Abdominal Examination/Dr.

Abdulqadr

1/Inspection:

-From nipple to mid thigh,include genitalia.

-injuries in 4th intercostal may duo to liver injury.

-blood supply of testes the right one from aorta and left one
from abdominal aorta.

-paraaortic lymph node:located in left side of umbilical.

-Symmetric and borders of abdomen.

-Abdominal dissension:abdomen may distended or may

flat,by the ruler or something else from xiphoid to
symphysis pubic ,if touch all abdomen is flat,but if not
touched distended,and also we have abdominal
scaphoid,and there is gap.

-Hair distribution.

-Umbilical: invertd or everted.

-Also ask the patient cough we look to there is any hernia.

-Venous dilatation:three site for venous dilatation.

-Around umbilical.

-Costal margin.

-Flank.

visible in Inferior vena cava obstruction,duo to

And this venous dilatation called caput medusae,which is

dilation of veins,which occur in chronic liver disease,and
portal hypertension duo to that in normal person systemic
pressure more higher than portal pressure but in portal
hypertension portal pressure higher than systemic pressure.

Other sign of arteroivenous anastomoses left epigastric vein

and azygos vein around lower third of esophagus.

Third anorectal region,Fourth bare area of liver that not

covered by peritoneum,Five retro diaphragmatic.

Also for examination index finger over middle part of dilated

vein then empty the vein by to index finger remove blood
from vein and if see the vein no dilated from that mean
blood from umbilical to away .

If there is inferior vena cava obstruction from dawn to

umbilical.

In lateral aspects inguinal axillary from inguinal venous

plexus to axillary because by passing IVC and there’s
obstruction here.by passing upward.

-color:redness of abdomen may duo to cellulitis,which is

inflammation of subcutaneous tissue.

Or maybe yellow discoloration duo to jaundice,for different

between obstructive jaundice(surgical) and medical
jaundice(Hemolytic anemia)by Inspection:we look for
scratch,in surgical jaundice duo to disposition of bile
secretion(disposition of bilirubin),treatment for itching

Is cholesterol amine.

Which change bile salt to water soluble and secreted with

urine.tablespoon in glass of water.

-visible pulse:eye level to upper surface of abdomen.

We look to supraumbilical area,possibilities of pulsation

May duo to abdominal aortic aneurysm.

AA:mean Acute Abdomen.

AA:mean Acute Appendicitis.

AAA:Abdominal Aortic Aneurysm.

AAAA:Anemia Asthenia Anorexia Group A blood is for

gastric cancer.

And blood group O mostly may has gastric ulcer.

Asthenia mean weakness and lack of energy.

And this visible pulse may duo to transmitted pulsation for

example abdominal aorta and there is mass sitting on
abdominal aorta.

And this mass could be retro peritoneal mass,or CA

pancreases,or CA stomach,or hydrated cysts of the retro
peritoneal area.

How we can differentiate between AAA and transmitted

pulsation?both index finger on it and two movements for
aortic aneurysm,wider separation and elevation of finger.

But in transmitted pulsation only elevation no expansion.

-Scar:site of Scar:midline,right paramedian,left paramedian,

Subcostal margin,right subcostal margin called koxer

incision for cholecystectomy,and left subcostal margin.

Cadaveric incision form xiphoid sternum to suprapubic use

for bomb injuries(shell injury).

-huge mass if present.

-Movement with respiration:if no movement with respiration

is indicate pain,or paralysis of all intestine and generalized
peritonitis.

-Peristalsis:movements of intestine,if you check from left to

right in upper part of abdomen,usually occur in midday
called hunger peristalsis.and audible peristalsis called

Borborigmi.and diagnosis of it gastric outlet obstruction.

Petechiae:small subcutaneous bleeding,occur in ITP

Hematoma:large size.

-spider nevi :is composed of central arterial surrounded by

capillaries.by the pin press if spider nevi remove but if
ordenari nevi not removed.also we cam difference between
them by magnifying glass.

In liver cirrhosis patient has jaundice+spider nevi+dilated

vein around umbilical.

We should say Acute appendicitis or its chronic.

Check for Acute appendicitis:

McBurney line. we draw imaginary line between

supraanterioilliacspine and umbilical,junction of medial two
third and lateral third called mcburnery .

Test for Acute appendicitis:

1.Pointing test:ask patient to cough where site of pain.

2.McBurney test:Press to medial two third and lateral third

and look to face of patient.

How we know it’s right iliac fossa?

Two vertical line two horizontal line,vertical line mid clavicle

line to midinguinal point.

We have two term midinguinal ligament and point.

Midinguinal ligament is the ligament that join pubic tubercle

to anterior iliac spine,but midinguinal point extend from
anterior iliac spine to symphysis pubis.

Two horizontal line upper from subcostal.

We can’t touch ten rib,and its nine and ten comes to touch
nine above this line.

11 and 12 called floating rib.

Lower horizontal:transtubercle.

DDH/development dislocation of hip.

From lower why not from anterior iliac spine?

Duo to limping leg In DDH if stand is not horizontal line is

oblique line.

How you can find iliac crest?

Find anterior iliac spine then follow anterior iliac spine the
second most prominent iliac crest.

3.Most important test is localized tenderness.

4.rebound tenderness mechanism of pain:

Visceral peritoneum and parietal peritoneum,visceral nerve

supplied by Autonomic nervous system but parietal by
lower six intercostal nerve,when press on it you are
touching parietal peritoneum lowering down when you
move your hand upward suddenly cause irritation of parietal
peritoneum by acute appendix causing pain.

5.rolfzen test:press over left iliac fossa,pressings on

sigmoid colon Other name called pelvic colon By this
mechanism feeling severe pain in right side of abdomen,the
mechanism is increasing pressure,gas inside colonic lumen
will be reflected backward,increasing pressure in cecal area
appendix attached to cecum increase intralumen pressure
cause severe pain in acute appendicitis,mechanism number
two most of small bowel presents in left side.and cause
pressure.

6.obturator test:.90 degrees Reflexion of hip joint and 90

degree reflexion of hip joint then internal rotation feel severe
pain in right iliac fossa.obturator muscle attached to inner
aspect of upper head of femur cause contraction touched
to infected appendix and cause severe pain .

7.Sous test :palm of left hand over hip joint take all lower
limb by right hand and has pain duo to contraction of sous
muscle.

8.sheren test:there is triangle umbilical and anterior iliac

spin and pubic symphysis bring something not sharp press
over skin there is nothing when you reach right side patient
shout duo to severe pain,mechanism of test Hyperesthesia
by dermatome.

Palpation of kidney:bimanual examination:left hand below

costal margin below last rib never mention number lateral to
paraspinal muscle,right hand over lumbar region,pushing by
left hand and detecting by right hand.anterior hand called
watching hand posterior hand called depressing hand.

Renal angle tenderness:lower border of last rib,the angle

that located between horizontal line of last rib and
paraspinatous muscle called renal angle.

Two test by local pressure on renal angle and percussion,

And third one by hitting for very obese patient.

Second lecture abdominal examination:

Best way to relax muscle take breath from mouth.

In history taking say right upper abdomen and.....no right

iliac fossa we say right iliac fossa in Examination.

-Aim of superficial palpation: locate site of pathology.

-Aim of deep palpitation:details os superficial pathology.

-Temperature.

Rectus Abdominal joined by linea alba.

-Spleen palpation:for splenomegaly,why we start from right

iliac fossa?duo to direction of spleen enlargement is right
iliac fossa.

Say to patient to breath.why?because during respiration

spleen intraperitoneal organ and move with respiration,and
move dawn.

Sometimes there is resistance and can’t relax abdomen

such in perforated vesicous For this hand over hand .

How we know I know this is spleen?

.Notch.

.sharp edge.

.direction enlargement.

.can not get above it.

.in percussion dull.

Kidney resonant duo to lobes of bowel between kidney and

anterior abdominal wall.

Spleen should be 2.5 enlarged then palpable.

.spleen is mobile kidney is not mobile.

Bimanual palpation of spleen(just palpable):lateral right

position put one hand support other hand above.

Liver palpation:say to patient to breath also liver move duo

to its intraperitonum.

Also measure how many cm below costal margin.

If it’s nodules,may has cirrhosis or mitastaic.also for

tenderness.

Test for Acute cholistaytis?

1.Murphy sign:say to patient breath mid clavicular below

costal margin put your hand here position of hand funds of
gallbladder then deep deep breath during one of breath
press patient stop from respiration then that mean murphy
sign positive.

Or palm of hand parallel to costal margin and thumb below

costal margin in mid clavicular line ask patient deep breath
during one inspirations press and patient stop from
inspiration.

Auscultation:

Bowel sound:for bowel sound stethoscope in right iliac

fossa because sound pass from iliac to cecum here and
sound pass from narrow lumen to wider lumen there’s
amplification of sound.and wait for one minute.

1.No bowel sound/called ileus.

2.sluggish bowel sound/less than 3 in one minute.

3.normal bowel sound.

4.exaggerated bowel sound.More than 3 in 1 minuetIn

intestinal obstruction for two day but then became
paralysis.

Also auscultation for AAA.

Also for renal artery stenosis.

Also when we have pulsation in epigastric region.

Also we should do back Examination.

Also we should do rectal examination.

For rectal examination lateral position,but best one is knee

elbow position,very tiered patient in same position.

First inspection:

For swelling,thrombosis,abscess,strangulated pay.

Contraindication for PR examination:

-Acute painful fissure

-Thrombosed pile

-perianal abscess/sub mucus abscess.

-thrombitis of pile. /infection of pile.

Index finger put over annul pressure then after few second
become relaxation.

Put your brain on tip of finger.

Any palpable mass,foreign body,hard feces,palpable ulcers,

Prostate benign or malignancy in benign mobile but in

malignancy fixed.and normally there is groove between
right and left lobe but in malignancy this groove not remain.

Also we have shifting dullness in Abdominal Examination:

In huge a cities assistant hand? other hand opposite side

and tap there is impulse hitting hand.also transmission is
positive.

In huge acitis can’t exam spleen and liver so push spleen

down hitting your hand when come back.

In percussion is dull but when patient move lateral upper

part become resonant because fluid go dawn.

Also we should palpate left supraclavicular Lymph node

Varicose Lymph node and sign called trozas sign.

Why left side?

Because cictema chyli start in portal hepatic then move to

right side but at level of maniburnum sterni pass to left
side .