1. ASSESSMENT OF THE ABDOMEN
Prepared by
Hamdia Mohammed

2. Learning Objectives:-
At the end of this lecture each student will be able to:
Identify landmarks for the abdominal assessment
Correctly perform techniques of inspection, auscultation, percussion and palpation
Differentiate between normal & abnormal findings.

3. Overview of abdominal structure.
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Overview of abdominal structure.
1- Large oval cavity.
2- Extends from diaphragm to symphysis.
3- Viscera: solid and hollow.
A- Solid viscera are those organs that maintain their shape consistently ( liver, pancreas, spleen, adrenal glands, kidneys, ovaries and uterus ).

4. The liver is the largest solid organ in the body.
B- The hollow viscera consist of structures that change shape, depending on their contents . These include ( stomach, gallbladder, small intestine, colon , bladder ).
4- Vascular structures:
The abdominal organs are supplied with arterial blood by abdominal aorta & its major branches.

5. Locating abdominal structures by quadrants
Divided to four quadrants:-
1- Right upper quadrant ( RUQ )
2- Right lower quadrant ( RLQ )
3- Left upper quadrant ( LUQ )
4- Left lower quadrant ( LLQ )

6. Right upper quadrant
( RUQ ).
Left Upper Quadrant
(LUQ ).
- stomach
- spleen
- left lobe of liver
- body of pancrea
- left kidney and adrenal
- spleen flexure of colon
- part of transverse & descending colon
- Liver - Gallbladder - Duodenum - Head of pancreas -Right kidney and adrenal - Hepatic flexure of colon - Part of ascending and transverse colon. - Right ureter.

7. Midline: Right Lower Quadrant: Left Lower Quadrant:
-Part of descending colon -Sigmoid colon -Left ovary and tube -Left ureter -Left spermatic cord
-Cecum
-Appendix
-Right ovary and tube
-Right ureter
-Right spermatic cord
Midline:
-Aorta
-Uterus.
-bladder.

8. Abdominal Landmarks

9. Preparation for abdominal assessment
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Preparation for abdominal assessment
Preparing the exam room
preparing the patient
positioning the examiner

10. Health History:
Any chronic diseases that affect GIT or urinary systems? Describe.
Does he drink alcohol? How much? How often? When was last drink?
Smoke? How much and how long? Considered stopping or cutting down?
How often do you have a bowel movement? When was the last one? What are color and consistency of stool?

11. Abdominal pain: Nausea or vomiting for how long? Frequency?
How much do vomit? What does it look like? Contain blood? Have an odor?
Abdominal pain:
How long have he had ? Where? When did he first feel pain? What activity were he doing?
Describe pain. Constant/intermittent? Had episodes before? Did pain start suddenly?

12. Types of pain Vesceral pain. Parietal pain : as in appendicitis
Referred pain

13. Character of abdominal pain
Dull, aching( e.g cystitis )
Burning (e.g dyspepsia )
Colicky (e.g colon cancer)
Sharp, knifelike (e.g renal colic )
Pressure ( urinary retention )

14. Assessment Techniques
1- Inspection.
2- Auscultation.
3- Percussion.
4- Palpation.

15. 1- Inspection skin: color, scars, veins, lesions.
umbilical hernia, bleeding, inflammation.
contour of the abdomen :flat ,rounded, protuberant .
symmetry
enlarged organ.
Masses.
Peristalsis ,pulsation , distention.

16. Inspection Deviation from normal Normal finding Procedure Skin:
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Deviation from normal
Normal finding
Procedure
1- Dark bluish striae is seen in cushing syndrome, redness in
inflammation ……
2- Rashes or lesions.
3-Engorged veins.
1-Pale ,with white striae
2- No rashes or lesions.
3- Fine veins observable
Skin:
1-Color
2-Integrity
3-Venous pattern
1- Deviation from midline with mass ,hernia,everted with distention..
2- Bluish
1- Sunken, centrally location
2- Pinkish
Umbilicus:
1- Position
2- Color

17. Inspection con’t Deviation from normal Normal finding Procedure
Black, bright red, tarry ( melena ).
Brown to dark brown
Color of stool
Bloody
( hematemesis )
Varies
Color of emesis

18. Distention:- Definition: unusual stretching of abdominal wall
Abdominal distention can be caused by three factors:
1. Obesity – Abdomen is soft and rounded with a sunken umbilicus.
2. Ascites – Skin is shiny and glistening with an everted umbilicus. Veins are dilated and prominent (more visible in thin, malnourished skin).
3. Obstruction – There may be visible, marked peristalsis; restlessness; lying with knees flexed; grimacing facial expression; and uneven respirations.

19. Distention:- note position of umbilicus
note portion of abdomen that is
distended
reasons for distention: flat(obesity),
flatus(gas), feces, fluid, tumor , fetus(pregnancy )

20. 2- Auscultation
Auscultation performed before palpation and percussion.
Use diaphragm of stethoscope
Listen to bowel sounds for up 5 minutes in each quadrant.
Normal sounds are clicks and gurgles, irregular, 5-30 times per minute
Influenced by digestion

21. Auscultation con’t
Increased bowel sounds are due to hypermotility of peristalsis
Decreased are due to paralytic ileus or peritonitis
Intestinal obstruction can present with increased or decreased sounds

22. Abdominal Vessels
Sites for Auscultating the Abdomen

23. Additional Sounds Bruits:
Bruits are low pitched, vascular sounds, resembling murmur
Caused by partially obstructed artery– turbulence
Listen in epigastrum and each upper quadrant
Listen in costovertebral angle(with patient seated)
Listen over aorta, iliac arteries, femoral arteries
Arterial insufficiency in legs

24. 3- Percussion
Assessment technique used to assess size and density of organs in the abdomen e.g used to measure size of liver or spleen.
In the right midclavicular line, percuss down from lung resonance to liver dullness.

25. Percussion con’t Used to identify air in stomach or in bowel.
Used to identify masses.
Used alone or in conjunction with palpation or to validate palpatory findings.
Orient to the abdomen by lightly percussing all 4 quadrants for tympany or dullness.

26. Percussion con’t Tympany usually predominates due to gas in the bowel.
Dullness may be present due to feces or fluid or over organs or a solid mass.
Develop a specific percussion route and stick to it.

27. Percussing the spleen Where is the spleen located?
In the curve of the diaphragm just posterior to the left midaxillary line.
When the spleen enlarges, it does so anteriorly, downward and medially. This will replace the tympany of the stomach and colon with dullness

28. Tricks to Assessing the Spleen
Percuss in the lowest interspace in the left anterior axillary line for tympany.
Ask the patient to take a deep breath and percuss on inspiration.
The percussion note should remain tympanic.
A change to dullness suggest spenomegally
This is known as a positive splenic percussion sign

29. Percussion Sites for all Quadtrants
(Abdominal percussion seqences may proceed clockwise)

30. 4- Palpation
To differentiate voluntary from involuntary resistance: rectus muscle will relax with expiration.
Palpation is light or deep
Deep palpation used to define and delineate organs or abdominal masses.
Use palmar surface of fingers and feel in all four quadrants

31. Palpation con’t Used to assess muscle tone, tenderness, fluid, organs.
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Palpation con’t
Used to assess muscle tone, tenderness, fluid, organs.
Use pads of fingertips in light dipping motions and avoid short jabs.

32. Palpation of the liver Stand on patients right side
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Palpation of the liver
Stand on patients right side
Place left hand behind patient parallel to and supporting 11-12th ribs
Patient should relax
Press with left hand forward and place right hand on abdomen with fingertips below lower edge liver dullness
Press in and up while patient takes deep breath; if palpable, liver should come down
What does a normal liver edge feel like? Abnormal?
If you can’t feel it, start lower and try again
Ask patient to use abdominal breathing

33. Palpation of the spleen
The spleen is usually not palpable
From patient’s right side, reach over and around under patient with left hand
Place right hand below left costal margin and press in toward spleen. Ask patient to take deep breath---will feel if palpable

34. B- Auscultating the abdomen A-Inspecting the abdomen
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B- Auscultating the abdomen
A-Inspecting the abdomen
D- Percussing the abdomen
C- Palpating the abdomen

35. Assessment of the urinary system

36. Learning Objectives:-
1- Identify the important new terms related to urinary system. 2- List the factors which influencing urination. 3- Enumerate function of kidneys. 4- Differentiate between normal and abnormal finding.

37. Important new Terms * Oliguria: voiding a scanty amount of urine.
* Anuria: inability to produce urine, less common, but caused by a decrease in renal perfusion.
* Polyuria: excessive output of urine.
* Hematuria: blood noted in urine.
* Nocturia: having to void at night.

38. * Dysuria: difficulty in voiding or pain in voiding.
* Enuresis: involuntary loss of urine at night.
* Pyuria : presence of pus in the urine.
* Glycosuria: presence of sugar in urine.
* Albumin urea: presence of albumin in the urine.

39. Factors influencing urination
Socio cultural
psychological
muscle tone
fluid balance
surgical procedures
medication

40. Functions of the kidneys Kidney:- •Urine formation • Excretion of waste products • Regulation of electrolytes • Regulation of acid–base balance • Control of water balance • Control of blood pressure • Renal clearance • Regulation of red blood cell production • Synthesis of vitamin D to active form • Secretion of prostaglandins.

41. Palpation of kidney
Find the costovertebral angle which formed by the lower border of the 12th rib and the transverve processes of the upper lumbar vertebrae.
Place left hand flat in this area on one side, hit the hand sharply with the fist of the other patient will admit to tenderness if present.
Repeat on the other side

42. Palpation cont. Kidney: not palpable in normal adult.
May be able to feel lower right kidney pole in very thin person.
Technique for palpating the right
kidney (top).
Technique for palpating the left kidney.

43. Deep palpation
If masses are felt, note: location, size, shalpe, consistency, tenderness, pulsations, mobility with respiration or with hand.
If patient is obese or rigid, use 2 hands to palpate
Place one on top of other and feel with lower hand

44. Palpation of the bladder
Bladder percussion is unnecessary unless there is a suspicion of urinary retention.
Palpate above the symphysis.
An empty bladder is not palpable.

45. The bladder should be percussed after the patient voids to check for residual urine.
Percussion of the bladder begins at the midline just above the umbilicus and proceeds downward.
The sound changes from tympanic to dull when percussing over the bladder.

46. The bladder, which can be palpated only if it is moderately distended, feels like a smooth, firm, round mass rising out of the abdomen, usually at midline.
Dullness to percussion of the bladder following voiding indicates incomplete bladder emptying.

47. Assessing the Aorta
Press firmly deep in upper abdomen slightly to left of midline.
Feel for aortic pulsations
Determine width of aorta by pressing deeply on either side of aorta
What is the normal width of the aorta?
If pulsatile mass is found, feel for femoral pulses which may be dimished.

48. Special test for appendicitis:
Rebound tenderness: mean deeply palpation& withdrawal quickly, this caused pain in appendicitis. Psoas sign : pt lie in supine position & raise right leg , if the pain found this is indicate to appendicitis. Oburator sign: pt flex right leg at hip and knee. Then rotate leg internally and externally.