Physical Examination ABDOMEN

RULE #1

POSITION The patient should be lying flat on bed Arms on the sides

From the level of nipples to the level of knees. exposure From the level of nipples to the level of knees.

Don’t forget to : Have warm hands and a warm stethoscope. Avoid quick, unexpected movements. Distract the patient with questions. Monitor your examination by watching patient's face.

Abdominal examination Abdomen Back PR / PV

inspection Contour and symmetry : Flat abdomen (قابلوني اذا شفتوها )

Inspection 2. Scars : a. Location b. Length c. Color

Inspection 3. skin / dilated veins : Striae - prolonged stretching of the skin; seen in ascites, obesity, tumor, pregnancy, and Cushing's Syndrome Spider angioma

Inspection 4. umbilicus: a. Contour b. Location c. Signs of hernia - lifting head or coughing Turner’s sign

Inspection 5. masses / enlarged organs : hepatomegaly

Inspection 6 Peristalsis 7 . Distribution of Pubic Hair (Escutcheon): a. Female distribution - triangle with base above the symphysis b. Male distribution - diamond with upper vertex extending as high as the umbilicus 8. respiration pattern : female : thoracoabdominal Male : abdominothoracic

Inspection 9. epigasric pulsation : AAA https://www.youtube.com/watch?v=CQzjJQmarNk

If it was your mother lying on the bed , would you do the same thing ? RULE #2 If it was your mother lying on the bed , would you do the same thing ?

Auscultation You must auscultate before you percuss or palpate abdomen because these maneuvers may alter the frequency of bowel sounds. Enhanced peristaltic sounds may mask other abnormal abdominal sounds such as bruits and friction rubs.

Auscultation 1. Bowel sounds - listen and note frequency and character (normal sounds consist of clicks and gurgles and occur 5 to 34 per minute) . Absence of bowel sound - established only after 5 minutes of continuous listening. Caused by an immobile bowel of adynamic ileus (peritonitis, severe hypokalemia, complete obstruction, paralytic ileus, gangrene). A full bladder can obscure sounds.

Auscultation 2. Vascular Sounds : Location Indication   Location Indication Over abdominal aorta Atherosclerosis Aneurysm Aortic compression by a tumor Renal arteries Renal artery stenosis (check for hypertension) Right upper quadrant Vascular tumor of the liver (Hepatoma, Hemangioma) Iliac arteries Femoral arteries

Auscultation Sounds : https://www.youtube.com/watch?v=ZoXbHvFhbi0&list=PL37B77CC6BEDF3DEB

RULE #3

Percussion Percussion of the abdomen helps assess for intestinal distention, free fluid, solid masses, hepatomegaly, and splenomegaly. It is contraindicated in patients with AAA , organ transplants or injured spleen. Percussion for beginners : https://www.youtube.com/watch?v=P4Ryk5IKf_4

Percussion Abdominal organs Liver – percuss up from RIF then down from right side of chest to determine the size of the liver Spleen – percuss up from RIF moving towards the LUQ to assess for splenomegaly Bladder – percuss suprapubic region – differentiating suprapubic masses (bladder (dull) / bowel (resonant))

Percussion Shifting dullness 1. Percuss from the centre of the abdomen to the flank until dullness is noted 2. Keep your finger on the spot at which the percussion note became dull 3. Ask patient to roll onto the opposite side to which you have detected the dullness 4. Keep the patient on their side for 30 seconds 5. Repeat your percussion in the same spot 6. If fluid was present (ascites) then the area that was previously dull should now be resonant 7. If the flank is now resonant, percuss back to the midline, which if ascites is present, will now be dull (i.e. the dullness has shifted)

Percussion Liver : https://www.youtube.com/watch?v=D0G7353qfYw https://www.youtube.com/watch?v=LmNQGKvTck0

Percussion Spleen : https://www.youtube.com/watch?v=hhvGnBUNCgo . Shifting dullness : https://www.youtube.com/watch?v=b7glKxy7VvI

BE patient with patients who are not patient . RULE #4 BE patient with patients who are not patient .

Palpation Remember: The pads and tips (the most sensitive areas) of the index, middle, and ring fingers are the examining surfaces used to locate the edges of the liver and spleen as well as the deeper structures Apply slow, steady pressure, avoiding any rapid/sharp movements that are likely to startle the patient or cause discomfort . Examine each quadrant separately, imagining what structures lie beneath your hands and what you might expect to feel. In general, it is easier to detect abnormal if you start in an area that you're sure is normal. Ask if the patient has any pain anywhere before you begin! Look at patients face throughout the examination for signs of discomfort.

Palpation 1. Light palpation : Assess each of the four quadrants for the following… Tenderness – note the areas involved and the severity of the pain Rebound tenderness – pain is worsened on releasing the pressure – peritonitis Guarding – involuntary tension in the abdominal muscles – assess if localized or general  Masses – large / superficial masses may be noted on light palpation

Palpation 2 .Deep palpation Assess each of the four quadrants again, but with greater pressure on palpation 1.liver 2. gallbladder 3. spleen 4 .Kidneys 5 . Aorta 6 .Bladder

Palpation Liver 1. Start palpation in the right iliac fossa 2. Press your right hand into the abdomen as you ask the patient to take a deep breath 3. Feel for a step, as the liver edge passess below your hand 4. If you don’t feel anything, repeat the process with your hand 1-2 cm higher . If you feel the liver edge, note the following: Degree of extension below the costal margin Consistency of the liver edge (smooth/irregular) Tenderness – suggestive of hepatitis  Pulsatility – a pulsatile enlarged liver can be caused by tricuspid regurgitation

Palpation Gallbladder The gallbladder is not usually palpable when healthy An enlarged gallbladder suggests obstruction to biliary flow / infection (cholecystitis) Perform palpation at the right costal margin, mid-clavicular line (9th rib tip) If enlarged, a round mass, moving with respiration may be palpated – note any tenderness   Murphys sign: Place your hand in the area noted above Ask the patient to take a deep breath As the gallbladder is pushed down into your hand they may suddenly develop pain & stop inspiring This is a positive Murphy’s sign, which is suggestive of cholecystitis

Palpation Spleen The spleen is not usually palpable, therefore if you feel it, it’s at least 3x it’s normal size! 1.  Start in right iliac fossa – as massive splenomegaly can extend this far! 2. Align your fingers in the same direction as the left costal margin 3. Press your right hand into the abdomen as you ask the patient to take a deep breath 4. Feel for a step, as the splenic edge passess under your hand (a notch may be noted) – note position 5. If you don’t feel anything, repeat process with your hand 1-2 cm closer to the LUQ

Palpation Kidneys 1. Place your left hand behind the patients back at the right flank 2. Place your right hand just below the right costal margin in the right flank 3. Press your right hands fingers deep into the abdomen 4. At the same time press upwards with your left hand 5. Ask the patient to take a deep breath 6. You may feel the lower pole of the kidney moving inferiorly during inspiration  7. Repeat this process on the opposite side to assess the left kidney

Palpation Aorta 1. Palpate using fingers from both hands 2. Palpate just above the umbilicus at the border of the aortic pulsation 3. Note the movement of your fingers: Upward movement = pulsatile Outward movement = expansile (suggestive of AAA

Palpation Bladder An empty bladder will not be palpable (pelvic) However an enlarged full bladder can be felt arising from behind the pubic symphysis This may suggest a diagnosis of urinary retention 

Palpation https://www.youtube.com/watch?v=aSPqXd9PILo

PR/GENETALIA !!! Say you would carry out the following if appropriate… Check hernial orifices – e.g. if there’s signs of obstruction Perform a digital recta examination (PR)– e.g. if there’s a suggestion of UGIB Perform an examination of the external genitalia .

Don’t forget to : 1.Thank patient 2. Wash hands 3. Summarize findings .

DDx Think Anatomically: When looking, listening, feeling and percussing imagine what organs live in the area that you are examining. The abdomen is roughly divided into four quadrants: right upper, right lower, left upper and left lower. By thinking in anatomic terms, you will remind yourself of what resides in a particular quadrant and therefore what might be identifiable during both normal and pathologic states

All the best