Abdominal examination

summary of abdominal examination

1. ABDOMINAL EXAMINATION PRESENTED BY:- DR SHASHANK AGRAWAL MODERATOR :- DR A.B.MOWAR SIR

2. COMMON COMPLAINTS Anorexia Nausea vomiting Dysphagia flatulance Retrosternal Burning Diarrhoea Constipation Clay colour stool Worms/mucous in stool Black tarry stool Abdominal pain/ lump Abdominal distension Hematemesis Melena Epistaxis Bleeding per rectum

3. PAST HISTORY Tuberculosis malaria Kala azar Leukemia Hemolytic crisis Sexual contact Bleeding disorder H/O Blood transfusion Surgery Jaundice

4. GENERAL INSPECTION Nutritional state (wasting ) BMI Pallor Jaundice (liver disease) Pigmentation ( hemochromatosis ) Mental state (encephalopathy)

5. hands Nails Clubbing Koilonychia Leuconychia Palmar erythema Dupuytren’s contractures Hepatic flap

6. HANDS Palmar erythema Dupuytren’s contractures

7. ARMS Spider naevi ( telangiectatic lesions) Bruising Scratch marks (chronic cholestasis )

8. FACE, EYES … Conjuctival pallor Sclera: jaundice Cornea: Kaiser Fleischer’s rings (Wilson’s disease) Xanthelasma (primary biliary cirrhosis) Parotid enlargement (alcohol)

9. Parotid enlargement Xanthelasma

10. … AND MOUTH Fetor H epaticus Lips Angular stomatitis Cheilitis Ulceration Gums Gingivitis, bleeding Candida albicans Pigmentation

11. Atrophic glossitis Thrush

12. NECK AND CHEST Cervical lymphadenopathy Left supraclavicular fossa ( Virchow’s node) Gynaecomastia Loss of hair

13. POSITIONING Abdomen can be divided in four quadrants Patient should be lying on supine position

14. REGIONAL DIVISION OF ABDOMEN

15. Liver: left lobe Spleen Stomach Jejunum and proximal ileum Pancreas: body and tail Left Kidney Left Suprarenal gland Left colic ( splenic ) flexure Transverse colon: left half Descending colon: superior part 15 LEFT UPPER QUADRANT

16. RIGHT UPPER QUADRANT Liver: right lobe Gallbladder – Murphy’s sign Stomach: pylorus Duodenum: parts 1-3 Pancreas: head Right suprarenal gland Right kidney Right colic (hepatic) flexure Ascending colon: superior part Transverse colon: right half 16

17. RIGHT LOWER QUADRANT Cecum Vermiform appendix Most of ileum Ascending colon: inferior part Right ovary Right uterine tube Right spermatic cord Uterus (if enlarged) Urinary bladder (if full) 17

18. LEFT LOWER QUADRANT Sigmoid colon Descending colon: inferior part Left ovary Left uterine tube Left ureter : abdominal part Left spermatic cord: abdominal part Uterus (if enlarged) Urinary bladder (if full) 18

19. BEFORE EXAMINATION Ensure that bladder is empty Patient comfort Arms at side or crossed over chest Ask the patient to point to any painful areas; examine last Warm hands and stethoscope 19

20. INSPECTION Shape and movements Scars Distension Prominent veins Striae Bruises Pigmentation Visible peristalsis - pyloric stenosis - left to right large intestine obstruction- left to right

21. normal pregnancy ascites fatty abdomen SHAPE

22. SCARS

23. ABDOMINAL MOVEMENT Normal: Male : Abdomino -thoracic Female : Thoraco -abdominal Infant : Thoraco - abdominal Disease : Diaphragmatic palsy : bulging during expiration Peritonitis : no movement

24. ABDOMINAL PULSATION Aortic pulsation- visible in nervous, anemia Aortic aneurysm- expansile pulsation in any position Transmitted pulsation- any mass lying over major artery produce pulsation. On making puddle sign it will disappear. Rt ventricular pulsation seen in epigastric region Congestive liver produce pulsation posteriorly

25. DILATED VEIN

26. HERNIAL SITES

27. PALPATION Ensure that your hands are warm Stand on the patient’s right side Help to position the patient Ask whether the patient feels any pain before you start Begin with superficial examination Move in a systematic manner through the abdominal quadrants Repeat palpation deeply.

28. PALPATION Characteristics of an abdominal mass 1. location 2. size 3. shape 4. consistency 5. surface 6. tenderness 7. movable or fixed 8. shifting by respiration

29. LIGHT PALPATION

30. DEEP PALPATION

31. PALPATION Tenderness : discomfort and resistance to palpation Involuntary guarding: reflex contraction of the abdominal muscles Rebound tenderness : patient feels pain when the hand is released Tenderness + rigidity : perforated viscus Palpable mass (enlarged organ, faeces, tumour) Aortic pulsation

32. Pain in RUQ Inflammation of gallbladder ( cholecystitis ) MURPHY’S SIGN

33. 1/3 ASIS to umbilicus Location of AV in retrocecal position Deep tenderness ( = acute appendicitis) MCBURNEY’S POINT

34. rebound tenderness Pain upon removal of pressure rather than application of pressure to the abdomen Peritonitis and/ or appendicitis BLUMBERG’S SIGN

35. FLUID THRILL Place the palm of your left hand against the left side of the abdomen Flick a finger against the right side of the abdomen Ask the patient to put the edge of a hand on the midline of the abdomen If a ripple is felt upon flicking we call it a fluid thrill = ascites

36. Puddle sign

37. PALPATION OF THE LIVER Flex the knee joint Ask the patient to take a deep breath in Start palpating in the right iliac fossa Move hand progressively further up the abdomen Try to feel the liver edge Check for tha liver span.

38. PALPATION OF THE SPLEEN Roll the patient towards you Start from right illiac fossa Palpate with right hand while using left hand to press forward on the patient’s lower ribs from behind Feel along the costal margin

39. SPLEENOMEGALY Traube's Space boundaries -Left anterior axillary line, 6th rib, costal margin Castell’s - resonating traube’s area Nixon’s method - dullness extends >8 cm

40. BIMANUAL PALPATION

41. PERCUSSION Dull sounds : solid or fluid-filled structures Resonant sounds : structures containing air or gas Shifting dullness

42. SHIFTING DULLNESS

43. AUSCULTATION Place the diaphragm of the stethoscope to the right of the umbilicus Bowel sounds (borborygmi) are caused by peristaltic movements Occur every 5-10 sec. Absence of b.s.: paralytic ileus or peritonitis Bruits over aorta and renal a. could be a sign of an aneurysm and stenosis

44. OTHER EXAMINATION EXAMINATION OF HERNIA PER RECTAL EXAMINATION INSPECTION PALPATION

45. FEW DIFFERENCE ASCITES MYSENTRIC CYST SPLEEN LUMP KIDNEY LUMP ASCITES OVARIAN CYST

46. THANK YOU