1. Physical Examination
ABDOMEN

2. RULE #1

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

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

5. 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.

6. Abdominal examination
Abdomen
Back
PR / PV

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

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

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

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

12. Inspection
5. masses / enlarged organs :
hepatomegaly

13. 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

14. Inspection 9. epigasric pulsation : AAA

15. 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 ?

16. 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.

17. 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.

18. 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

19. Auscultation
Sounds :

20. RULE #3

21. 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 :

22. 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))

23. 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)

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

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

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

27. 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.

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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 

36. Palpation

37. 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 .

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

39. 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

40. All the best