomen. • Listen for bowel sounds. Are they normal, increased, decreased, or absent? • Listen for bruits over the renal arteries, iliac arteries, and aorta. • Venous hum: below xyphoid cartilage in portal hypertension… engorgement of splenic vein

Abdominal sounds • Absent bowel sounds, ileus, is a condition in

which the examiner is unable to hear any bowel sounds after listening to each area of the abdomen .

• Reduced bowel sounds (hypoactive) include a

reduction in the loudness, tone, or regularity of the bowel sounds. Hypoactive bowel sounds are normal during sleep, and also occur normally for a short time after the use of certain medications and after abdominal surgery.

Abdominal sounds • Increased bowel sounds (hyperactive sounds) are sometimes heard even without a stethoscope. They occur at a higher pitch and greater frequency than normal bowel sounds. Hyperactive bowel sounds reflect an increase in intestinal activity.

• The sudden stopping of bowel sounds, or absent

bowel sounds after a period of hyperactive bowel sounds, are significant findings that can indicate a potentially life-threatening crisis such as rupture of the intestines or strangulation of the bowel

Abdominal sounds • Common Causes: Hyperactive, hypoactive, or • •

absent bowel sounds: mechanical bowel obstruction (caused by hernia, tumor, adhesions, or similar conditions that can physically block the intestines) paralytic ileus, a problem with the nerves to the intestines (reduced nerve activity can result from infection, overdistended bowel, trauma, bowel obstruction, vascular obstruction, and chemical imbalances such as hypokalemia)

Abdominal sounds • Hyperactive bowel sounds (other causes): • diarrhea (any cause including emotional stress) • Crohn’s disease • GI bleeding • ulcerative colitis • food allergy • infectious enteritis

Special Tests • Rebound Tenderness This is a test for peritoneal irritation. Warn the patient what you are about to do. Press deeply on the abdomen with your hand. After a moment, quickly release pressure. If it hurts more when you release, the patient

Special Tests • Costovertebral Tenderness CVA tenderness is often associated with renal disease. Warn the patient what you are about to do. Have the patient sit up on the exam table. Use the heel of your closed fist to strike the patient firmly over the costovertebral angles. Compare the left and right sides.

Special Tests • Psoas Sign • This is a test for appendicitis. • Place your hand above the patient's

right knee. • Ask the patient to flex the right hip against resistance. • Increased abdominal pain indicates a positive psoas sign.

Special Tests • Obturator Sign • This is a test for appendicitis. • Raise the patient's right leg with the

knee flexed. • Rotate the leg internally at the hip. • Increased abdominal pain indicates a positive obturator sign.

RECTAL EXAMINATION • THE RECTAL EXAMINATION – Position on left side with knees drawn right up into chest – KY on glove – Inspection first – Index inserted to full length – Comment on tenderness, prostate, mass, blood, mucous, faeces

HERNIA • Swelling : increase on cough & decrease in lying down. Usually painless Complication: irreducibility,obstruction,strangulation

• • Exam: standing up,inspection:

Inguinal hernia, femoral hernia D.D: Pubic tubercle test site, size, surface,shape, expansile impulase on cough, scrotum, other swelling Palpation: Temp., tenderness, consistency, gurgling,edge D.D scrotal from inguinoscrotal swelling, D.D between direct &indirect inguinal hernia (Int. ring test, Ext.ring test) Auscultation: Intestinal sounds if content is intestine Transillumination : a hydrocele is translucent while hernia is not

The scrotum • C/O : Pain, swelling, infertility, discharge

urinary troubles Inspection: Symmetry, size of testis, absent testis, swelling , skin (ulcers, sinuses), penis Palpation : a. Spermatic cord matted :filariasis, nodules : T.B, cyst: encysted hydrocele .varicocele (bag of warm) b. Testis : loss of testicular sensation (malignancy,Gumma), mass c. Transillumination