abdomen PE.pptx

Abdomen Physical Examination

1. Abdominal Physical Examination

2. REFERENCE: Bickley, Lynn S. (12th Edition). Bates' guide to physical examination and history taking. Philadelphia :Lippincott Williams & Wilkins

3. Tips for Abdominal Examination ● Make the patient comfortable in the supine position, with a pillow under the head and perhaps under the knees. ● Ask the patient to keep the arms at the sides or folded across the chest. ● Draping the patient ● Before you begin, ask the patient to point to any areas of pain so that you can examine these areas last. ● Warm your hands and stethoscope. ● Approach the patient calmly and avoid quick unexpected movements. ● Stand at the patient’s right side and proceed in a systematic fashion with inspection, auscultation, percussion, and palpation. ● If necessary, distract the patient with conversation or questions.

4. Inspection General Appearance Temperature Color Scars Striae Dilated veins Rashes or ecchymoses

5. Inspection The umbilicus Contour, location, inflammation Contour of the Abdomen Flat, Rounded, Protuberant or Scaphoid Flanks bulges Symmetric Visible organs or masses Peristalsis Thin people Pulsations Aortic Pulsation

6. Auscultation Bowel sounds Frequency- clicks and gurgles 5-34 per minute Character- borborygmi RLQ Bowel sounds may be: ■ Increased, as in diarrhea or early intestinal obstruction ■ Decreased, then absent, as in adynamic ileus and peritonitis. Before deciding that bowel sounds are absent, sit down and listen where shown for 2 min or even longer. High-pitched tinkling sounds suggest intestinal fluid and air under tension in a dilated bowel. Rushes of high-pitched sounds coinciding with an abdominal cramp signal intestinal obstruction.

7. Auscultation Bruits A hepatic bruit suggests carcinoma of the liver or cirrhosis. Arterial bruits with both systolic and diastolic components suggest partial occlusion of the aorta or large arteries. Bruits in the epigastrium are suspicious for renal artery stenosis or renovascular hypertension.

8. Auscultation Friction Rub Friction rubs are rare grating sounds with respiratory variation. They indicate inflammation of the peritoneal surface of an organ, as in liver cancer, chlamydial or gonococcal perihepatitis, recent liver biopsy, or splenic infarct. When a systolic bruit accompanies a hepatic friction rub, suspect carcinoma of the liver.

9. Auscultation Venous Hum A venous hum is a rare soft humming noise with both systolic and diastolic components. It points to increased collateral circulation between portal and systemic venous systems, as in hepatic cirrhosis.

10. Percussion Note any dull areas suggesting an underlying mass or enlarged organ. This observation will guide subsequent palpation. On each side of a protuberant abdomen, note where abdominal tympany changes to the dullness of solid posterior structures. Briefly percuss the lower anterior chest above the costal margins. On the right, you will usually find the dullness of the liver; on the left, the tympany that overlies the gastric air bubble and the splenic flexure of the colon.

11. Palpation Light Palpation Gentle palpation aids detection of abdominal tenderness, muscular resistance, and some superficial organs and masses. It also reassures and relaxes the patient. Identify any superficial organs or masses and any area of tenderness or increased resistance to palpation Palpate after asking the patient to exhale, which usually relaxes the abdominal muscles. Ask the patient to mouth-breathe with the jaws wide open.

12. Palpation Deep Palpation Deep palpation is usually required to delineate the liver edge, the kidneys, and abdominal masses

13. Palpation Signs of Peritonitis Guarding Rigidity Rebound Tenderness

14. The Liver https://youtu.be/839KX_-B1O0

15. Percussion Identify the lower border of dullness in the MCL Start: level below umbilicus in the RLQ. Percuss upward towards the liver Identify the upper border of liver dullness: Start: nipple line Percuss downward in the MCL until lung resonance shifts to liver dullness.

16. Percussion Vertical span of liver dullness: measure the cm between the 2 points If liver seems enlarged, outline LOWER EDGE : percuss medially & laterally

17. Palpation Place your left hand behind the patient, parallel to and supporting the right 11th and 12th ribs and adjacent soft tissues below. Press left hand upward Place your right hand on the patient’s right abdomen lateral to the rectus muscle , with your fingertips well below the lower border of liver dullness Ask the patient to take a deep breath. Try to feel the liver edge as it slides down to meet your fingertips.

18. Palpation liver edge: adapt your examining pressure to the thickness and resistance of the abdominal wall . If you cannot feel the edge , move your palpating hand closer to the costal margin and try again. Trace the liver edge both laterally and medially .

19. Hooking Technique Stand to the right of the patient’s chest. Place both hands, side by side , on the right abdomen below the border of liver dullness . Press in with your fingers and up toward the costal margin Ask the patient to take a deep breath . The liver edge shown in Figure 11-19 is palpable with the fingerpads of both hands .

20. The Spleen bates' video: Spleen examination - YouTube

21. Percussion Percuss the left lower anterior chest wall roughly from the border of cardiac dullness at the 6th rib to the anterior axillary line and down to the costal margin. As you percuss along the routes marked by the arrows in the Figures 11-20 and 11-21, note the lateral extent of tympany

22. Percussion SPLENIC PERCUSSION SIGN Percuss the lowest interspace in the left anterior axillary line Then ask the patient to take a deep breath , and percuss again . When spleen size is normal , the percussion note usually remains tympanitic. If it becomes dull, positive.

23. Palpation With your left hand, reach over and around the patient to support and press forward the lower left rib cage and adjacent soft tissue. Right hand below the left costal margin, press in toward the spleen. Ask the patient to take a deep breath. Try to feel the tip or edge of the spleen as it comes down to meet your fingertips Note any tenderness, assess the splenic contour.

24. Palpation Repeat with the patient lying on the right side with legs somewhat flexed at the hips and knees

25. The Kidneys bates' video: Kidney & Aorta examination - YouTube

26. Palpation of the Left Kidney Move to the patient’s left side. Place your right hand behind the patient, just below and parallel to the 12th rib, with your fingertips just reaching the CVA. Lift, trying to displace the kidney anteriorly. Place your left hand gently in the LUQ, lateral and parallel to the rectus muscle. Ask the patient to take a deep breath. At the peak of inspiration, press your left hand firmly and deeply into the LUQ, just below the costal margin. Try to “capture” the kidney between your two hands.

27. Palpation of the Left Kidney Ask the patient to breathe out and then to stop breathing briefly. Slowly release the pressure of your left hand, feeling at the same time for the kidney to slide back into its expiratory position. Alternatively, try to palpate the left kidney using the deep palpation technique similar to palpation of the spleen. Standing at the patient’s right side, with your left hand, reach over and around the patient to lift up beneath the left kidney, and with your right hand, feel deep in the LUQ. Ask the patient to take a deep breath, and feel for a mass. A normal left kidney is rarely palpable.

28. Palpation of the Right Kidney To capture the right kidney , return to the patient’s right side. Use your left hand to lift up from the back, and your right hand to feel deep in the RUQ.

29. Percussion Tenderness of the Kidneys Assess percussion tenderness over the CVAs. Pressure from your fingertips may be enough to elicit tenderness; if not, use fist percussion. Place the ball of one hand in the CVA and strike it with the ulnar surface of your fist. Use enough force to cause a perceptible but painless jar or thud.

30. The Bladder

31. Palpation of the Right Kidney Percuss for dullness and the height of the bladder above the symphysis pubis. On palpation, the dome of the distended bladder feels smooth and round.

32. The Aorta

33. The Aorta Press firmly deep in the epigastrium, slightly to the left of the midline, and identify the aortic pulsations. In adults over age 50 years, assess the width of the aorta by pressing deeply in the upper abdomen with one hand on each side of the aorta. Detection of pulsations is affected by abdominal girth and the diameter of the aorta.

34. Digital Rectal Examination

35. Male Patient Inspect the sacrococcygeal and perianal areas for lumps, ulcers, inflammation, ashes, or excoriations Examine the anus and rectum Palpate the anal canal Palpate the rectal surface Palpate the prostate gland

36. Fem ale Patient The rectum is usually examined after examining the female genitalia while the woman is in the lithotomy position. I f only a rectal examination is needed, the lateral position is satisfactory and affords a better view to the perianal and sacrococcygeal areas.

37. Special Techniques

38. Assessing Possible Ascites Percuss for dullness outward in several directions from the central area of tympany. Map the border between tympany and dullness

39. Assessing Possible Ascites Test for shifting dullness Percuss the border of tympany and dullness with the patient supine, then ask the patient to roll onto one side. Percuss and mark the borders again

40. Assessing Possible Ascites Test for a fluid wave Ask the patient or an assistant to press the edges of both hands firmly down the midline of the abdomen. While you tap one flank sharply with your fingertips, feel on the opposite flank for an impulse transmitted through the fluid.

41. Assessing Possible Ascites Identifying an Organ or Mass in an Ascitic Abdomen Try to ballotte the organ or mass Straighten and stiffen the fingers of one hand together, place them on the abdominal surface, and make a brief jabbing movement directly toward the anticipated structure.

42. Assessing Possible Appendicitis Ask the patient to point to where the pain began and where it is now. Ask the patient to cough to see where pain occurs. Palpate carefully for an area of local tenderness. Palpate the tender area for guarding, rigidity, and rebound tenderness. Palpate for Rovsing sign and referred rebound tenderness. Assess the psoas sign O bturator sign Perform a rectal examination and, in women, a pelvic examination.

43. Assessing Possible Acute Cholecystitis When RUQ pain and tenderness suggest acute cholecystitis, assess Murphy sign.

44. Assessing Ventral Hernias Ventral hernias are hernias in the abdominal wall exclusive of groin hernias.

45. Mass in the Abdominal Wall Occasionally, there are masses in the abdominal wall rather than inside the abdominal cavity. Ask the patient either to raise the head and shoulders or to strain down, thus tightening the abdominal muscles. Feel for the mass again.

46. Thank You!