PHYSICAL EXAMINATION Abdomen

The abdomen is a large oval cavity extendinng from the diaphragm down to the brim of pelvis. Surface landmarks of the abdomen:

Inside the abdominal cavity, all the internal organs are the viscera. Solid viscera (those that maintain a characteristic shape): liver pancreas spleen adrenal glands kidneys ovaries & uterus Hollow viscera (the shape depends on the contents): stomach gallbladder small intestine colon bladder

Subjective data: Appetite Dysphagya Food intolerance Abdominal pain Nausea/vomiting Bowel habits Past abdominal history Medications Nutritional assessment

Examiner asks (Rationale) Appetite Any changes in appetite? Is this a loss of appetite? Any changes in weight? How much weight gained or lost? Over what time period (Anorexia is a loss of appetite for food that occurs with GI disease or is a side effect to some medications, with pregnancy, or with psychological disorders)

Examiner asks (Rationale) Dysphagia Any difficulty swallowing? When did you first notice this? (Dysphagia occurs with disorders of the throat & esophagus)

Examiner asks (Rationale) Food intolerance Are there any foods you cannot eat? What happens if you do eat them: allergic reaction, heartburn, belching, bloatng, indigestion? Do you use antacids? How often? (FI, e.g., lactase deficiency resulting in bloating or excessive gas after taking a milk products Pyrosis (heartburn), a burning sensation in esophagus & stomach, due to reflux of gastric acid Eructation (belching) )

Examiner asks (Rationale) Abdominal pain Any abdominal pain? Please point to it Is the pain in one spot or does it move around? How did it start? How long have you had it? Constant or does it come & go? Occur before or after meals? Does it peak? When? How would you describe the character: cramping (colic type), burning in pit of stomach, dull, stabbing, aching? Is the pain relived by food, or worse after eating? Is the pain associated with: menstrual period or irregularities, stress, dietary indiscretion, fatique, nausea & vomiting, gas, fever, rectal bleeding, frequent urination, vaginal or penile discharge? What makes the pain worse: food, position, stress, medication, activity? What have you tried to relieve pain: rest, haeting pad, change in position, medication?

Examiner asks (Rationale) Abdominal pain (Abdominal pain may be visceral from an internal organ (dull, general, poorly localized), parietal from inflammation of overlying peritoneum (sharp, precisely localized, aggravated by movement), or referred from a disorder in another site)

Examiner asks (Rationale) Nausea/vomiting Any nausea or vomiting? How often? How much comes up? What is the color? Is there an odor? (N&V is a common side effect of many medications and occurs with gastrointestinal disease as well as early pregnancy. Is it bloody? (Hematemesis occurs with stomach or duodenal ulcers and esophageal varices) Is the nausea and vomiting associated with colicky pain, diarrhea, fever, chills? What food did you eat in the last 24 h? Where? At home, school, restaurant? Is there anyone else in the family with same symptoms in last 24 h? (Consider food poisoning)

Examiner asks (Rationale) Bowel habits How often do you have a bowel movement? What is the color? Consistency? Any diarrhea or constipation? How long? Any recent change in bowel habits? Use laxatives? Which ones? How often do you use them? (Black stools may be tarry due to passage of occult blood (melena) from GI bleeding or nontarry from injection of iron medications Red blood in stools occurs whith GI bleeding or localized bleeding aroun the anus)

Examiner asks (Rationale) Past abdominal history Any past history of GI problems: ulcer, gallbladder disease, hapatitis/jaundice, appendicitis, colitis, hernia? Ever had any operations in the abdomen? Please describe Any problems after surgery? Any abdominal x-ray studies? How were the results?

Examiner asks (Rationale) Medications What medications are you currently taking? How about alcohol – how much would you say you drink each day? Each week? When was your last alcoholic drink? How about cigarettes – do you smoke? How many packs per day? For how long? (Peptic ulcer disease has risk factors that include frequent use of nonsteroid antiinflammatory drugs (NSAIDs), alcohol, smoking, and HP infection)

Examiner asks (Rationale) Nutritional assessment Now I would like to ask you about your diet. Please tell me all the food you ate yesterday, starting with breakfast

Objective data: Inspection (symmetry, umbilicus, skin, pulsation or movement, hair distribution, demeanor) Auscultation (bowel & vascular sounds) Percussion (general tympany, liver span & splenic dullness) Palpation (superficial & deep)

Preparation The lighting should include a strong overhead light and a secondary stand light. Expose the abdomen so that is fully visible. Drape the genitalia and female breasts. The person should have emptied the bladder Keep the room warm to avoid chilling and tensing of muscles Position the person supine, with the head on the pillow, the knees bent or on pillow, and the arms at the sides or acroos the chest The stethoscope endpiece must be warm, your hands must be warm, and your fingernails must be very short Inquire about any painful areas. Examine such an area last to avoid any muscle guarding Enhance muscle relaxation through breathing exercises; emotive imagery; your low, soothing voice; and the person relating his or her abdominal history while you palpate

Inspect the abdomen Contour Stand on the person’s right side and look down on the abdomen. Then stoop or sit to gaze across the abdomen. Determine the profile from the rib margin to the pubic bone. Normally the contours are the flat or rounded.

Inspect the abdomen Symmetry Umbilicus Shine a light across the abdomen toward you, or lengthwise across the person. The abdomen should be symmetric bilaterally. Note any localized bulging, visible mass, or asymmetric shape. Step to the foot of the examination table to recheck the symmetry. Ask the person to take a deep breathe to further highlight any change. Or ask the person to perform a sit up without pushing up with his or her hands. Umbilicus Normally it is midline and inverted, with no sign of discoloration, inflammation or hernia.

Inspect the abdomen Skin The surface is smooth, with homogeneous color. One common pigment change is striae. They occur when elastic fibers in the reticular layer of the skin are broken following rapid or prolonged stretching (pregnancy, excessive weight gain). If a scar is present, draw its location in the persons record, indicating the length in cm. Veins usually are not seen Skin turgor. Gently pinch up a fold of skin, then release (skin immediately returns to original position)

Inspect the abdomen Pulsation or movement (aorta, respiratory movements, waves of peristalsis) Hair distribution

Auscultate bowel & vascular sounds Bowel sounds Begin auscultation from the RLQ. Note the character and frequency. Bowel sounds are high pitched, cascading, occurring from 5 to 30 times per minute. Vascular sounds Check over the aorta, renal arteries, illiac and femoral arteries

Percussion General tympany Percuss lightly in all four quadrants to determine the prevailing amount of tympany or dullness. Tympany should predominate because air in intestines rises to the surface when the person is supine

Percussion Liver span Measure in the right medclavicular line. Begin in the area of the lung resonance and percuss down the interspaces untill the sound changes to a dull quality. Mark the spot (N - V intercostal space) Find abdominal tympany and percuss up. Mark where the tympany changes to the dullness (N – right costal margin) Measure the distance between to marks. (N – 6-12 cm; m – 10,5 cm; f – 7 cm)

Percussion Splenic dullness You may locate it by percussing for a dull note from the 9th to 11th intercostal space just behind the left midaxillary line Normally is not wider than 7 cm Percuss in the lowest interspace in the left anterior axillary line

Percussion Costovertebral angle tenderness

Palpation Light palpation With the first 4 fingers close together, depress the skin about 1 cm Make a gentle rotary motion, sliding the skin and fingers together. Than lift the fingers and move to the next location (muscle guarding (voluntary or involuntary), rigidity, large masses, tenderness)

Palpation Deep palpation Push down about 5 to 8 cm To overcome the resistance of a very large or obese abdomen, use a bimanual technique

Palpation Liver Place your left hand under the persons back parallel to the 11th and 12th ribs and lift up to support abdominal contents Place your right hand in RUQ, with fingers parallel to the midline Push deeply down and under the right costal margin Ask the person to take a deep breathe Try to feel the liver edge bump your fingertips

Palpation Spleen Normally the spleen is not palpable Reach your left hand over the abdomen and behind the left side at the 11th and 12th ribs. Lift up for support Place your right hand on the LUQ with the fingers pointing toward the left axilla and just inferior to the rib margin Push your hand deeply down and under the left costal margin and ask the person to take a deep breathe. You should feel nothing firm

Palpation Kidneys Search for the right kidney by placing your hands in a “duck-bill” position at the person’s right flank Press your two hands together firmly and ask the person to take a deep breathe In most people you will fell no change. Occasionally, you may feel the lower pole of the right kidney as a round, smooth mass slide between you fingers

Palpation Kidneys The left kidney is not palpable normally Search it by reaching your left hand across the abdomen and behind the left flank to support Push you right hand deep into the abdomen and ask the person to breathe deeply You should feel no change

Palpation Aorta Using your opposing thumb and fingers, palpate the aortic pulsation in the upper abdomen slightly to the left of midline Normally it is 2,5 to 4 cm wide and pulsates in the anterior direction

Palpation Special procedures Rebound tenderness (Blumberg’s sign). Choose a site away from the painful area. Hold your hand 90 degrees to the abdomen. Push down slow and deeply; than lift up quickly. The normal (negative) response – no pain on release or pressure.

Palpation Special procedures Inspiratory arrest (Murphy’s sign). Hold your fingers under the liver border. Ask the person to take a deep breathe.

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