1. EXAMINATIO N OF THE ABDOMEN

7. ABDOMEN: Inspection There should be adequate exposure of the abdomen for proper inspection. The patient should be exposed from the inferior chest to the anterior iliac spines bilaterally.

8. the contents of inspection 1. abdominal contour 2. respiratory movement 3. abdominal veins 4. peristalsis 5. abdominal skin

9. INSPECTION Shape Shape Skin Abnormalities Skin Abnormalities Masses Masses Scars (Previous op's - laproscopy) Scars (Previous op's - laproscopy) Signs of Trauma Signs of Trauma Jaundice Jaundice Caput Medusae (portal H-T) Caput Medusae (portal H-T) Ascities (bulging flanks Ascities (bulging flanks) Spider Navi-Pregnant women Spider Navi-Pregnant women Cushings (red-violet) Cushings (red-violet)......

10. 1. Abdominal contour in healthy person abdomen is usually flat from xiphoid to symphysis pubis, we call abdominal flat or even abdomen. the umbilicus is located in the abdominal center. depending on the nutritional status, the abdominal contour may be lightly protuberant or scaphoid.

11. 2. Respiratory movement the manner of breathing: in men and children, manner of breathing is abdominal respiration. But in women the manner of breathing is thoracic respiration. In some diseases such as perforation because acute peritonitis., the respiratory movement is limited or disappear.

12. (3) Striae silver striae distribute on the lower quadrants of abdomen or iliac regions, it is seen after a large gain of weight or after pregnancy. bluish striae (purple) distribute on lower quadrants of abdomen upper legs or hips this is found in hypercortisolism.

13. (4) Scar when you find a operation scar on the patient abdomen, you should ask some question about the scar, when and why the patient got the scar, the history of operation may be helpful to diagnosis of the disease

15. (5). Hernia umbilical hernia may be seen in belly or patient with a massive ascites incisional hernia operation scar femoral hernia mainly seen in female inquinal hernia mainly seen in male

16. Abdominal bulge generalized abdominal bulge is usually caused by ascites some causes for ascites: heart failure cirrhosis of liver nephrotic syndrome TB peritonitis

17. both the patients with massive ascites and obesity have abdominal distention, how do we distinguish from each other, you can observe the appearance of the umbilicus, umbilicus is usually deeply inverted in obesity and everted in long—standing ascites

19. Abdominal Palpation Palpate lightly in all 4 quadrants. Press down around 1 cm. Remember to look at the patient’s face during palpation to see if any tenderness is elicited

21. Palpation: Liver Stand on the pt’s right side. Place your left hand behind the patient’s R side under the 11 th and 12 th rib area. Press upward with the L hand. Place your R hand on the pt’s abdomen well below where you percussed the liver edge

22. PERCUSSION Percussion: the left and right abdomen should be percussed above and below the umbilicus. Most examiners will percuss 8 or more areas.

23. Right lateral decubitus

24. 132-133: Palpation: Spleen Palpation: Spleen (correctly - position, breaths, palpating deepest full inspiration, 1 hand under L side, 1 feeling) Palpation: Spleen (if not palpable, R lateral decubitus)

26. Hepatomegaly… This assessment of liver size may be unreliable if other non hepatic factors (e.g., lung disease) push diaphragm lower and thus the liver below the costal margin Liver span a more reliable measurement of liver size distance determined by percussion between upper margin of liver dullness and its lower edge Span of 5–7cm is normal in infants and children, whereas 8–10 cm is normal in adolescents

27. Hepatomegaly Liver size may be estimated by degree of extension of liver edge below costal margin or by span of liver dullness to percussion In children liver edge may be normally palpable up to 2 cm below right costal margin

28. Hepatomegaly… Principal Causes of Hepatomegaly Infection/inflammation Hepatitis Viral Lymphoma Connective tissue disease hepatoma

29. splenomegaly defective RBCs hereditaryspherocytosisspherocytosis thalassemia leukemiasleukemias (acute, chronic, lymphoid, and myeloid) lymphomas (Hodgkins and non-Hodgkins)Hodgkinsnon-Hodgkins C M L Infection:typhoid,brucellosis,malarria

32. Fluid wave test / Iceberg Sign Test for ascites. Test for ascites. Have patient push their hands down on the midline of the abdomen. Have patient push their hands down on the midline of the abdomen. Then you tap one flank, while feeling on the other flank for the tap. Then you tap one flank, while feeling on the other flank for the tap. > 1 litre of fluid allows the tap to be felt on the other side. > 1 litre of fluid allows the tap to be felt on the other side.......

33. how to ascertain the direction of blood flow you can choice a segment of vein, then the vein is emptied between two fingers to a distance of a few centimeters, then allows blood to refill the vein from one direction by removing one compressing finger