abdominal examination
TRANSCRIPT
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ABDOMINAL EXAMINATION
PRESENTED BY:- DR SHASHANK AGRAWAL
MODERATOR :- DR A.B.MOWAR SIR
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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
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PAST HISTORY
Tuberculosis malaria Kala azar Leukemia Hemolytic crisis Sexual contact Bleeding disorder H/O Blood transfusion Surgery Jaundice
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GENERAL INSPECTION• Nutritional state (wasting) BMI• Pallor• Jaundice (liver disease)• Pigmentation (hemochromatosis)• Mental state (encephalopathy)
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hands
• Nails– Clubbing– Koilonychia– Leuconychia
• Palmar erythema• Dupuytren’s contractures• Hepatic flap
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HANDS
Palmar erythema Dupuytren’s contractures
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ARMS• Spider naevi (telangiectatic lesions)• Bruising• Scratch marks (chronic cholestasis)
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FACE, EYES …• Conjuctival pallor • Sclera: jaundice• Cornea: Kaiser Fleischer’s rings (Wilson’s disease)• Xanthelasma (primary biliary cirrhosis)• Parotid enlargement (alcohol)
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Parotid enlargement
Xanthelasma
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… AND MOUTH• Fetor Hepaticus• Lips
– Angular stomatitis– Cheilitis– Ulceration
• Gums– Gingivitis, bleeding– Candida albicans– Pigmentation
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Atrophic glossitis Thrush
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NECK AND CHEST• Cervical lymphadenopathy• Left supraclavicular fossa (Virchow’s node)• Gynaecomastia• Loss of hair
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POSITIONING• Abdomen can be divided in four quadrants• Patient should be lying on supine position
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REGIONAL DIVISION OF ABDOMEN
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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
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LEFT UPPER QUADRANT
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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
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RIGHT LOWER QUADRANTCecumVermiform appendix Most of ileumAscending colon: inferior
partRight ovaryRight uterine tubeRight spermatic cordUterus (if enlarged)Urinary bladder (if full)
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LEFT LOWER QUADRANT
Sigmoid colonDescending colon:
inferior partLeft ovaryLeft uterine tubeLeft ureter: abdominal
partLeft spermatic cord:
abdominal partUterus (if enlarged)Urinary bladder (if full)
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BEFORE EXAMINATION
Ensure that bladder is emptyPatient comfortArms at side or crossed over chestAsk the patient to point to any painful areas; examine
lastWarm hands and stethoscope
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INSPECTION
• Shape and movements• Scars• Distension• Prominent veins • Striae• Bruises• Pigmentation• Visible peristalsis - pyloric stenosis- left to right large intestine obstruction- left to right
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normal pregnancy ascites fatty abdomen
SHAPE
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SCARS
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ABDOMINAL MOVEMENT
• Normal:– Male : Abdomino-thoracic – Female : Thoraco-abdominal– Infant : Thoraco- abdominal
• Disease : – Diaphragmatic palsy : bulging during
expiration– Peritonitis : no movement
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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
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DILATED VEIN
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HERNIAL SITES
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PALPATION
1. Ensure that your hands are warm
2. Stand on the patient’s right side
3. Help to position the patient
4. Ask whether the patient feels any pain before you start
5. Begin with superficial examination
6. Move in a systematic manner through the abdominal quadrants
7. Repeat palpation deeply.
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PALPATION
• Characteristics of an abdominal mass1. location2. size3. shape4. consistency5. surface6. tenderness7. movable or fixed8. shifting by respiration
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LIGHT PALPATION
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DEEP PALPATION
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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
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• Pain in RUQ
• Inflammation of gallbladder (cholecystitis)
MURPHY’S SIGN
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• 1/3 ASIS to umbilicus• Location of AV in retrocecal position• Deep tenderness (= acute appendicitis)
MCBURNEY’S POINT
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rebound tenderness• Pain upon removal of pressure rather than application of
pressure to the abdomen • Peritonitis and/ or appendicitis
BLUMBERG’S SIGN
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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
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Puddle sign
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PALPATION OF THE LIVER1. Flex the knee joint
2. Ask the patient to take a deep breath in
3. Start palpating in the right iliac fossa
4. Move hand progressively further up the abdomen
5. Try to feel the liver edge
6. Check for tha liver span.
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PALPATION OF THE SPLEEN1. Roll the patient towards you
2. Start from right illiac fossa
3. Palpate with right hand while using left hand to press forward on the patient’s lower ribs from behind
4. Feel along the costal margin
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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
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BIMANUAL PALPATION
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PERCUSSION• Dull sounds: solid or fluid-filled structures
• Resonant sounds: structures containing air or gas
• Shifting dullness
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SHIFTING DULLNESS
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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
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OTHER EXAMINATION
EXAMINATION OF HERNIA
PER RECTAL EXAMINATION INSPECTION PALPATION
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FEW DIFFERENCE
• ASCITES MYSENTRIC CYST
• SPLEEN LUMP KIDNEY LUMP
• ASCITES OVARIAN CYST
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THANK YOU