PAPER ASSIGNMENT ABOUT PHYSICAL EXAMINATION ABDOMEN

MADE TO FULFILL ASSIGNMENT OF ENGLISH COURSES

Supporting Lecturer :

Rahma Kasimbara, M.Pd.

MADE BY :

Fitria Ayu Ningsih 18.1.189

Mar'atus Sholicha 18.1.196

Moch Satria Utama 18.1.199

Rudi Sentot 18.1.207

Rezita Immi Faradina 18.1.208

Verinta Sari Yulia 18.1.217

PROGRAM STUDI KEPERAWATAN

INSTITUSI TEKNOLOGI SAINS DAN KESEHATAN

RS. dr. SOEPRAOEN MALANG

TAHUN AKADEMIK 2020/2021

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 INTRODUCTION

Praise be to almighty god who bestows mercy upon us. Shallown and
salutations may always overflow to the prophet (peace and blessings be upon him).

We also extend our thanks to friends and to the parties. Giving support to the
completion of the paper with the title “PHYSICAL EXAMINATION ABDOMEN” as
one fulfills an English course to study the medical care of Dr. Soepraoen Poor
Hospital.

The paper is far from perfect then constructive criticism and advice we had
hoped. And so we thank our teacher for the English course of Mom Rahma
Kasimbara, M.Pd, who was able to make allowances for us, and we could only
plead with god.may we all receive the Ridho and god’s blessing. As well as the
merits of this paper.

Malang, October 5th 2020

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 Table of Contens

COVER i
INTRODUCTION ii
TABLE OF CONTENS iii
CHAPTER 1 PRELIMINARY 4
1.1 Background 4
1.2 Formulation of the problem 4
1.3 AIM 4
CHAPTER II LITERATURE REVIEW 6
2.1. Abdomen Anatomy 6
2.2. Abdomen blunt trauma 8
2.3. Pathophysiology of Blunt Abdomen Trauma 9
2.4. Intra-abdominal Organ Injury Due to Blunt Abdomen Trauma 10
2.5 Footprints in the Region Abdomen 14
2.6 Abdomen Pain 15
CHAPTER III Learning Learaders Gastroenterohepatology System 18
A. Anamnesia Of Man Complaints18
B. Physical Examination Gastroenterohepatology 18
C. My Aus Lay it out 19
CHAPTER 4 CONCLUSION AND RECOMMENDATION 23
4.1. Conclusion 23
4.2. Recommendation 23
REFERENCES 24

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 CHAPTER 1

PRELIMINARY

1.1 Background

A physical examination or clinical examination is a process by which a

medical professional examines the patient's body for clinical signs of disease. The
results of the examination will be recorded in the medical record. Medical records
and physical examinations will assist in the diagnosis and planning of patient care.

Usually the physical examination is carried out systematically, starting with the
head and ending at the limbs. After examination of the main organs by examination,
palpation, percussion, and auscultation, some special examinations such as
neurological examination may be required.

With the instructions obtained during the history and physical examination, the
medical professional can make a differential diagnosis, listing possible causes of
symptoms. Several tests will be performed to determine the cause.

A complete examination will consist of an assessment of the patient's general

condition and specific organ systems. In practice, vital signs or checks of
temperature, pulse and blood pressure are always done first.

1.2 Formulation of the problem

1. Understand what a abdominal physical exam is

2. Pathophysiology of trauma the abdomen is blunt
3. Clinical symptoms performed abdominal examination
4. Procedures for physical examination of the abdomen

1.3 AIM

1.3.1 General purpose

Able to identify and identify definitions, techniques, and assessment of

physical examination results on the cardiovascular and abdominal sections.

1.3.2 Special purpose

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a. Know and understand the definitions and objectives and
physical examination techniques
b. Know and understand the abdominal physical exam

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 CHAPTER II

LITERATURE REVIEW

2.1. Abdomen Anatomy

Abdomen is a cavity between the thorax and the body pelvis. This cavity
contains the viscera and is enclosed in an abdominal wall formed from muscle
abdomen, vertebral column, and the ilium bone. To help determine a location on
the abdomen, the most commonly used is the division of the abdomen by two
planes horizontal shadow and two vertical shadow planes. The shadow field
divides the anterior abdominal wall into nine regions ( regiones). Two of them
runs horizontally through the level of the ninth rib cartilage, the lower one as high
as the part over the iliac crista and two other vertical areas on the left and right of
the body, namely of cartilage eighth rib to the middle of the inguinal ligament. The
abdominal regions are: 1) hypocondriaca dextra, 2) epigastrica, 3) hypocondriaca
sinistra, 4) lumbar dextra, 5) umbilical, 6) lumbar left, 7) right inguinal, 8) pubica /
hypogastrica, 9) inguinalist sinistra ( Image 1)

Figure 1.The division of the abdominal anatomy based on the location of

the organs in it (Griffith, 2003)

1. Hypocondriaca dextra includes organs: the right lobe of the liver, gall bladder,
in part duodenum hepatic flexure of the colon, part of the right kidney and
right suprarenal gland.
2. Epigastrica includes organs: gastric pylorus, duodenum, pancreas and part of
liver.

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3. Hypocondriaca sinistra includes organs: gastric, spleen, caudal part of the
pancreas, flexure splenic colon, proximal part of the left kidney and left
suprarenal gland.
4. Lumbar dextra includes organs: ascending colon, distal part of the right
kidney, partially duodenum and jejenum.
5. Umbilical includes organs: Omentum, mesentery, lower part of the duodenum,
jejenum and ileum.
6. Lumbar left includes organs: ascending colon, distal part of the left kidney,
partially jejenum and ileum.
7. Inguinalist dextra includes organs: cecum, appendix, distal ileum and ureter
right.
8. Pubica / Hypogastric includes organs: ileum, bladder and uterus (in
pregnancy).

Inguinalist sinistra includes organs: sigmoid colon, left ureter and left
ovary. By knowing the projection of the intra-abdominal organs, one can predict
which organs who may experience injury if the physical examination finds
abnormalities in the area or region (Griffith, 2003)

For clinical purposes the abdominal cavity is divided into three regions,
namely: cavity peritoneum, retroperitoneum cavity and pelvic cavity. the pelvic
cavity actually consists of part intraperitoneal and part retroperitoneal. The
peritoneal cavity is divided into two namely the top and bottom. the upper
peritoneal cavity, which is covered with thoracic bones, including the diaphragm,
liver, spleen, gastric and transverse colon. This area is also known as thoraco-
abdominal component of the abdomen. While the lower peritoneal cavity contains
the intestines smooth, most ascending and descending colon, sigmoid colon,
caecum, and reproductive organs in women (Trauma, 2012)

The retroperitoneal cavity is located in the back of the abdomen,

containing the abdominal aorta, inferior vena cava, most of the duodenum,
pancreas, kidneys, and ureters, surface posterior ascending and descending
colon and the retroperitoneal component of the pelvic cavity. Meanwhile, the
pelvic cavity is surrounded by pelvic bones which are basically parts bottom of

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 the peritoneal and retroperitoneal cavities. Contains the rectum, bladder, vessels
iliac blood, and internal reproductive organs in women (Griffith, 2003)

2.2. Abdomen blunt trauma

Abdominal trauma is defined as damage to located structures between

the diaphragm and pelvis resulting from a blunt or stab wound (Ignativicus &
Workman, 2006). In the United States, victims of trauma are estimated
approximately 57 million annually, resulting in approximately 2 million people
being hospitalized and 150,000 deaths. With the economic burden caused by
trauma is quite significant, it is estimated that trauma results in a loss of life of
26% and more half of them lose their productive age (Tentilier, E. Masson,
2000). Abdominal trauma, is a fairly frequent cause of death, found in about 7
- 10% of patients trauma. In Europe, blunt abdominal trauma accounts for
about 80% of all traumas abdomen. The most common causes of blunt
abdominal trauma are car accidents or motorcycles, falls from heights, and
industrial accidents. An American study stated that traffic accidents accounted
for 83.6% of blunt abdominal trauma. 45.5% due to car accidents and 38.1%
due to motorcycle accidents. The mortality rate is higher in patients with blunt
abdominal trauma versus puncture trauma (Aziz, Bota and Ahmed, 2014). In
Indonesia, it is found that the national prevalence of injury is equal to 8.2%,
where the highest prevalence was found in South Sulawesi (12.8%) and the
lowest in Jambi (4.5%). The most common causes of injury were falls (40.9%)
and motorcycle accidents (40.6%), then the cause of injury was due to an
object sharp / blunt (7.3%), other land transportation (7.1%) and falling
(2.5%). Cause of injury the highest motorbike transportation was found in
Bengkulu (56.4%) and the lowest was in Papua (19.4%) (Ministry of Health,
2013).

Blunt abdominal trauma is trauma that affects the abdomen caused by

trauma with high energy. It is very important to know the mechanism of the
trauma to assess the amount of trauma energy that hits the patient. Some
trauma categorized as high energy trauma are: falls from a height of more
than 10 feet, bouncing off of the vehicle, motor vehicle accident with over
speed 45 miles / hour, a major fracture, invoice of the first rib and fracture of

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 the rib the bottom, the seat belt sign ( Seat Belt Sign), pedestrians or
motorists bikes that were hit, and a high rate of vehicle damage (Jones et al.,
2014).

In blunt abdominal trauma, intra-abdominal organ injury is common is

a solid organ, especially the spleen and liver where these two organs can
cause intra abdominal bleeding. As for hollow organs it is quite rare, and often
associated with seat-belt or high speed decelerations (Iga et al., 2010). The
key to successful management of blunt abdominal trauma is high awareness
intra-abdominal injury in each trauma patient, so as to detect it as early as
possible an intra abdomenal injury (Gad et al., 2012).

2.3. Pathophysiology of Blunt Abdomen Trauma

The pathophysiology of intra-abdominal injury in blunt abdominal

trauma is associated with mechanism of the trauma that occurs. High energy
trauma patient will experience severe physical shock causing organ injury.
(Mehta, Babu and Venugopal, 2014). There are several mechanisms of injury
to blunt abdominal trauma which can cause intra-abdominal organ injury,
namely:

1. Direct impact to the intra-abdominal organs between the abdominal walls

anterior and paskaerior

2. Avulsion injury caused by the deceleration force in an accident with high

speed or falling from a height. The deceleration force is divided into horizontal
decelerations and vertical decelerations. In this mechanism stretching occurs
on fixed organ structures such as pedicles and ligaments that can be causing
bleeding or ischemia (Guillion, 2009).

3.External compression force that causes increased intraabdominal

abruptness that reaches a peak usually causes hollow organ injury. The
weight of the perforation depends on the style and area the surface of the
injured organ

4. Intra-abdominal organ laceration caused by bone fragments (pelvic

fracture, rib fracture)

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 5. A sudden, massive increase in intra-abdominal pressure may result
diaphragm injuries and even cardiac injuries.

Direct trauma to the abdomen or rapid decelerations resulting in

damage to intraan abdomen that does not have flexibility ( noncomplient
organ) such as liver, spleen, kidneys and the pancreas. Injury pattern in blunt
abdominal trauma is often caused by accidents between motorized vehicles,
pedestrians who are hit by motorized vehicles, falling from height and beating
with blunt objects. Blunt abdominal trauma occurs due to direct compression
of the abdomen with a solid object resulting in tearing of the subscapular solid
organs such as the liver or spleen. It could also be the deceleration force that
causes it tear of organs and blood vessels in the fixed region of the abdomen
(liver or artery renalis). Or it could be due to external compression causing an
intraluminal increase which causes injury to the hollow organ (small intestine).
Blunt abdominal trauma the majority often affects the spleen around 40% -
55%, the liver 35% - 45% and the small intestine 5% - 10% (Avini et al.,
2011).

2.4. Intra-abdominal Organ Injury Due to Blunt Abdomen Trauma

Depending on the type of organ injured, intra-abdominal organs can be

divided into two namely solid organs and hollow organs. Included in solid organs,
namely: liver, mesentery, kidney, spleen, pancreas, bladder, internal genetalia in
women, and diaphragm, while the hollow organs include the intestines (stomach,
duodenum, jejunum, ileum, colon, rectum), ureters, and bile ducts. Several organ
injuries are common in patients who have experienced blunt abdominal trauma,
among others:

1. Liver Injury / Liver

The liver is the largest organ in the abdominal cavity which is well protected.
but these organs are often injured other than the spleen organs. Most liver
injuries mainly due to its size, location and the so-called thin capsule Glisson
capsule. Liver injury is generally injury due to blunt trauma. The heart occupies
almost the whole region hypochondrica dextra, partially in the epigastrium and
often extends to region hypochondrica sinistra as far as the mammilaria line,

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protected by the IX and X ribs right side. The liver can be injured due to blunt
trauma or trauma translucent. The liver is an organ that often experiences
lacerations, while the gallbladder trauma is very rare and difficult to diagnose.
Management of deep liver trauma The last 30 years have seen a lot of
development along with a lot of research and literature on the management of
liver trauma. One of the retrospective studies ever conducted in 1992-2008 in the
city of Barcelona, Spain in 143 patients with a diagnosis liver trauma, 87 patients
were conservative (74%) while 56 patients were treated surgery (26%) (She et
al., 2016).

Upper right abdominal pain accompanied by injury after trauma is a symptom

which happens a lot. The tenderness and rigidity of the abdominal muscles will
not appear until bleeding in the abdomen can cause irritation of the peritoneum.
Examination CT scan accurate inside determining the location and extent of liver
injury, assessing the degree of hemoperitoneum, shows other intra-abdominal
organs that may be involved in injury, identify complications after liver trauma that
requires immediate treatment especially in trauma patients heavy heart, and used
to monitor recovery. Use CT scan proved to be very useful in the diagnosis and
management of liver trauma. With CT scan decreased the number of laparotomy
in 70% of patients or caused a shift from routine surgical handling is a non-
operative treatment of liver trauma cases (Njile, 2012).

2. Spleen / Lien Injury

The spleen is an organ of the reticulo-endothelial system, which is the largest

lymphoid (lymphoid) tissue of the body. The spleen is about the size of a fist and
is located just below the left hemidiaphragm. Projection of the location of the
spleen on the abdomen i.e. located in hypocondriaca sinistra. This organ is
located in the upper left quadrant of the dorsal abdomen,attached to the lower
surface of the diaphragm and protected by the curve of the left rib. Parallel to the
posterior ribs IX, X XI, and separate from the diaphragm and pleura (Sander,
2015)

The spleen or spleen is an organ that is often injured during blunt trauma
abdomen. Spleen injury is a life-threatening condition due to its presence heavy
bleeding. The spleen is located just below the left thoracic skeleton, a vulnerable

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place to experience injury. The spleen helps our body to fight infections that are
on in the body and filter all the material that is no longer needed in the body such
as cells body that's been damaged. The spleen also produces red blood cells and
various types of cells White blood. Tearing of the spleen causes a large amount
of blood in the abdominal cavity. Injury to the spleen is usually caused by impact
on the left upper or left abdomen under. The events that most often cause spleen
injuries are sports accidents, fights and car accidents (Alonso et al., 1997).

Several studies explain that the symptoms and signs are the most common by
spleen trauma patients is pain (90%) and abdominal tenderness ( 85%).
Suspicion the occurrence of spleen injury is also found in the presence of fracture
of the left IX and X ribs, or left upper quadrant abdominal pain. Peritoneal signs
such as tenderness and muscular defenses will appear after bleeding that
irritates the peritoneum. All patients with symptoms of tachycardia or hypotension
and pain in the left upper quadrant abdomen after trauma, should be spleen
injury is suspected until it can be ruled out by investigations. Diagnosis using CT
scan routinely performed at the central hospital trauma (Ribs et al., 2010).

3. Intestinal injury
Peritonitis is a characteristic sign of intestinal injury. From a physical
examination got symptoms' burning epigastric pain 'followed by tenderness
and defense muscular of the abdomen. Bleeding in the colon and small
intestine will be followed by symptoms generalized peritonitis in the next hour.
While bleeding in the duodenum is usually symptomatic of pain in the back.
The diagnosis of bowel injury is confirmed by finding free air on conventional
abdominal X-rays. While in patients with injury to the duodenum and sigmoid
colon were obtained examination on X-ray of the abdomen with the discovery
of air in the retroperitoneal cavity (Mehta, Babu and Venugopal, 2014).
4. Kidney Injury
The retroperitoneal organs most commonly injured are the kidneys. Trauma
the kidney accounts for 1% -5% of all trauma. Kidney trauma can be a problem
life-threatening acute, but most kidney trauma is mild and can treated
conservatively. Kidney trauma is injury to the kidneys that is caused by various
kinds of trauma, both blunt and sharp. Kidney trauma is trauma most of the
urogenital system. Approximately 10% of trauma to the abdomen injures kidney

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 Developments in imaging and the degree of trauma over the last 20 years
have been reduced rates of surgical intervention in cases of renal trauma.
Usually blunt trauma occurs in cases of traffic accidents, falls from heights, sports
injuries or fight. Information about the history of trauma is very important to know
so can judge the magnitude of the deceleration process that occurs. Very fast
deceleration can be cause damage to blood vessels, renal artery thrombosis,
stretching of blood vessels veins, or avulsion of the renal pedicles (Lynch et al.,
2005). Hematuria is a diagnostic point which is important for kidney trauma. But
not sensitive and specific enough to differentiate whether a minor trauma or a
major. Keep in mind that the severity of hematuria is uncorrelated straight with
the severity of kidney trauma. Even for severe kidney trauma, such as; tearing
ureteropelvic junction, renal pedicle trauma, or arterial thrombosis may present
without being accompanied with hematuria (Lynch et al., 2005).

5. Pancreatic Injury
Trauma to the pancreas is very difficult to diagnose. Most cases are known
with exploration at surgery. Pancreatic injury should be suspected once it has
occurred trauma to the center of the abdomen, for example from a motorcycle
handlebar impact or car steering wheel impact. Injuries to the pancreas have a
high mortality rate. Patient may show symptoms of pain in the upper and mid-
abdomen that radiates down to the back. Within hours of trauma, irritation
symptoms can be seen peritonial. Diagnosis by determination of serum amylase
is usually of little help acute process. Examination CT scan can make a more
specific diagnosis (Aziz, Bota and Ahmed, 2014).
6. Ureter injury
Trauma to the ureter is rare but has the potential to cause morbidity and
morbidity mortality. Ureteral trauma is often not recognized when the patient
arrives or in patients with multiple trauma. Suspicion of ureteral injury may be
found in the presence of hematuria post trauma. The mechanism of blunt trauma
to the ureter can occur due to sudden circumstances from decelerations and
accelerations associated with hyperextension, direct impact on lumbar region II
and III, The sudden movement of the kidneys causes an upward movement
descending in the ureter causing a pull on ureteropelvic junction. On Patients with
suspicion of blunt ureteric trauma usually present with pain flank down to the
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 lower abdomen. Shock features occur in 53% of cases, which indicates the
occurrence of bleeding more than 2000 cc. The diagnosis of blunt ureteric trauma
is frequent It is known too late because of the frequent findings of symptoms due
to other trauma, so levels the highest suspicion was for trauma with more
pronounced symptoms. Therapeutic options are depending on the location, type
of trauma, time of occurrence, patient's condition, and prognosis patient. The
most important thing in choosing surgery is knowing for sure renal function that is
contralateral to the site of the trauma (Lynch et al., 2005).

7. Diaphragm Injury
In blunt abdominal trauma, diaphragmatic tears can occur anywhere on both
diaphragms. The most important and dangerous if it hits the left diaphragm,
related to the surrounding organs. The site of injury is usually the postero lateral
region from the left diaphragm. On the initial thoracic photo examination, you will
see a larger diaphragm high or hazy, usually in the form of hematorax, or the
presence of air shadows make the diaphragm image blurry, or show the NGT that
is attached to the stomach seen in thorak. In a small portion of the chest
radiograph shows no abnormalities. Diaphragm injury can be seen on
examination CT scan abdomen in blunt trauma patients abdomen

2.5 Footprints in the Region Abdomen

The presence of injury or injury to the abdominal region can predict injury
the organs underneath. In abdominal trauma usually found contusions,
abrasions, lacerations and ecchymosis. Ecchymosis is an indication of intra-
abdominal bleeding. There is Ecymosis in the umbilical region we usually call
Cullen's Sign while the ecchymosis found on one of the pelvis referred to as
Turner's Sign. Traces or injuries found in patients with blunt abdominal trauma
is an important predictor in assessing whether the injury also resulted in injury
to the underlying organs. Patient with blunt abdominal trauma we often notice
lesions in the abdominal region but there are also those without injuries. The
presence of injury makes us think more to do further examination to prove if
there is an organ injury in in it or not. Meanwhile, if there are no lesions, it is
still necessary to pay attention to whether the patient is experiencing intra-
abdominal injury or not by assessing other clinical symptoms. Because the
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 mechanism of intra-abdominal injury can also be due to the deceleration
process, not only because trauma directly. Assessment of the injury can
predict what organs are affected underneath according to the location of the
abdominal anatomy, and according to other clinical symptoms (Neeki et al.,
2017). One type of injury that is often found is a lesion that resembles a belt
safety ( Seat Belt Sign). An American study states that patients with Seat Belt
Sign after a traffic accident there are more likely to be intra-abdominal injuries
than patient without Seat Belt Sign. Patients with SBS but without abdominal
pain are at risk lower incidence of intra-abdominal organ injury (Sokolove,
2000). Other research also supports that patients with seat belt marks ( Seat
beat sign) after motor vehicle accidents carry a greater risk of intra-abdominal
injury than those without the mark Seat Belt Sign. Even so, at some cases of
intra-abdominal injury are often not accompanied by injury and no initial
complaints of abdominal pain on examination. The risk of intra-abdominal
injury always exists before it is proven not to occur. especially those caused
by the deceleration process. Evaluation by observation, examination
laboratory, and computed tomography is generally required (José Gustavo
Parreira and Juliano Mangini Dias Malpaga, 2015).

2.6 Abdomen Pain

Abdominal pain is a clinical sign that is evaluated on palpation. Pain can also
spontaneous without palpation. The location of the pain is very important to know
possibly the organs affected. Generalized abdominal pain is a sign important
possibility of peritonitis due to irritation of the peritoneum, both by blood and
intestinal contents. Tendency to move the abdominal wall ( voluntary guarding)
can be difficult abdominal examination. Otherwise defans muscular (involuntary
guarding) is a sign important of peritoneal irritation. Palpation determines the
presence of superficial tenderness, tenderness deep, or loose pain. Loose pain
occurs when the hand that touches the stomach is released suddenly - sudden,
and usually indicates peritonitis arising from blood or intestinal contents irritating
to the peritonium (Rostas et al., 2015). The presence of blood or intestinal fluid in
the cavity peritoneum will give signs of peritoneal stimulation in the form of
tenderness, pain knock, loose pain and stiffness ( rigidity) abdominal wall.
Abdominal wall stiffness can be also caused by hematomaa on the abdominal
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wall. The presence of blood in the cavity abdomen can be determined by shifting
dullness, whereas free air is defined by deaf-hearted who leave or disappear.
Abdominal trauma accompanied by peritoneal stimulation can give symptoms in
the form of pain in the shoulder area, especially the left. This symptom known as
referred pain who can help make the diagnosis (Gallagher et al., 2004)
There are 4 tools Unidimentional Pain Rating Scale ( UPRS) the main used in
clinical practice to assess pain. Consists of Numeric Rating Scale ( NRS), Verbal
Rating Scale ( VRS), Faces Pain Scale ( FPS) and Visual Analogue Scale
( VASE). Visual Analogue Scale ( VAS) is one of the quick methods used in the
emergency department to assess the degree of pain in trauma patients. The main
requirement of this examination is the patient must be well aware. The
examination can be done immediately without intervention or by palpating the
abdomen. VAS is a simple technique for measuring the patient's subjective
experience of pain. VAS has been validated and can reliable clinical and research
applications, although there is also evidence increased error and decreased
sensitivity when used in some groups the subject. VAS has been used very widely
in recent decades in research related to pain relief with reliable, valid and
consistent results. VAS is a instrument used to assess pain intensity by means of
a table 10 cm line with the following interpretations: 0 (no pain), 1-2 (mild pain), 3-
6 (pain moderate), 7-8 (severe pain), 9-10 (very severe pain). The way of
assessing is sufferers Mark yourself with a pencil on a scale value that
corresponds to the intensity of the pain he felt after being given an explanation
from the examiner about the meaning of each scale the. Determination of the VAS
score is done by measuring the distance between the ends of the line
demonstrated painlessness to the point indicated by the patient (Laeseke and
Gayer, 2012)
Abdominal pain is a specific sign to assess the presence of intraabdomen in
trauma patients, ranging from moderate pain, with VAS 3 to pain very heavy So
this examination is very important for patient management Furthermore. In his
research Neeki, et al stated that mild abdominal pain in Blunt abdominal trauma is
associated with a lower splenectomy rate. Trauma patient dull abdomen with mild
abdominal pain takes a longer period of time to perform diagnostic actions such
as ultrasound and CT scan abdomen to rule out any intra-abdominal injury (Neeki
et al., 2017). Other research revealed that abdominal pain in blunt abdominal
16
trauma is associated with laparotomy, in which the absence of abdominal pain in
abdominal trauma reduces the rate surgical intervention undertaken to save the
patient (Zago et al., 2012).
Delay in recognizing signs of intra-abdominal injury including pain abdomen is
very dangerous to patient safety and increases morbidity and rates mortality of
patients with blunt abdominal trauma. Overall patients with blunt trauma The
abdomen shows many clinical symptoms which are difficult to identify. So that it
takes the doctors in the emergency department carefully to assess it. Besides
pain the abdomen should also be seen for other signs associated with
intraabdomen resulting in better diagnosis and patient management (Farrath et
al., 2012).

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 CHAPTER III
Learning Lear\aders
Gastroenterohepatology System
No STEP / ACTIVITIES CASE
A. ANAMNESIA OF MAN COMPLAINTS 1 2 3

1. Say hello, the examiner stands and performs a

handshake
2. Please sit down

3. Create an atmosphere of help and fun

4. Ask for identity : name, age, address, occupation

5. Ask about the main complaints and current history
(depending on ech scenario):
1. The onset (since when) and the duration (how
long) the factors that reduce complaint
2. Weight and any part / region associated with the
complaint
3. Other symptoms related to the
6. Patient’s history
1. History of living habits : food and drink,
medication, disease
2. Past medical history, family history of disease.

B. PHYSICAL EXAMINATION 0 1 2
GASTROENTEROHEPATOLOGY
Inspection
1. Lay the patient in a supine position, with the light source
covering the feet to the head, or covering the abdomen
Stand on the patient's right side, let the
2. examiner be able to see the patient's abdomen clearly
and without obstruction Examine the hair, conjunctiva,
sclera and skin.

3. Inspection of normal or abnormal abdominal contours

18
 4. If abdominal distension appears, evaluate for obesity,
tympanitis (presence of excess air or gas), ascites,
pregnancy, stool and neoplasms
5. Look for abnormal features on the abdominal surface
such as: scar tissue (scar), venous congestion (portal
venous hypertension, caput medusae) peristalsis (pyloric
obstruction, small bowel-colonic obstruction) or an
abdominal mass.
C. My Aus Lay it out
1. Patients are asked to relax and breathe normally
2. Place the membrane or stethoscope bell (if unclear)
above the mid-abdomen (umbilicus) or below the
umbilicus and over the suprabupic
3. Listen for peristalsis / bowel sounds (such as the sound
when the stomach is hungry or twisted), if not
immediately heard, continue listening for 5 minutes
4. Determine normal or abnormal based on the number of
times it occurs per minute
5. Evaluate bowel sounds in the four quadrants of the
abdomen properly
6. Abnormal vascular noise that can be found
- Hepatic rub: above and to the right of the umbilicus like
a loud grumbling sound
- Bruit of pancreatic carcinoma in the left epigastric and
splenic friction region rub in the left lateral abdomen, as
flow through a narrow gap, periodic according to systolic
contractions
7. Record the auscultation results

Palpation

1. Before palpation, hand rubbed warm according to room /

19
 body temperature
2. The patient is asked to bend both knees and breathe with
the mouth open (if the patient appears tense and the
abdomen is hardened to allow abdominal relaxation)
3. Have a conversation with the patient while palpating
4. Perform light palpation by placing the palms of the hands
on the abdomen slowly, add the fingers while pressing
gently into the abdominal wall about 1 cm (fingernails do
not pierce the abdominal wall) If pain is immediately
found on palpation, the patient's head can be elevated
using a pillow
5. Assess tenderness or not by paying attention to the
patient's face or expression
6. Perform palpation in a bimanual manner, assessing the
liver and spleen (normally not palpable), with the same
steps on light palpation but pressing deeper (4-5 cm) up
and down
7. Palpation of the spleen (Schuffner method & Hacket
method). The spleen tip palpable under the left costal
arch indicates splenomegaly
- The right hand is inserted behind the margin of the
left rib at the maxillary line. The left hand is placed
under the thorax with the added radius under the
ribs.
- The patient is asked to inspire deeply, the right
hand goes deeper behind the rib margins and is
raised, while the left hand raises the back of the
costovertebra.
- Do it several times according to the rhythm of
inspiration while placing the position of the right
hand in different places / directions. Palpation of
the liver: value of surface, edge, tip and liver
tenderness
8. Palpation of the liver: value of surface, edge, tip and liver
tenderness
- The right hand with the adduction radius is
inserted starting in the lower right quadrant region

20
 with the volar surface of the hand touching the
abdominal surface. The left hand is placed under
the thorax in a supine position
- On deep inspiration, the right hand is moved
superiorly and deep, when final inspiration is
reached, together with the left hand raises the area
of the right costovertebrae. This step is carried out
below the margin of the right rib.

9. Abnormal Palpation
- Blumberg's sign (+) /
rebound tenderness: it
hurts if you press the
fingertips lightly against

21
 the abdominal wall in the
lower left area, then
suddenly pull back the
fingers.

- Rovsing's sign (+): pain

when pressed in the
lower left area
- Psoas sign (+): pain when
the lower leg is flexed
towards the abdomen
- Obturator sign (+): it hurts
when the leg is lifted up
with the knee extension

10. If an abdominal mass is found, assess:

location, size, size, elasticity, mobility and pulse
Percussion
1. Perform percussion on all four
quadrants of the abdomen
2. Perform percussion of the border of
the lungs in the right midclavicle line,
starting from the second intercostal
3. The chest resonant sound becomes faint when
it reaches the liver, when it continues
downward, the faint sound changes to tympanic
when percussion is above the colon
4. Determine the location and size of the liver

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 CHAPTER 4

CONCLUSION AND RECOMMENDATION

4.1 Conclusion

Abdomen is the cavity between the chest and pelvis of the body. This
cavity contains the viscera and is covered by the abdominal wall which is
formed from the abdominal muscles, spine, and illium bones. To help locate
the abdomen, the most common method is to divide the area by two
horizontal and two vertical image planes. These areas of the abdomen
include: 1) hypocondriaca right, 2) epigastrica, 3) hypocondriaca left, 4) right
lumbar, 5) umbilical, 6) lumbar left. For clinical purposes, the abdominal
cavity is divided into three regions, namely: peritoneal cavity, retroperitoneal
cavity and pelvic cavity.

Abdominal trauma is defined as damage to the structures that lie

between the diaphragm and pelvis as a result of blunt or puncture wounds.
The most common causes of blunt abdominal trauma are car or motorcycle
accidents, falls from heights, and industrial accidents.

4.2 Recommendation
With the completion of this writing, the writer hopes the readers if they
find errors in writing to correct them. And if there is something that can be
used as study material by the reader, the writer will feel motivated. Readers’
suggestions and criticisms of the writer are writing.

23
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