abdominal examination

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

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Page 1: Abdominal examination

ABDOMINAL EXAMINATION

PRESENTED BY:- DR SHASHANK AGRAWAL

MODERATOR :- DR A.B.MOWAR SIR

Page 2: Abdominal examination

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

Page 4: Abdominal examination

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

Page 5: Abdominal examination

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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Page 17: Abdominal examination

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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Page 18: Abdominal examination

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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Page 19: Abdominal examination

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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Page 20: Abdominal examination

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

Page 24: Abdominal examination

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

Page 35: Abdominal examination

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

Page 36: Abdominal examination

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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Page 39: Abdominal examination

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

Page 40: Abdominal examination

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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Page 42: Abdominal examination

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

Page 46: Abdominal examination

OTHER EXAMINATION

EXAMINATION OF HERNIA

PER RECTAL EXAMINATION INSPECTION PALPATION

Page 47: Abdominal examination

FEW DIFFERENCE

• ASCITES MYSENTRIC CYST

• SPLEEN LUMP KIDNEY LUMP

• ASCITES OVARIAN CYST

Page 48: Abdominal examination

THANK YOU