Sequence Of Abdominal Assessment

Part 2:

SEQUENCE OF Abdominal ASSESSMENT

The physical Examination The elective physical Examination • The examining room and table should be comfortable • And drapes should be used • Inform the patient • Lay the subject supine with arms by the side • Expose the abdomen, including the groin parts • Only from xiphoid process (xiphisternum) to pubic symphysis

SEQUENCE OF ASSESSMENT • • • • •

Inspection Auscultation Percussion Palpation Examination of the body orifices

INSPECTION • Stand at his right side and perform general inspection of the abdomen Noting in particular: Symmetry of its shape and the presence of markings and scars ►Lower yourself until the anterior abdomen wall is at eye level and note: the shape (contour) and movement of the abdomen ►Ask the patient to breath normally while you are doing so

INSPECTION • ►►Stand up again and direct your attention to the subject’s groin bilaterally • Ask him to cough and observe the cough impulse along the inguinal canal

INSPECTION

Normal Findings ■ Contour (shape) Flat Rounded Scaphoid Protuberant (distended)

INSPECTION • Normal Findings • Movement • ►Rises and falls rythmically with inspiration and expiration respectivelly • ►Pulsation of abdominal aorta may be seen in the epigastrium of a slender person • Cough impulse • ► No cough impulse should be seen along the inguinal canal

INSPECTION

• Abnormal findings • Skin Pigmentation (change) lesion (dermatologic) Striae Turgor Scars Superficial vessels Shape (asymmetrical ► enlargement of intraabdominal organ, Gross tumor) Movement ( minimal or absent ► peritonitis) •

Abdominal Striae

Superficial vessels Illustration

AUSCULTATION The purpose of auscultation of the abdomen is to listening for bowels sounds produced by peristaltic activities and vascular sounds (bruits)

• ►►Bowel sounds may be * Active bowel sounds 5-30/min * Hypoactive bowel sounds 4/min or less * Hyperactive bowel sounds 30 or more /min

AUSCULTATION • Vascular sounds (bruits) * The abdominal aorta sounds at the epigastrium • The renal arteries sounds at the hypochondrium bilaterally • (or costovertebral angle at the back bilaterally) * The iliac arteries sounds in the center of each lower quadrant * The femoral arteries sounds just below the mild-point of the inguinal ligament bilaterally

AUSCULTATION FOR BRUITS

Percussion • Purpose: • To delineate ►The borders of the liver, the enlarge spleen, presence of other masses ► Presence of fluid (ascites) ► Abdominal distention (gas-filled bowels)

Percussion • ►Five (5) sound notes may be evoked, depending on the site and underlying pathology • 1) the sound noted is flat when the site is over soft tissue or fluid • 2) the sound noted is dull when the site is over solid organ beneath a layer of lung • 3) the sound noted is resonant when the site is over air-filled lung tissue • 4) the sound noted is hyper resonant when the site is over air-filled pleural cavity • 5) the sound noted is tympanic when the site is over air-filled bowel

PERCUSSION OF SPLEEN

Exercise (percussion) • 1) Percuss your thigh and listen to the evoked sound note. (The underlying tissue is fat, muscle and bone).

• 2) Percuss your right chest just under the clavicle and listen to the evoked sound note. ( The underlying tissue is air-filled lung).

• 3) Percuss your right chest at the right mid-clavicle line above the costal margin and listen to the evoke sound note. (the underlying tissue is lung over liver

• 4) Percuss the left upper quadrant of your abdomen below the costal margin and listen to the evoke sound note. (the underlying stomach may contain a large gas bulbble.

On the back Pounding on the Costovertebral angle ► Should not cause pain. If pain ►►often it is associated with renal disease

Percussion • ► If dullness in flanks►► check for shifting dullness test

Percussion • ► If indicated check for fluid wave test

PALPATION • It is important that you warm your hand before your palpate the abdomen of your patient • Half flexing the patient’s knees will help to relax the abdominal musculature and make the palpation easier • There are 4 phases to palpation of the abdomen: 1) light palpation • 2) deep palpation • 3) bimanual palpation, and • 4) palpation of groin •

PALPATION

• 1) Light palpation: • The purpose of light palpation is to check: • • ►) abdominal muscle tone • ►) cutaneous hepersensibility • ►) tenderness • ►) Presence of superficial masses • When it is performed well it can help gain the confidence of the patient and prepared him for deep and, bimanual palpation

PALPATION ►

Deep palpation The purpose of deep palpation is to feel for organs in the deep of the abdominal cavity The procedure is similar to light palpation but firm steady pressure is used However you should avoid digging your fingers into the abdominal wall Some practitioner use a two-hand approach to apply firm pressure when palpating for the cecum or sigmoid colon in the right and left iliac region respectively

Exercice (light palpation) • 1) Ask the patient if any part of the abdomen is tender • Start palpation as far from that area as possible • 2) Place the palm of your hand flat on the abdomen Palpate gently and apply pressure by flexing the finger in unison at the metacarpal phalangeal joints. Check for muscle tone, tenderness and rebound tenderness as you proceed • 3) Move your hand through all regions and palpate the entire abdomen in systematic manner •

Light and Deep Palpation Illustration

Bimanual Palpation • ► Should be applied to organs that move with respiration • Example liver and gallbladder: • Exercise: • • • • • • •

Lay the patient supine and stand on his right. Slide your left hand behind the patient’s lowermost ribs on the right. Place your other hand flat on the anterior abdominal wall, with fingerpoints upwards, lateral to the rectus muscle, and just below the costal margin. Simultaneously push forwards with the posterior hand and press inward and upward with anterior hand. Ask the patient to take deep breath through the mouth. Near the peak of the inspiration allow the finger hand to rise the abdominal wall. You may feel the edge of liver or slide under your hand. A normal liver is not tender.

PALPATION palpation for liver

Liver Palpation Other alternative

Palpation for Spleen

Rebound tenderness

ON BACK

IF ABDOMINAL PAIN Tachypneic Learning Forward * Murphy’s sign * Rovsing’s sign * Iliopsaos test * Obturator’s sign

RULES IF IN ABDOMINAL PAIN • Do not administer pain medication: Antispasmodics Anticholinergics Smooth muscle relaxants Before a medical diagnosis, because mask pain

CONTREINDICATION FOR ABDOMINAL ASSESSMENT

• Never palpate a if suspected: • • •

Appendicitis ?? Dissecting abdominal aortic aneurysm Polycystic kidneys

• Do not palpate or percuss transplanted organs

Things to Remember • Consider groin / rectal examination in males • Consider pelvic/ rectal examination in females

THANKS