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examination of abdomen.pptx

  2. ABDOMINAL REGIONS • Divided into 9 regions • 4 dividing lines : 1. midclavicular – 2 lines 2. subcostal – upper horizontal 3.trans tubercular – lower horizontal
  3. INSPECTION • Pt should be relaxed ,hips and knees may be flexed to relax abdominal muscles. • Abdomen should be exposed [from xiphisternum to the suprapubic area- inguinal and genital areas are covered until they are to be examined] • Examiner should have warm hands
  4. 1. Skin and subcutaneous tissue: [a]Look for any visible swelling or erythema [b].dilated veins[c].Subcutaneous nodules near umbilicus [d] position of umbilicus.[e] skin discoloration eg: left flank – grey turner sign , around umbilicus – cullens sign , both seen in acute hemorrhagic pancreatitis. 2. Hernial orifices 3. Contour of abdomen : distension of abdomen varies in each condition , small bowel obstruction- central , large bowel obstruction- peripheral distension, but in biliary colic, a/c cholecystitis, a/c appendicitis,renal colic- contour remains normal. 4. Respiratory movements- sluggish in diffuse peritonitis or hemorrhage into peritoneal cavity.localized irritation of peritoneum causes localized limitation of respiration.
  5. 5. Peristalsis – visible peristalsis in pyloric stenosis [ left to right ] and small and large bowel obstruction[right to left in transverse colonic obstruction] 6. Pulsatile swelling in case of aortic aneurysm.
  6. PALPATION • Pt should lie flat on his back , relaxed and ask to breathe deeply with mouth open. • Always start away from the site of pain. Palpate systematically all abdominal regions , look at the face of patient for signs of discomfort. • Superficial palpation- using light pressure , assess for tone , tenderness and any obvious abnormalities.
  7. Assessing muscle tone with superficial palpation • Gentle pressure on abdominal wall should allow the examiner to depress the anterior abdominal wall as the muscles relax. • Contraction of muscles underlying the hand as pressure is applied – guarding. , indicates underlying inflammation. • A rigid abdominal wall resisting any attempt to push back the abdominal wall and not ,moving with respiration –rigidity , indicates peritoneal inflammation. • A marked , acute exacerbation of pain on sudden release of pressure applied to abdominal wall –rebound.
  8. Palpation of abdominal organs • LIVER – lies predominantly under the ribs , on right side , although it does cross the midline. • Lowermost edge lies approximately parallel to costal margin. • Liver moves inferiorly on inspiration , enlargement also occurs in an inferior direction , hence palpation of liver should commence well away from costal margin in the RIF. • Hand is positioned so that the lateral margin of index finger is parallel with costal margin.
  9. • Pt asked to take deep breath in and pressure applied to abdominal wall. • If liver is not palpated , examiners hand is moved closer to costal margin by about 1cm , process is repeated , until liver edge is palpated or costal margin is reached . • An enlarged liver may be palpated distal to the costal margin , the distance is measured in cms from the costal margin
  10. • SPLEEN – lies entirely under the ribs on the left side • Long axis of spleen lies along the line of the 10th rib. • Spleen moves inferomedially on inspiration , enlargement also occurs in same direction • Even on deep inspiration , normal spleen cannot be felt on palpation. • To be palpable , spleen must be enlarged to atleast twice normal size. • A massive spleen may extend into the right lower abdomen.
  11. • Palpation should commence well away from the costal margin in RIF. • Hand is positioned so that the lateral margin of index finger is parallel with the left costal margin • Pt is asked to take a deep breath in and pressure applied by the examiners hand to the abdominal wall . • If the spleen is not palpated the examining hand is moved closer to the costal margin by about 1-2 cm • Process is repeated until spleen is palpated or the costal margin is reached • Distance is measured in cm from the costal margin
  12. • Palpation for spleen can be facilitated by placing the left hand under and behind the lower left rib and applying traction in an inferomedial direction
  13. • KIDNEY- not normally palpable unless the patient is thin • Right kidney is lower than left due to position of the liver • They move downwards towards the end of respiration • Retroperitoneal organ- deep bimanual palpation is required. • To examine , position the patient close to edge of the bed, tuck the palmar surfaces of one hand into patient’s flank , nestle the finger tips in the renal angle.
  14. • Bimanual examination of kidney- one hand under the patients flank, fingers in the renal angle, other hand with fingers flat placed below the costal margin later
  15. • Palpate the lower pole of the kidney between the fingers of both hands. • Ask the pt to breath deeply and press the fingers of both hands firmly together. • The rounded lower pole of the kidney may be felt passing between the opposing fingers as the patient breathes in and out.
  16. PERCUSSION • Light percussion – to elicit tenderness • General abdomen : should be resonant • Organs : liver –dull spleen – dull kidneys- resonant bladder- dull.
  17. • 1. shifting dullness : to determine presence of free fluid in the peritoneal cavity. Pt lies on his back –fluid gravitates down to flanks, intestine floats on the centre ,therefore resonant and flanks dull • Start from the centre and carried down to one the point where dullness starts the finger is kept in position and pt is asked to turn to opp. Side .this area is again percussed after few minutes to allow the fluid to settle down,. Now the note will be resonant— shifting dullness positive. • False positive shifting dullness in : abnormal retention of enema, leading to distension of intestine
  18. • 2. fluid thrill : large amount of fluid • Gentle tap on one flank of the abdomen, thrill is felt with the other hand placed on the other flank., asst’s hand placed vertically in the midline, pressing deeply. • Also obtained in case of encysted fluid like large ovarian cyst.
  19. • 3 .Obliteration of liver dullness :right midaxillary line is percussed from above downwards. At upper border of liver –dull note. • liver dullness replaced by resonant note ---indicates free gas under diaphragm.
  20. AUSCULTATION • BOWEL SOUNDS: produced due to normal peristaltic activity of small bowel causing movement of its contents. • Part of steth to be used : bell of stethoscope • Site of auscultation : one site until the bowel sounds are heard is sufficient –right to umbilicus , close to ileoceacal jn.
  21. • Minimum amount of time to auscultate before concluding that no bowel sounds are heard : 30secs { 2 min in macleod} • Normal frequency : 2 -4 / minute . • Sequence: auscultate before palpation because palpation can stimulate peristalsis.
  22. • Silent abdomen – absent bowel sounds , seen in generalized peritonitis . • Aortic and iliac bruits – heard in vessel stenosis. • Succussion splash – sound like ‘shaking a half filled bottle with water’ . Heard in gastric stasis , due to gastric outlet obstruction.