abdominal examination
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Structured examination of the gastro intestinal system.
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abdominal examination
- 1. Abdominal Examination Jonathan Downham Advanced Nurse Practitioner 2008 Jonathan Downham 2010
- 2. Abdominal Examination •Gastrointestinal •Weight loss •Nausea, vomiting •Dysphagia •Regurgitation, flatulance, heartburn •Abdominal pain •Stool frequency Jonathan Downham 2010
- 3. Abdominal Examination Jonathan Downham 2010
- 4. Abdominal Examination Jonathan Downham 2010
- 5. Clinical History Taking- Review of systems. • Gastrointestinal – Surgery – Weight loss – Medications – Nausea, vomiting – Last Period – Dysphagia – Family History – Regurgitation, flatulan – Alcohol ce, heartburn – Diet – Abdominal pain – Stress – Stool frequency Jonathan Downham 2010
- 6. Abdominal Examination Patient Position •Good lighting •Undressed nipple to knees •Modesty blanket •Flat on couch with single pillow for head •Arms by their sides •If unable to fully relax abdomen than flex hips to 45 degrees and knees to 90 degrees. Jonathan Downham 2010
- 7. Abdominal Examination General Inspection •Pain, distress, cachexia, pallor or jaundice. •Hands •Metabolic flap- hepatic encephalopathy, carbon dioxide retention or ureamia •Aneamia •Eyes •Face •Abnormal pigmentation around lips •Angular stomatitis •Oral cavity Jonathan Downham 2010
- 8. Abdominal Examination Jonathan Downham 2010
- 9. Abdominal Examination Inspection. •Symmetry •Abdominal pulsation •Shape •The five F’s •Scars •Sinuses •Fistulas e.g. crohns •Visible peristalsis due to intestinal obstruction •Distended veins Jonathan Downham 2010
- 10. Abdominal Examination Auscultation •May be best to do this before palpating. •Listen specifically for bowel sounds •Place stethoscope to right of umbilicus and do not move it. •Normal sounds occur every 5-10 seconds •Listen above umbilicus over aorta for bruits •Place stethoscope 2-3cm above and lateral to umbilicus and listen for renal artery bruits. Jonathan Downham 2010
- 11. Abdominal Examination Percussion •Percuss over whole abdomen •Pay attention to any masses you may have detected. •If ascites is suspected test for shifting dullness •Orientate your hands correctly Jonathan Downham 2010
- 12. Abdominal Examination Palpation Ask the patient where the pain is. Warn the patient you are about to put your hand on them. Light palpation Deep palpation Specific palpation of the intra-abdominal organs Jonathan Downham 2010
- 13. Abdominal Examination Light Palpation •Commence palpation at a site remote from any area of discomfort. •All areas must be palpated systematically •Use the nine quadrants as a guide. •Is performed to elicit any tenderness or guarding •Lie hands and fingers flat •Press very gently. Deep Palpation Jonathan Downham 2010
- 14. Abdominal Examination Jonathan Downham 2010
- 15. Abdominal Examination Palpation of intra abdominal organs. Liver •Start with hand at right iliac fossa, fingers pointing to head •Palpate deeply whilst patient breathes in and out deeply •If nothing is felt repeat the process moving the hand up slightly. •If edge is palpable describe: •Size •Contour •Texture •Tenderness Jonathan Downham 2010
- 16. Abdominal Examination Percuss out liver edges Jonathan Downham 2010
- 17. Abdominal Examination Palpation of the spleen Jonathan Downham 2010
- 18. Abdominal Examination Palpate the Kidney Jonathan Downham 2010
- 19. Abdominal Examination Abdominal Aorta Jonathan Downham 2010
- 20. Abdominal Examination Hernias •Examine groin with patient standing upright •Inspect inguinal and femoral canals and scrotum for any lumps and bumps •Ask patient to cough; look for any impulses •Ask the patient to lie down and establish if the hernia reduces. •Press two fingers over the internal inguinal ring at the mid inguinal point and ask patient to cough •If it reappears it is a direct hernia, if not it is indirect. Jonathan Downham 2010
- 21. Abdominal Examination Rectal Examination •Explain •Position- left lateral, knees drawn up •Examine peri-anal area •Lubricate •Pulp of finger at 6 0’clock an anal margin •Anal spasm- stop, try again, local suppository may be required. •Ask patient to squeeze your finger •Identify cervix/prostate •Withdraw finger and examine for colour/blood Jonathan Downham 2010
- 22. Abdominal Examination Common abdominal conditions •Dysphagia/odynophagia •Questions •Trouble swallowing both solids and liquids? •Where does blockage seem to be? •Intermittent or persistent •Has it been getting worse? •Coughing or choking when starting to swallow •Heartburn or acid indigestion •Weight loss Jonathan Downham 2010
- 23. Abdominal Examination Common abdominal conditions •Pain •SOCRATES •Site •Onset •Character •Radiation •Associated symptoms •Timing •Exacerbating or relieving factors •Severity Jonathan Downham 2010
- 24. Abdominal Examination Common abdominal conditions •Diarrhoea •Secretory •Osmotic •Abnormal intestinal motility •Exudative •Malabsorption Jonathan Downham 2010
- 25. Abdominal Examination Common abdominal conditions •Diarrhoea- questions •How many stools per day •What do they look like •?urgency •Woken at night? •Blood mucus or pus? •Pale, greasy, smelly? •Lost weight? •Recent travel? •Antibiotics? •Family history •Recent fevers? Jonathan Downham 2010
- 26. Abdominal Examination Nausea and vomiting •Questions •Acute or chronic? •Vomiting with or without nausea? •How long after meal? •What does it look like..blood/bile/faeculent •Abdo pain •Weight loss? •Medications? Jonathan Downham 2010
Notas del editor
- GastrointestinalWeight lossChronic...over what time period....if unsure of weight loss have their clothes/jewellery become too bigDeliberate....dietingNausea, vomitingNature of vomit....bile, blood, coffee groundsWhen does it occur in relation to eating?Do you have any appetite?DysphagiaWhere does it stick...ask patient to pointIs it for food or drink or both?Abdominal painAre there any foods particularly associated with pain....fatty?SOCRATES!S- siteO- onsetC- characterR- radiatingA- associated symptomsT- timingE- exacerbating or relieving factorsS- severityStool frequencyWhen were bowels last opened?When was flatus last passed?Change in colour of stoolsHas there been a change in bowel habit?
- Normal FindingsLiverUpper border – 5th right intercostal space on full expirationLower border – at costal margin in the midclavicular line on full inspirationSpleenUnderlies left ribs 9, 10, 11 to the mid axillary lineGallbladderIntersection of right lateral vertical plane and the costal marginPancreasNeck – level of L1Head below and rightTail above and rightKidneysUpper pole lies deep to the 12th rib posteriorly, 7cm from the midlineRight is 2-3cm lower than the left.
- GastrointestinalWeight lossChronic...over what time period....if unsure of weight loss have their clothes/jewellery become too bigDeliberate....dietingNausea, vomitingNature of vomit....bile, blood, coffee groundsWhen does it occur in relation to eating?Do you have any appetite?DysphagiaWhere does it stick...ask patient to pointIs it for food or drink or both?Abdominal painAre there any foods particularly associated with pain....fatty?SOCRATES!S- siteO- onsetC- characterR- radiatingA- associated symptomsT- timingE- exacerbating or relieving factorsS- severityStool frequencyWhen were bowels last opened?When was flatus last passed?Change in colour of stoolsHas there been a change in bowel habit?MedicationsAspirin, ibuprofenH2 channel blockers DietHow much, how oftenCaffeineHow much noncaffeinated fluid each day
- General InspectionPain, distress, cachexia, pallor or jaundice.HandsMetabolic flap- hepatic encephalopathy, carbon dioxide retention or ureamiaAneamiaEyesScelera for jaundice and lower eyelid for aneamiaFaceAbnormal pigmentation around lipsjaundiceAngular stomatitisIron deficiency aneamia or vit b deficiencyOral cavityUlcerationInflammationOral CandidiasisHalitosis
- Infection: This can increase the number of white blood cells, which multiply in response to stimulation with a foreign substance (antigen)Virus: Immune reaction to a generalized infection in the body such as viral infections that can occur with the common cold as well as more serious infections such asHIVInflammation: Infiltration with inflammatory cells during infection or inflammation in a region of a given lymph nodeCancer: Infiltration with malignant cells (metastases) brought to the node with the lymph flowing from an area of certain types of cancerCancer of the Blood: Uncontrolled, malignant multiplication of lymphocytes as in lymphoma or leukemiaFor palpation of preauricular nodes, roll your finger in front of the ear, against the maxilla.Sub occipital lymph nodes are palpable immediately behind the ear.Posterior cervical nodes are behind sternomastoid and in front of Trapezius.Sub maxillary and Sub mental nodes: Roll your fingers against inner surface of Mandible with patient's head gently tilted towards one side.Tonsillar nodes: At the angle of MandibleDeep cervical lymph nodes should be palpated, one side at a time. Gently bend the patient's head forward and roll your fingers over the deeper muscles along the carotid arteries.To feel Scalene nodes roll your fingers gently behind the clavicles. Instruct the patient to cough or to bear down like they are having a bowel movement. Occasionally an enlarged lymph node may pop up.
- Inspection.SymmetryMassive splenomegaly produces a bulge on the left sideAbdominal pulsationDue to abdominal aortic dissectionShapeDistensionThe five F’sCauses of abdominal distensionFatFluid FaecesFetusflatusScarsSinusesFistulas e.g. crohnsVisible peristalsis due to intestinal obstructionDistended veins
- Listen above umbilicus over aorta for bruitsAtheramatous or anuerysmal aorta or superior mesenteric stenosis
- Animation CAREFUL!!Percussion words move outPic Moves in.
- Need to get patients confidence and prevent voluntary guarding.Deep palpationWarn patient that you will be pressing more firmly and feel for any obvious masses.
- If edge is palpable describe:Size- as finger breadths below costal marginContour- regular or irregularTexture- smooth, nodularTenderness-
- Normal 7-10 cm
- Start in the right iliac fossa with the fingers pointing towards the left costal marginIf you cannot feel the splenic edge ask the patient to roll towards you.Palpate with your right hand, placing your left hand behind the patients left lower ribs pulling the ribcage forward.
- Left KidneyPlace left hand in the left loin below the 12th rib, lateral to the erector spinae muscles and above iliac crestPlace right hand anteriorly just above the anterior superior iliac spineAsk patient to take a deep breath and press down with upper hand.Right KidneySame as above
- An AAA is both pulsatile and expansile (fingers will be pushed outwards)A non-aneurysmal abdominal aorta is only pulsatile.
- The inguinal canal extends from the pubic tubercle to the superior anterior iliac spineIt has an internal ring at the mid-inguinal point and an external ring at the pubic tubercle.
- Abnormal stool colour:Abnormally pale- biliary obstructionBlack and tarry- bleeding from upper GI tractGrey/black- iron therapyPale and greasy- steatorrhoeaFresh blood- large bowel, rectal or anal bleedingStool mixed with pus- infective colitis, or inflammatory bowel disease.
- Common abdominal conditionsDysphagia/odynophagiaCausesOesophagitisCarcinomaPharyngeal pouchForeign bodyGoitreMediastinal tumourAchalsia- motility disorder involving the smooth muscleQuestionsTrouble swallowing both solids and liquids?- if so suggestive of achalasiaWhere does blockage seem to be?
- SOCRATESSiteAsk patient to point to the area of pain.Parietal peritoneal inflammation usually causes localised painOnsetCharacterEg. Colicky or steady, dull or sharp.Colicky pain can come from obstruction of bowel or ureters.RadiationOften radiates to the back with pancreatic disease or penetrating peptic ulcerAssociated symptomsTimingExacerbating or relieving factorsEating may precipitate pain (ischaemic gut)Antacids or vomiting may relieve peptic ulcer pain or that of gastro-oesphageal reflux.Relief by rolling around may be colickyRelief by staying perfectly still could be peritonitis.Severity
- DiarrhoeaSecretoryHigh volumePersists when patient fastsCaused by infections (e-coli, staph)OsmoticCharacterised by its disappearance with fasting.Large volume stools related to ingestion of foodCaused by solute dragLactose intolerance, magnesium antacids or gastric surgery.Abnormal intestinal motilityIBSExudativeInflammation of the colonSmall volume but frequentMaybe blood or mucusMalabsorptionSteatorrhoeaFatty pale, smelly, float.