12. Constipation
• an inability to have spontaneous complete
and releiving bowel movements…
– Slow colonic transit type
• Frequency<2 per week
• Consistency: Hard
• Colonic dysfunction
– Difficult evacuation type
• Frequency>2 per week
• Consistency: Soft
• Anorectal dysfunction
18. Hepatitis and liver failure
• Jaundice
• Fatique
• Weight loss or gain
• Loss of apetite
• Cirrhosis
– History of jaundice
– Abdominal distention
– Change in consinousness
20. Why Abdominal Examination?
• Treatment should be urgent or elective
– GI Bleeding? Perforation? Acute abdomen?
– Peptic ulcer activation? Or Acute pancreatitis?
• Findings in physical examination targets to the
diagnosis
• Differential diagnosis?
• How do we decide the lab. Tests for diagnosis
• Does the patient need any intervention
immediately?
21. Be carefull!!
• Introduce yourself before examination
• Outpatient clinic should not be crowded
– Only one person with the patient, close relative
• Be calm and cool
– Do not shout, be angry or talk with sarcastic
words
• Always have the records on the files
• Always give detailed information for the
diagnosis & the treatment
22. General Physical Examination
• Always before the abdominal
examination
• Upper part of the patient’s body
should be naked
• Outpatient room should be warm
• Be at the right side of the patient
• All your belongings should be ready
– White coat
– Light source
– ruler
– Pencil, notebook etc.
• Enogh day light
• Hands should be warm and clean
23. Periferic Findings at the general physical
examination
• Generally
• Cachexia
• Orianted or not, dehidrated? Etc.
• Head and Neck
• Pale conjuctiva
• Jaundice or icterus
• xantelazma
• Kayser-Fleisher ring
• Temporal muscle wasting
• Rhinophyma
• Periferic extremities
• Clubbing
• White nail
• Palmar erythema
• Dupuytren Contractures
• Tenar ve hypotenal muscle atrophia
• Spider nevus,
• pyoderma gangrenozum
24.
25.
26. Glossitis
• inflammation of the tongue…
• GI related causes
– Pernisious anemia
– Pemphigus vulgaris
– Iron deficiency anemia
27. Angular Stomatitis
• an inflammatory lesion at the labial
commissure…
• GI related causes:
– Celiac disease
– Crohn’s disease
– Plummer-Vinson syndrome
Fe, B vit. deficiency
33. – Midclavicular line
– Anterir, posterior
and midaxillary
lines
– Midline
– Horisontal line
• Points
– Murphy
– Mc-Burney
34. – Left and right
hypochondrium
– Left and right
paraumblical
(lumbar) regions
– Left and right iliac
regions
– Epigastrium, umblical
and hypogastric
regions
35. Findings of inspection
– Abdominal respiration
• Increases at lower lung function
• Decreases at large ascitis
– Peritonitis
• Shape
– Protuberant
– Flat
– Saggy
– Obese
36. • You should define the lesion and its location when
you find a lesion.
– Diastasis recti
– Hernias
• İncisisonal
• Umblical
• ınguinal
• Others
– Scars
44. Friction Rubs
On the liver side
– After liver biopsy
– Acute Budd-Chiari syndrome
– Perihepatitis with gynecologic infections
– Hepatoma localised at he capsule of the liver
On the Spleen Side
– Spleen infarction
– Subcapsuller hematoma after trauma
45. Percussion
rgans
– Liver
• Midclavicular line and 2.
intercostal
• Through the midclavicular
line
• Total vertical diamter of hte
liver, right lobe 12 cm, left
lobe 8 cm
46. Spleeen
• Splenic percussion sign
– Right anterior axillay line
and 12th intercostal
space
– Dullness at deep
inspiration
47. Spleen Total vertical diameter
• Percussion
– Midaxllay line and 2.th intercostal
– Located at 9-12th . costal spaces
– Diameter: 6-8 cm
55. Deep palpation:
– Sensitive sides
• Patient has defence ?
• Muscular defense
• Abdominal guarding
– automically
• Rebound
• Rigidity
– Mass lesions
• Steely, smooth,
subcutan, deep, with
pain, or painless
56. Liver Palpation
• Diameter
– Midclavicular 6-12 cm right lobe
– 4-8 cm left lobe
– Use midsternal line for left lobe
• Steely, fibrotic, smooth
• Any pain
• Nodüler, irregüler
63. Conclusion
• Repeat again and again
• Spend more time at internal medicine ward
• Performphysical examinaitonto your parents
• My kid is a doctor, oh ı am so happy
• Of course ask any time you want
• Look at B.Bates
64. Unutmamak lazım ki doktorun çok hastası olabilir,
ancak size gelen hastanın tek doktoru var o da
sizsiniz.
Notas del editor
Regurgitation should be distinguished from vomiting, the term applied to the ejection of gastroduodenal content preceded by nausea and accompanied by the abdominal muscular activity.
Esophageal regurgitation is rarely acidic, on the other hand gastric regurgitation is frequently acidic.
Abdominal distention refers to increased abdominal girth—the result of increased intra-abdominal pressure forcing the abdominal wall outward. Distention may be mild or severe, depending on the amount of pressure. It may be localized or diffuse and may occur gradually or suddenly. Acute abdominal distention may signal life-threatening peritonitis or acute bowel obstruction.
Abdominal distention may result from fat, flatus, a fetus (pregnancy or intra-abdominal mass [ectopic pregnancy]), or fluid. Fluid and gas are normally present in the GI tract but not in the peritoneal cavity. However, if fluid and gas can&apos;t pass freely through the GI tract, abdominal distention occurs. In the peritoneal cavity, distention may reflect acute bleeding, accumulation of ascitic fluid, or air from perforation of an abdominal organ.
Abdominal distention doesn&apos;t always signal pathology. For example, in anxious patients or those with digestive distress, localized distention in the left upper quadrant can result from aerophagia —the unconscious swallowing of air. Generalized distention can result from ingestion of fruits or vegetables with large quantities of unabsorbable carbohydrates, such as legumes, or from abnormal food fermentation by microbes. Don&apos;t forget to rule out pregnancy in all females with abdominal distention.
The globus sensation, a sense that something is lodged continuously in the throat, must be differentiated from dysphagia or odynophagia before embarking on an unnecessary investigation . The globus sensation typically is sensed midline at the laryngeal level, but can lateralize in as many as 20% of patients. The sensation classically is reported as a “lump in the throat,” but feeling that a foreign body, sharp object, or food particle is lodged also is a compatible description. Most notably, globus sensation does not interfere with swallowing; although one in five patients with globus sensation notes something abnormal during food swallows, the original symptom abates during the process. Globus may accompany a variety of disorders that cause dysphagia, such as GERD and distal esophageal motility disorders. Furthermore, up to 45% of the general population may have intermittent symptoms resembling globus. This symptom most often reflects a functional gastrointestinal disorder.
In some instances globus is associated with substantial anxiety; that anxiety is sometimes thought to be etiological (globus hystericus).
Patients consider themselves to be constipated when they pass stools more infrequently, require more effort for passage (“straining”), or experience more pain or discomfort during passage than they think appropriate. Difficult evacuation of feces, especially when the consistency of stools is softer than normal, is more likely to be caused by disorders of the pelvic floor or anorectum than by slow colonic transit.
A decrease in stool consistency or fluidity and stools that cause urgency or abdominal discomfort are more likely to be termed diarrhea by patients than increases in frequency alone.
A bilateral, coarse movement, asterixis is characterized by sudden relaxation of muscle groups holding a sustained posture. This elicited sign is most commonly observed in the wrists and fingers, but may also appear during any sustained voluntary action. Typically, it signals hepatic, renal, or pulmonary disease.
Angular cheilitis (also called cheilosis or angular stomatitis) is an inflammatory lesion at the labial commissure, or corner of the mouth, and often occurs bilaterally. The condition manifests as deep cracks or splits. In severe cases, the splits can bleed when the mouth is opened and shallow ulcers or a crust may form.