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KKD UNPAR
Kamis, 14 Februari 2013
PEMERIKSAAN ABDOMEN
Anamnesis
HISTORY QUESTIONS
PAIN IN ABDOMEN CHANGE IN APPETITE CHEWING AND SWALLOWING PROBLEMS HEARTBURN NAUSEA, VOMITING, REGURITATION RECTAL BLEEDING
HISTORY QUESTIONS
ELIMINATION HEMORRHOIDS VOIDING DIFFICULTY PREVIOUS SURGERY WEIGHT GAIN OR LOSS TYPE OF DIET MEDICATIONS
Dysphagia
Signs and symptoms
Reports of difficulty swallowing Difficulty controlling food or saliva in mouth Facial droop Dementia, frailty, confusion Inability to sit upright
PEMERIKSAAN ABDOMEN
Think Anatomically
Think Anatomically
When looking, listening, feeling and percussing imagine what organs live in the area that you are examining.
RLL: right lateral plane LLL : left lateral plane TPP: transpyloric plane (L 1) TTP: transtubercular plane (L 5)
Epigastric Area
Stomach, pancreas (head and body), aorta
General Considerations
1. 2. 3. 4. 5. 6. 7. The patient should have an empty bladder. The patient should be lying supine on the exam table and appropriately draped. The examination room must be quiet to perform adequate auscultation and percussion. Watch the patient's face for signs of discomfort during the examination. Use the appropriate terminology to locate your findings Disorders in the chest will often manifest with abdominal symptoms. It is always wise to examine the chest when evaluating an abdominal complaint. Consider the inguinal/rectal examination in males. Consider the pelvic/rectal examination in females.
1. INSPECTION
Physicians locate findings in the abdomen in one of four quadrants or one of nine regions. The four quadrants are: right upper (RUQ), right lower (RLQ), left upper (LUQ) and left lower (LLQ). THE NINE REGIONS epigastric, umbilical, hypogastric/suprapubic, right hypochondriac, left hypochondriac, right lumbar, left lumbar, right inguinal and left inguinal.
1. INSPECTION
HAIR DISTRIBUTION UMBILICUS CONTOUR o a. FLAT o b. ROUNDED o c. SCAPHOID o d. PROTUBERANT (DISTENDED) PERISTALSIS
Jaundice : warna kuning pada kulit Prominent veins : may be due to portal vein obstruction or inferior vena cava obstruction
ABDOMINAL DISTENSION
Distension of the lower abdomen only can be caused by pregnancy, full bladder, ovarian tumor, or uterine fibroids (common benign growths) Diffuse abdominal distension can be caused by any of the 6 Fs:
Fat (obesity) Fluid (ascites - peritoneal fluid - or obstructed viscera filled with fluid) Flatus (air) - e.g. from air swallowing or intestinal obstruction Feces (constipation Fetus (pregnancy) Fatal cancer.
Symmetrical in shape
slightly full but not distended in older age group due to poor muscle tone or in subjects who are mildly overweight
An aortic aneurysm
Palpable mass Patient feeling of pulsation On rare occasions, a lump can be visible.
An aortic aneurysm
1 in 10 men over 65 may have some enlargement of the abdominal aorta. About 1 in 100 will have a large aneurysm requiring surgery.
Striae
Stretch marks are a light silver hue. Pregnancy and obese individuals Cushings syndrome (more purple or pink).
Cullens sign
Ecchymosis periumbilically. (intraperitoneal hemorrhage ruptured ectopic pregnancy, hemorrhagic pancreatitis..)
Grey-Turners sign
Ecchymosis of flanks. (retroperitoneal hemorrhage such as hemorrhagic pancreatitis)
hernias
Visible Pulsations
More conspicuous in the thin than in the fat Greater in the old than in the young. Increased in thyrotoxicosis, hypertension, or aortic regurgitation) In those with an aortic aneurysm and tortuous aorta In those who have a mass joining the aorta to the anterior abdominal wall.
Gastric peristalsis is commonly seen in neonates with congenital hypertrophic pyloric stenosis
Intestinal peristalsis in partial and chronic intestinal obstruction Colonic obstruction is usually not manifest as visible peristalsis
comfortable
position
2. AUSCULTATION
GUT SOUNDS
Use the diaphragm of your stethoscope to listen to gut sounds Normal gut sounds are gurgling, 5 to 35 per minute Borborygmi are loud, easily audible sounds. They are normal, too. High pitched , tinkling (raindrops in a barrel) sounds are a sign of early intestinal obstruction Decreased sounds: (none for a minute) are a sign of decreased gut activity. Gut sounds may be markedly decreased after abdominal surgery; abdominal infection (peritonitis) or injury. Absent Sounds : (no sounds for 5 minutes) are a bad sign. They can be caused by longer-lasting intestinal obstruction, intestinal perforation or intestinal (mesenteric) ischemia or infarction
2. AUSCULTATION
Active bowel sounds 5-30/min Hypoactive 4/min or less Hyperactive 30 or more /min Bruits o A. Aorta o B. Renal o C. Iliac Friction rub
activity.
Peristalsis: A pregressice wavelike movement that occurs involuntarily in hollow tubes of the body.
pathognomonic
for any particular process.
Auscultation
1.Diaphragm of stethoscope used 2.Skin depressed to approximately 1 cm
Auscultation
3.Listening in one spot is usually sufficient 4.Listening for 15-20 or 30-60 seconds
5.Bowel sounds cannot be said to be absent unless they are not heard after listening for 3-5 minutes.
Splash Sign
Splashing sound indicative of air or fluid in body cavity with shaking individual: normal in s stomach.
Bruits
Bruits confined to systole do not necessarily indicate disease.
Rubs Rubs-Rubs
Liver Spleen Cardiac Pulmonary
3. PERCUSSION
What it finds: liver size (kind of), spleen, fluid. Percussing the body gives one of three notes: Tympany is found in most of the abdomen, caused by air in the gut. It has a higher pitch than the lung. Resonance is found in normal lung. It is lower pitched and hollow. Dullness is a flat sound, without echoes. The liver and spleen, and fluid in the peritoneum (ascites: ah-SY-teez), give a dull note.
A. Liver Span Percuss downward from the chest in the right midclavicular line until you detect the top edge of liver dullness. Percuss upward from the abdomen in the same line until you detect the bottom edge of liver dullness. Measure the liver span between these two points. This measurement should be 6-12 cm in a normal adult. B. Splenic Dullness Percuss the lowest costal interspace in the left anterior axillary line. This area is normally tympanitic. Ask the patient to take a deep breath and percuss this area again. Dullness in this area is a sign of splenic enlargement.
Percussion
Technique Liver Spleen
Percussion (technique)
DIP joint of third finger (pleximeter) pressed firmly on the abdomen remainder of hand not touching the abdomen
Percussion (technique)
Striking hand should move only at the wrist, with only little more than force of gravity
Percussion (technique)
Middle finger of striking hand (plexor) should knock the pleximeter firmly, with a strong note
Spleen percussion
Enlarged spleen produce a dull tone, in the left upper quadrant percussion but should then be verified by palpation.
Shifting Dullness This is a test for peritoneal fluid (ascites). ++ Percuss the patient's abdomen to outline areas of dullness and tympany. Have the patient roll away from you. Percuss and again outline areas of dullness and tympany. If the dullness has shifted to areas of prior tympany, the patient may have excess peritoneal fluid. Psoas Sign This is a test for appendicitis. ++ Place your hand above the patient's right knee. Ask the patient to flex the right hip against resistance. Increased abdominal pain indicates a positive psoas sign. Obturator Sign This is a test for appendicitis. ++ Raise the patient's right leg with the knee flexed. Rotate the leg internally at the hip. Increased abdominal pain indicates a positive obturator sign.
ILIOPSOAS TEST
4. PALPATION
General Palpation 1. Begin with light palpation. At this point you are mostly looking for areas of tenderness. The most sensitive indicator of tenderness is the patient's facial expression (so watch the patient's face, not your hands). Voluntary or involuntary guarding may also be present. 2. Proceed to deep palpation after surveying the abdomen lightly. Try to identify abdominal masses or areas of deep tenderness
Abdominal Palpation Technique Light Deep Liver edge Spleen tip Kidneys Aorta Masses
Abdominal palpation
To palpate four quadrants superficially from LLQ
counterclockwise
Light Palpation
First warm your hands by rubbing them together before placing them on the patient. Abdominal wall depressed approximately 1 cm
Abdominal palpation
Use pads of three fingers of one hand and a light, gentle, dipping maneuver to examine abdomen
Palpation (light)
Any areas of pain or tenderness are reserved for evaluation at the end of the exam
Light Palpation
Mostly looking for areas of tenderness Tenderness is a physical exam finding a reflex occurs (muscle splinting, wide eyes, moaning, teeth gritting).
Palpation (deep)
Entire palm Either one- or two handed technique is acceptable
Deep Palpation
Use palmar surface of fingers of one hand (greatest number of fingers) and a deep, firm, gentle maneuver to examine abdomen
Palpation
Palpate deeply with finger pads (do not dig in with finger tips)
Deep Palpation
Palpate tender areas last Try to identify abdominal masses or areas of deep tenderness
Palpation (deep)
Push as deeply as patient will allow without significant discomfort
Abdominal mass
Intra abdominal masses or enlargements of the liver, gallbladder or spleen Abdominal wall mass
Paraumbilical node
Visceral pain
This is pain that arises from an organic lesion or functional disturbance within an abdominal viscus (dull, poorly localized, and difficult for the patient to characterize).
Somatic pain
Painful lesion of the skin Sharp, bright, and well localized Indicates involvement of parietal peritoneum or the abdominal wall itself
Tenderness
If there is tenderness determine the point of maximum tenderness and its distribution
Board-like rigidity
If abdominal wall is palpated as obviously tense, even as rigid as a board, board-like rigidity is so called. Is caused by the spasm of abdominal muscle due to peritoneal irritation.
Liver palpation
Another method of palpating the liver uses the radial border of the index finger. In this method the anterior hand is placed flat on the anterior abdominal wall with fingers parallel to the costal margin
Is useful when the patient is obese or when the examiner is small compared to the patient.
Hepatomegaly
More than 1cm below the costal margin An exception is a congenitally large right lobe of the liver Severe, chronic emphysema
Ballotable sign
Spleen palpation
Seldom palpable in normal adults. Causes include COPD, and deep inspiratory descent of the diaphragm.
Spleen palpation
Support lower left rib cage with left hand while patient is supine and lift anteriorly on the rib cage.
Spleen palpation
Palpate upwards toward spleen with finger tips of right hand, starting below left costal margin. Have the patient take a deep breath.
Kidney palpation
Place left hand posteriorly just below the right 12th rib. Lift upwards. Palpate deeply with right hand on anterior abdominal wall.
Examination of Kidney
Patient take a deep breath. Feel lower pole of kidney and try to capture it between your hands.
Examination of Kidney
Examination of Aorta
Examination of Aorta
Press down deeply in the midline above the umbilicus. The aortic pulsation is easily felt on most individuals.
Examination of Aorta
Hands then oriented vertically on either side of midline with distal fingers at level of pulsation; equal pressure applied until pulsation is palpated
A well defined, pulsatile mass, greater than 3 cm across, suggests an aortic aneurysm.
Examination of Aorta
Special exam
Murphys Sign McBurneys Point Rovsings Sign Psoas Sign Obturator Sign
Re bound Tenderness Costovertebral tenderness Shifting Dullness Fluid wave
McBurneys Point
Localized tenderness Just below midpoint of line between right anterior iliac crest and umbilicus. Heel strike, riding over bumps in road while driving, coughing, will produce pain.
Rovsings Sign
Patient will experience right lower quadrant pain (in region of McBurneys Point) when left lower quadrant is palpated.
Non-Classical Appendicitis
Iliopsoas Sign
Patient can lay on side and extend leg at the hip or have patient lay on back and try to flex hip against the resistance of examiners hand on thigh. If patient has an inflamed retrocecal appendix, this will produce pain.
Iliopsoas Sign
Anatomic basis for the psoas sign: inflamed appendix is in a retroperitoneal location in contact with the psoas muscle, which is stretched by this maneuver.
Obturator Sign
Internally rotate right leg at the hip with the knee at 90 degrees of flexion. Will produce pain if
Obturator Sign
Anatomic basis for the obturator sign: inflamed appendix in the pelvis is in contact with the obturator internus muscle, which is stretched by this maneuver.
Shifting Dullness
Fluid wave