Local abdominal examination

Local abdominal examination

1. Local abdominal examination

2. Local Examination framework

3. POSITIONING&EXPOSURE Patient lying flat Arms lying at sides Abdomen exposed from xiphoid to symphysis Doctor placed on the right side of the Patient

4. Detailed abdominal inspection

5. Scars – RIF (appendectomy) / right subcostal (cholecystectomy) Masses  –  organomegaly / malignancy Cullen’s sign –   bruising surrounding umbilicus –  (e.g. pancreatitis) Grey-Turner’s sign  – bruising in the flanks –  (e.g. pancreatitis) Abdominal distension –   f luid (ascites) /  f at (obesity) /  f aces (constipation) /  f latus /  f etus (pregnancy) Striae –  reddish/pink (new) or white (chronic) – abdominal distension  Umbilicus- site, shape and discharges

6. Abdominal mass Abdominal distention

7. Reddish / pink (new)  White  (chronic) Striae

8. Cullen's and Grey Turner's signs

9. Auscultation Before palpation & percussion! Auscultate 4 quadrants for 15 seconds for bowel sounds if you cannot hear any sound in the first area that you auscultate

10. Bowel sounds Normal –  gurgling Absent  – ileus / peritonitis Bruits: These are sounds produced by the turbulent fl ow of blood through a vessel Aortic bruits –  auscultate just above the umbilicus –   AAA Renal  bruits –  auscultate just above the umbilicus, slightly lateral to the midline

11. Palpation

12. General approach The patient should be positioned lying supine with the head supported by a single pillow and arms at their sides. Each of the four quadrants should be examined in turn with light and then by deep palpation before focusing on specific organs. The order in which they are examined doesn’t matter —find a routine that suits you. Ask the patient if there is any area of tenderness, and remember to examine this part last. Before you begin, ask the patient to let you know if you cause any discomfort. You should be able to examine the abdomen without looking at it closely. You should watch the patient’s face for signs of pain .

13. Light palpation Use the fingertips and palmar aspects of the fingers . Lay your right hand on the patient’s abdomen and gently press in by flexing at the metacarpophalangeal joints. If there is pain on light palpation, attempt to determine whether the pain is worse when you press down or when you release the pressure ( rebound tenderness ). If the abdominal muscles seem tense , Ensure that the patient is relaxed—it may be helpful for the patient to bend their knees slightly, relaxing the abdominal muscles. An involuntary tension in the abdominal muscles, apparently protecting the underlying organs, is called guarding

14. Light palpation Palpate each of the 9 abdominal regions, assessing for any of the below. Tenderness –  note the areas involved and the severity of the pain Rebound tenderness  – pain is worsened on releasing the pressure – peritonitis Guarding –  involuntary tension in the abdominal muscles    Masses –  large/superficial masses may be noted on light palpation

15. Deep palpation Assess each of the 9 regions again, but with greater pressure applied during palpation. If any masses are identified then assess: C C S S S L M N O P

16. DEEP PAPATION LIGHT PALPATION

17. MC BURNEY’S POINT ( appendicitis )

18. Liver 1. Begin palpation in the right iliac fossa using the flat edge of your hand (radial side of your right index finger) 2. Press your hand into the abdomen as you ask the patient to take a deep breath 3. Feel for a step, as the liver edge passes below your hand 4. The normal liver extends from the 5th intercostal space on the right of the midline to the costal margin, hiding under the ribs so is often not normally palpable

19. Gallbladder The gallbladder is not usually palpable. An enlarged gallbladder suggests obstruction to biliary flow/infection  (cholecystitis). Perform palpation at the right costal margin, mid-clavicular line  (9th rib tip). If enlarged, a rounded mass moving with respiration may be palpated  (note any tenderness).

20. Murphy’s sign Place your hand in the right costal margin, at the tip of the 9th rib mid-clavicular line Ask the patient to take a deep breath As the gallbladder is pushed down into your hand the patient may suddenly develop pain and stop inspiring. If this occurs and there is no discomfort in the same location on the left side of the abdomen then this is known as a positive Murphy’s sign, which is suggestive of cholecystitis

21. Spleen The spleen only becomes palpable when it’s at least three times its normal size! 1.    Start in right iliac fossa  – massive splenomegaly can extend this far! 2.   Align your fingers in the same direction as the left costal margin 3. Press your right hand into the abdomen as you ask the patient to take a deep breath 4. Feel for a step, as the splenic edge passes under your hand  (a notch may be noted) 5. If you don’t feel anything, repeat process with your hand 1-2 cm closer to the left hypochondrium

22. Kidneys 1. Place your left hand behind the patient’s back, at the right flank 2. Place your right hand just below the right costal margin in the right flank 3. Press your right hand’s fingers deep into the abdomen 4. At the same time press upwards with your left hand 5. Ask the patient to take a deep breath 6. You may feel the lower pole of the kidney moving inferiorly during inspiration  7. Repeat this process on the opposite side to assess the left kidney

23. Percussion

24. Abdominal organs Liver :   percuss up from RIF then down from right side of chest to determine the size of the liver (liver span)

25. Spleen percuss up from RIF moving towards the left hypochondrium to assess for splenomegaly

26. Shifting dullness for ascites 1.  Percuss from the center of the abdomen to the flank until dullness is noted 2.  Keep your finger on the spot at which the percussion note became dull 3.  Ask patient to roll onto the opposite side to which you have detected the dullness 4.  Keep the patient on their side for 30 seconds 5.  Repeat your percussion in the same spot 6.  If fluid was present ( ascites)  then the area that was previously dull should now be resonant 7.  If the flank is now resonant, percuss back to the midline, which if ascites is present, will now be dull ( i.e. the dullness has shifted)

27. Shifting dullness