abdominal examination

ABDOMINAL EXAMINATION

PRESENTED BY:- DR SHASHANK AGRAWAL

MODERATOR :- DR A.B.MOWAR SIR

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

PAST HISTORY

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

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

hands

• Nails– Clubbing– Koilonychia– Leuconychia

• Palmar erythema• Dupuytren’s contractures• Hepatic flap

HANDS

Palmar erythema Dupuytren’s contractures

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

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

Parotid enlargement

Xanthelasma

… AND MOUTH• Fetor Hepaticus• Lips

– Angular stomatitis– Cheilitis– Ulceration

• Gums– Gingivitis, bleeding– Candida albicans– Pigmentation

Atrophic glossitis Thrush

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

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

REGIONAL DIVISION OF ABDOMEN

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

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

normal pregnancy ascites fatty abdomen

SHAPE

SCARS

ABDOMINAL MOVEMENT

• Normal:– Male : Abdomino-thoracic – Female : Thoraco-abdominal– Infant : Thoraco- abdominal

• Disease : – Diaphragmatic palsy : bulging during

expiration– Peritonitis : no movement

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

DILATED VEIN

HERNIAL SITES

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.

PALPATION

• Characteristics of an abdominal mass1. location2. size3. shape4. consistency5. surface6. tenderness7. movable or fixed8. shifting by respiration

LIGHT PALPATION

DEEP PALPATION

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

• Pain in RUQ

• Inflammation of gallbladder (cholecystitis)

MURPHY’S SIGN

• 1/3 ASIS to umbilicus• Location of AV in retrocecal position• Deep tenderness (= acute appendicitis)

MCBURNEY’S POINT

rebound tenderness• Pain upon removal of pressure rather than application of

pressure to the abdomen • Peritonitis and/ or appendicitis

BLUMBERG’S SIGN

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

Puddle sign

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.

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

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

BIMANUAL PALPATION

PERCUSSION• Dull sounds: solid or fluid-filled structures

• Resonant sounds: structures containing air or gas

• Shifting dullness

SHIFTING DULLNESS

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

OTHER EXAMINATION

EXAMINATION OF HERNIA

PER RECTAL EXAMINATION INSPECTION PALPATION

FEW DIFFERENCE

• ASCITES MYSENTRIC CYST

• SPLEEN LUMP KIDNEY LUMP

• ASCITES OVARIAN CYST

THANK YOU