ABDOMINAL EXAMIMANATION IN SURGERY STUDY.pptx

Medicine and surgery

1. Abdominal examination TANUS JONATHAN BABALANDA 2019-08-09065

2. WIPE ABCDEV Wash hands Introduce yourself Position your patient/ privacy Expose your patience

3. Appearance Body built; weight gain or loss Connections Distress Vital signs

4. INSPECTION Shape of the abdomen: The shape of the abdomen can be either: Normal. Scaphoid (sunken). Distended abdomen:

5. Cont ……. Generalized distension: Differential diagnoses: F at (obesity). F luid (ascites). F oetus (pregnancy). F aeces (faecal impaction). F latus (air, as in intestinal obstruction).

6. Localized distension: Asymmetrical : Differentials diagnoses: Sigmoid volvulus. Intra-abdominal cyst or tumour. Gross enlargement of the spleen, liver, ovary, urinary bladder, kidney, pancreas or stomach.

7. Cont ………. Symmetrical and centred around the umbilicus: Intestinal obstruction

8. Shape of the umbilicus : The umbilicus can be either: Everted: As in umbilical hernia. Stretched (transverse): As in ascites. Slight retracted and inverted: Normal. Vertically drawn-up: Grossly enlarged ovarian cyst.

9. Abdominal wall movements Normal abdominal wall movements: Gentle rise in the abdominal wall during inspiration and a fall during expiration; the movements are free and equal on both sides of the abdomen. Diminished or absent movements: It suggests generalized peritonitis. Diminished or absence of abdominal movement helps to limit the spread of infection within the peritoneal cavity and pain of peritoneal irritation.

10. Visible peristaltic movements: Differential diagnoses: Gastric outlet obstruction. Congenital pyloric stenosis. Distal small intestinal obstruction. Co-existing small and large bowel obstruction.

11. Cont ….. In gastric outlet obstruction or congenital pyloric stenosis peristaltic abdominal wall movements are seen moving from left to right . Visible pulsations: At the Right hypochondrium may be caused by tricuspid regurgitation. Epigastrium in a thin, anxious person is normal (abdominal aorta pulsations). Auscultate the site of pulsations; a bruit may indicate the presence of aneurysm on the abdominal aorta.

12. Skin surface of the abdomen: Rash: Examples : Scabies, herpes zoster, eosinophilic folliculitis (pruritic papular eruptions, PPE).

13. STRIAE Wide purple striae: Differentials: Cushing’s syndrome and excessive steroid use. Striae atrophic or gravidarum: These are white ( linea Alba) or pink wrinkled linear marks on the abdominal skin. They are produced by gross stretching of the skin with rupture of the elastic fibers and indicate a recent change in size of the abdomen. Differentials: Pregnancy, ascites, wasting diseases and severe dieting

14. Cont …… Linea nigra : A black line seen on midline below the umbilicus in pregnancy Scars: Therapeutic. Surgical/incision. Decorative (cosmetic). Pigmentations: Vitiligo. Purpura. Acute pancreatitis

15. Scratch marks (excoriations): Differentials : Cholestasis , Onchocerciasis, allergy, scabies, dry skin, iron deficiency anaemia etc. Visibly distended veins: They are seen in the following situations Inferior vena cava obstruction. Venous anastomosis due to portal hypertension.

16. Hernial orifices: Inspect for swellings e.g. hernia and hanging groin swellings found in Onchocerciasis and lymphadenopathy. Genitalia : Look for: Swellings e.g. scrotal hernia, hydrocele etc. Abnormal discharge. Genital warts. Ulcerations

17. Cullen’s sign:  bruising of the tissue surrounding the umbilicus associated with haemorrhagic pancreatitis (a late sign). Grey-Turner’s sign:  bruising in the flanks associated with haemorrhagic pancreatitis (a late sign)

18. PALPATION There are two types of palpation Superficial palpation Ask the patient for the painful site on the abdomen where you have to be palpate it last. Palpation is done in anti-clockwise pattern starting from left iliac fossa to suprapubic area. It intends in looking for areas of tenderness, muscle guarding and rigidity .

19. Deep palpation : Examine the abdomen slowly and deeply with the left hand on top of the right to allow exertion of more pressure. Deep palpation includes palpation for:

20. Organ enlargement i.e. liver, spleen, ovaries, uterus, kidneys and urinary bladder. Hepatomegaly: The palpable liver is described with the following attributes Consistency: Firm: Hepatocellular carcinoma. Soft: CCF, hepatitis, liver abscess and hydatid cyst of the liver

21. Presence of tenderness: Differentials: It includes CCF, hepatocellular carcinoma, hepatitis, hydatid cyst of the liver and liver abscess. Regularity or smoothness of its surface: Smooth: CCF, liver abscess or hepatitis. Irregular: Liver cirrhosis or hepatoma.

22. Presence of pulsations: Tricuspid regurgitation. Degree of enlargement in centimetre measured along midclavicular line from the right costal margin

23. Splenomegaly: Differential diagnoses for massive splenomegaly: A spleen is enlarged to the extent of its lower pole been within the pelvis or crossed the midline into the right lower abdominal quadrant. Myelofibrosis. Gaucher’s disease. Thalassemia major. Chronic myeloid leukemia. Visceral leishmaniasis (Kala-azar).

24. Hyperactive malaria splenomegaly (HMS). AIDS with Mycobacterium avium complex. Lymphoma, usually indolent, including hairy cell leukemia.

25. Kidney enlargement: Kidney enlargement is elicited by bimanual examination. In order to assess the enlargement of the right kidney place the left hand posteriorly in the right loin and the right hand anteriorly vertically in the right lumbar area, then ask the patient to take deep breath in while pressing with the fingers of the right hand side. In order to assess the enlargement of the left kidney do the opposite

26. Enlarged uterus and distended urinary bladder: Palpate for their enlargement downwards along the midline, above the visibly distended mass to localize the upper border. They are measured in fundal height using fingers or tape measure

27. Presence of other isolated masses Description of mass: 7s Site. Size. Shape. Surface. Softness (Texture). Shifting (Movement). Smoothness (Regularity).

28. Rebound tenderness: It is elicited by palpating slowly deeply the abdomen and suddenly release of the hand. A patient will then jump up of pain. Its presence suggests peritonitis . Muscle guarding and rigidity : Muscle guarding is an involuntary muscle contraction which makes the abdomen feeling like a hard board (rigidity). Its presence suggests peritonitis .

29. Renal angle tenderness: Its presence suggests pyelonephritis . It is elicited by punching the back of both iliac fossae. Fluid thrill: Ask the patient to put his hand on midline of the abdomen and then put the palm of your hand on one side of the abdomen while tapping the opposite side. The palm will feel for tapping waves

30. Ballottement: It is performed when there is gross ascites to elicit the presence of organomegaly or other masses . It is done by suddenly pushing-in and suddenly release of the fingers without removing them and feeling for floating organs or mass of which will hit your examining hand from below

31. McBurney’s test: It is done on patient suspected to have appendicitis . It is elicited by deeply palpating the McBurney’s point THAT’S two third of the distance measured along the line joining the anterior superior iliac spine to the umbilicus. A positive test is indicated by the presence of tenderness on this point

32. Rovsing’s test : It is done in patients suspected to have appendicitis . It is elicited by deeply palpating the left flank/lumbar area. In cases of a positive Rovsing’s test, tenderness will be felt on the right flank/lumbar area. Murphy’s test : It is done in patients suspected to have acute cholecystitis . It is elicited by popping fingers in the right hypochondrial area along the 9 th intercostal space whiles the patient taking deep breath. In cases of positive test a patient will stop inspiring and wince in pain. Murphy’s sign is negative in chronic cholecystitis.

33. Hernial orifices: Examine for hernia and lymphadenopathy. How to distinguish between an indirect and a direct inguinal hernia: It is done by observing the direction of expansile impulse induced by asking the patient to cough. An indirect hernia passes through the internal inguinal ring and then if large enough, passes obliquely through the inguinal canal and through the external inguinal ring into the scrotum. The expansile impulse will therefore follow this route.

34. A direct inguinal hernia, however, protrudes directly forwards through the posterior wall of the inguinal canal medial to the internal ring and only very rarely, pushes its way through the external inguinal ring into the scrotum. The expansile impulse therefore is generally directly forwards. If indirect hernia is reducible, it can be controlled by placing a finger tip over the internal inguinal ring, about ½ inches (12 cm) above the femoral pulse which can be palpated at the mid-inguinal point. A direct hernia will not be controlled by pressure over the internal ring

35. How to distinguish between an indirect and a femoral hernia: An indirect inguinal hernia which protrudes through the external inguinal ring can be palpated above and medial to the pubic tubercle, whilst a femoral hernia lies below and lateral to this bony landmark .

36. Genitalia: How to distinguish between hydrocele and scrotal hernia: A cough impulse can be felt in cases of scrotal hernia while in hydrocele cough impulse cannot be felt. Transillumination test is positive in hydrocele and negative in scrotal hernia. It is elicited by directing the light of a torch through scrotal swelling and watching for the light on the opposite side.

37. PERCUSSION Liver enlargement: Not every palpable liver on abdominal examination is enlarged, the liver may be palpable because is been pushed by emphysematous lung . To be certain that the palpable liver is enlarged do the following.

38. How to do it: Percuss for the cephalad (upper) border of the liver, usually on the 5 th intercostal space along the mid-clavicular line. In cases of liver enlargement the upper border of the liver shifts upwards to 4 th , 3 rd , 2 nd intercostal spaces etc. but if the upper border of the liver shifts downwards to 6 th , 7 th , 8 th intercostal spaces etc mean the liver has been displaced downwards.

39. Measure liver span : This is done by measuring the length of the liver from the upper to lower margins of the liver. The normal liver span in adults is 12-15 cm and therefore in cases of liver enlargement the liver span is > 15 cm.

40. Shifting dullness Let the patient lie supine with his upper limbs on the sides. Percuss from the midline to one side of the abdomen till when you get dullness, leave the finger at the site of dullness and turn the patient to the opposite side of the percussion. Wait for some minutes for the fluid to move downwards. Percuss again at the same site of previous dullness. If there is fluid, the same site which was dull previously will become resonant For massive ascites do FLUID THRILLS

41. Enlarged urinary bladder Percuss along the midline from the epigastrium to the suprapubic area. If the urinary bladder is full of urine, the percussion note will change from resonant to dullness as soon as you reach the upper border of the urinary bladder. Measure the fundal height as in obstetrics in weeks of gestation.

42. Differential diagnoses of enlarged urinary bladder Ovarian cyst. Uterine fibroid. Gravid uterus: Firmer, mobile side to side with signs of pregnancy.

43. Differentiation of gross ascites from ovarian cyst and intestinal obstruction: Gross ascites, large ovarian cyst and intestinal obstruction are common causes of diffuse enlargement of the abdomen. Percussion rapidly distinguishes among these three: Gross ascites : Dull in flanks. Fluid thrill positive. Shifting dullness positive. Umbilicus stretched or transverse and/or hernia present.

44. Large ovarian cyst: Resonant in frank. Umbilicus vertically drawn-up. Large swelling felt arising out of pelvis which one cannot ‘get below’

45. Intestinal obstruction : Vomiting. Constipation. Colicky pain. Resonance throughout. Increased and/or ‘noisy’ bowel sounds

46. Ascultation Splenic rubs. Hepatic bruits. Bowel sounds. Vascular bruits. Succussion splash.

47. Bowel sounds The stethoscope should be placed on one side on the abdominal wall (just to the right of the umbilicus is best) and kept there until sounds are heard. Normal bowel sounds : Occurs intermittently in every 20 seconds, they are low- to medium-pitched gurgles interspersed with an occasional high-pitched noise or tinkle.

48. Abnormal bowel sounds: Frequently loud, low-pitched gurgling sounds (borborygmi): Suggests increased motility as in patients with diarrhoea . Bowel sounds occurring in excessive and exaggeration, increased intensity (high pitched), metallic in character and tinkling quality: Suggests intestinal obstruction. Absent bowel sounds: Suggests peritonitis or paraltic ileus.

49. Succussion splash It is done on patient suspected to have gastric outlet obstruction or pyloric stenosis. It is elicited by rocking the patient from side to side while listening onto the epigastrium with the ear or stethoscope. A positive succussion splash is heard as little water in big pot. It is only regarded as positive if present 2-3 hours after meal and suggests gastric outlet obstruction.

50. Vascular bruits: The presence of bruits on the flanks suggests renal artery stenosis. Hepatic bruits: The presence of bruits on the liver may occur in patients with hepatocellular carcinoma, hepatic metastases and tricuspid regurgitation. Splenic rubs: The presence of bruits on the over the spleen suggests splenic infarction.

51. Rectal examination The left lateral position is best for routine examination of the rectum (Fig. 12.29). Make sure that the buttocks project over the side of the couch with the knees drawn well up, and that a good light is available. Put on disposable gloves and stand behind the patient’s back, facing the patient’s feet.

52. On inspection around perianal area Look for signs of inflammation that vary from mild erythema to raw,red moist weeping dermatitis and in chronic cases thickened white skin with exaggerating of anal skin folds Any dimple or hole near the anus with tell-tale bead of pus or granulation tissue surrounding it which represents external opening of fistula in- ano Anal fissures Perianal hematoma Swelling Ulceration

53. I f rectal prolapse is suspected, ask the patient to bear down (as if trying to pass stool) and note whether any pink rectal mucosa or bowel appears through the anus, or whether the perineum itself bulges downwards. Downward bulging of the perineum during straining at bending down, or in response to a sudden cough, indicates weakness of the pelvic floor support musculature, usually due to denervation of these muscles.

54. Put a generous amount of lubricant on the gloved index finger of the right hand, place the pulp of the finger (not the tip) flat on the anus and press firmly and slowly (flexing the finger) in a slightly backwards direction. After initial resistance, the anal sphincter relaxes and the finger can be passed into the anal canal. If severe pain is elicited when attempting this manoeuvre , then further examination should be abandoned as it is likely the patient has a fissure and the rest of the examination will be very painful and unhelpful.

55. Feel for any thickening or irregularity of the wall of the canal, making sure that the finger is turned through a full circle (180° each way). Assess the tone of the anal musculature; it should normally grip the finger firmly.

56. Now pass the finger into the rectum. Try to visualize the anatomy of the rectum, particularly in relation to its anterior wall. The rectal wall should be assessed with sweeping movements of the finger through 360°, inwards or until the finger cannot be pushed any higher into the rectum. Repeat these movements as the finger is being withdrawn. In this way it is possible to detect malignant ulcers, proliferative and stenosing carcinomas, polyps and villous adenomas.

57. The hollow of the sacrum and coccyx can be felt posteriorly. Laterally , on either side, it is usually possible to reach the side walls of the pelvis. In men, one should feel anteriorly for the rectovesical pouch, seminal vesicles (normally not palpable) and the prostate. In a patient with a pelvic abscess, pus gravitates to this pouch, which is then palpable as a boggy, tender swelling lying above the prostate. Malignant deposits will feel hard and, in infection of the seminal vesicles, these structures become palpable as firm, almost tubular swellings deviating slightly from the midline just above the level of the prostate.

58. Assessment of the prostate gland is important. It forms a rubbery, firm swelling about the size of a large nut. Run the finger over each lateral lobe, which should be smooth and regular. Between the two lobes lies the median sulcus, which is palpable as a faint depression running vertically between each lateral lobe. While it is possible to say on rectal examination that a prostate is enlarged, In carcinoma of the prostate, the gland loses its rubbery consistency and becomes hard, while the lateral lobes tend to be irregular and nodular and there is distortion or loss of the median sulcus.

59. The cervix is felt as a firm, rounded mass projecting back into the anterior wall of the rectum. The body of a retroverted uterus, fibroid mass, ovarian cyst, malignant nodule or a pelvic abscess may all be palpated in the pouch of Douglas ( rectouterine pouch), which lies above the cervix. On withdrawing the finger after rectal examination, look at it for evidence of mucus, pus and blood. Finally , make sure to wipe the patient clean.

60. References: Essentials of clinical examination. Page 59-77. Hutchison R. Physical examination. Hutchison’s clinical methods. 21 st edition. Page 134-151. Rabinowitz S.S. Abdominal examination. www.emedicine.medscape.com last updated: October 20, 2011. -END-