Abdominal Examination

‡ Expose the patient from the xiphisternum pubic symphisis. ( leave the genitalia covered until u want to examine them)

egions of the abdomen:
‡ There are 9 regions in the abdomen divided by 2 horizontal lines and 2 vertical lines ( the midclaviclular lines)

Contents of each region: ‡ Lt. Iliac fossa: ± Terminal ileum ± Appendix ± Ovaries (also in LIF) ‡ Suprapubic area: ± Urinary bladder . Hypochodrium: ± Liver ± Rt. Kidney ± Gall bladder ‡ Rt. Hypochodrium: ± Spleen ± Lt. Kidney ‡ Rt.

INSPECTION ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Shape of the abdomen Movement of abdominal wall Umbilicus Surgical scars or dilated veins Cautery marks Striae Hair distribution Hernial orifices .

Fetus. Fluid.Shape of the abdomen ‡ Normal ‡ Schaphoid (sunken): ± Wasting ± Starvation ‡ Distension: by the 5 Fs (Fat. Feces & Flatus) .

‡ Can be absent in peritonitis. .Movement of abdominal wall ‡ Movement with respiration: normally present in normal people. (inflammation of the peritoneum) ‡ Visible peristalsis ( contractile movement of the intestines): usually absent.

Umbilicus ‡ Normally circular and inverted ( pushed inward) ‡ Look for any hernias .

. ‡ Dilated veins: indicate portal hypertension or obstruction of the inferior vena cava ± Assess the direction of blood flow in the veins if they are dilated.‡ Surgical scars: indicate the type of previous surgery according to their location in the abdomen.

.g. loss.Striae ‡ White striae: ‡ Are due to fast changes in abdominal size e. ascites. pregnancy. ‡ Purple striae: due to Cushing Syndrome. wt.

.Hair distribution ‡ Male hair distribution: is convex upward towards the umbilicus (like a triangle pointing upwards) ‡ Female hair distribution: is concave upwards (like a triangle pointing downwards).

.Hernial orifices ‡ Assessed by asking the patient to cough which causes hernias to bulge outwards due to increased intra abdominal pressure.

‡ Rub your hands if the are cold.PALPATION ‡ The patient abdominal wall muscles must be relaxed to be able to palpate the abdomen. . ‡ Ask the patient about any tender areas and palpate them at the end of the examination.

( liver.««) 3. Superficial Palpation 2. Deep Palpation & assessment of internal organs enlargement.1. spleen. kidney. Dipping .

± Rigidity: with tenderness they indicate underlying inflammation (peritonitis) ± Guarding ± Superficial Masses: ± temperature .1.Superficial palpation ‡ Palpate the whole abdomen gently in a circular movement assessing for the following signs: ± Tenderness: is pain on touching.

2.Deep palpation ‡ Press with your fingers during expiration. ‡ Keep looking at the patient face ( for detecting tenderness. wait for the organ to move downwards during inspiration and touch your finger tips. ‡ Rebound tenderness: press firmly then release suddenly induces pain this also indicates peritonitis .

Masses Asses for ‡ Site ( location) ‡ Size ‡ Shape ‡ consistency ‡ Surface ‡ Movement with respiration ‡ Mobility ( movement) ‡ Upper & lower limits of the mass ‡ Bimanually palpable or not .

‡ Size: asses the diameters of masses by using your finger width (1 finger=2 cms) ‡ Consistency: ± cystic: water filled balloon ± Very soft: like jelly ± Soft: like relaxed muscle ± Firm: like the tip of the nose ± Hard: like contracted muscle ± stony hard: bone like .‡ Site: According to the site of the mass. its possible to define its most likely cause(s).

kidney and gallbladder all move with respiration.g. . nodular ‡ Edge: sharp or rounded ‡ Movement with respiration: liver.‡ Surface: smooth. ‡ Mobility. spleen. ‡ Bimanually palpable or not: kidneys can be bimanually palpable if enlarged. irregular. ‡ Upper & lower limits of the mass: e. you can¶t get above an enlarged spleen.

. Lobe of the liver can be palpable esp.‡ Palpation of the liver: start from the right iliac fossa moving to the right hypochondrium. in thin people. ‡ The edge of the Rt. ‡ When the liver is palpable percuss for its upper border as it may be displaced downwards.

then it can be felt as a smooth globular swelling. Hypochondrium ‡ Normally not palpable. ‡ Murphy¶s Sign: sudden tenderness when palpating for the gall bladder and asking the patient to take a deep breath. ‡ If enlarged.Gall bladder ‡ Situated in the Rt. ‡ Moves with respiration. .

‡ It needs to be enlarged 2-3 times to be palpable (below the costal margin) ‡ Enlarges towards the Rt. Iliac fossa (RIF) ‡ Method: palpate from RIF moving towards Lt. to take a deep breath. hypochondrium.Spleen ‡ Lies in the Lt. ‡ Assess the spleen size below the costal margin using the width of your fingers. ‡ Ask the pt. hypochondrium using the same maneuver as the liver examination. .

Kidneys ‡ Renal angle tenderness: can be +ve if there is an abscess or infection in the kidney (pyelonephritis) ‡ If enlarged the can be bimanually palpable. ‡ They move with respiration. .

Kidney Spleen Downwards and medially Towards RIF Present No No Dull Direction of enlargement Downwards Towards LIF Notch Bimanually palpable Can get above it?? Absent Yes Yes Percussion note above it Resonant ( due to overlying gut) .Differential diagnosis of Lt. Kidney and Spleen feature Lt.

. when distended becomes palpable as a rounded swelling in the hypogastrium ( e.Urinary bladder ‡ Not palpable when empty.g. urine retention) ‡ Palpation of the mass induces desire to micturate.

.3. ‡ Done by making a quick press with your hand repeatedly which displaces fluid and if an organ is present it can be felt.Dipping ‡ Is a method to detect for organ enlargement when there is a large ascites.

Organ diameter: e.g. .Detection of ascites.percussion ‡ Used to asses: 1. Liver span 2.

Bowl sounds 2.Auscultation ‡ For: 1.Bruit 3.Friction rub .

‡ Are normally audible every 5-10 seconds.‡ Bowl sounds: best heard near to the Rt. ‡ Note for frequency (frequent or infrequent) and intensity( loud. Iliac fossa. ‡ They can be loud and frequent in intestinal obstruction. ‡ They can be absent in paralytic ileus . absent or normal).

‡ Bruit: ‡ Is an abnormal sound that occurs due to narrowing of arteries outside the heart ( if heard above the heart then it¶s a murmur) ‡ Can occur in renal artery stenosis. .

cauttery marks( ). . hernial orifices are intact. striae or dilated veins. no visible pulsation. umbilicus is central and of normal shape. No surgical scars. the abdominal wall is moving normally with respiration.The normal abdominal examination ‡ Inspection: shape of the abdomen is normal. or peristalsis. ‡ The pubic hair is of male distribution.

‡ Percussion: no fluid thrill & no shifting dullness. .‡ Palpation: no rigidity or tenderness. ‡ Auscultation: bowl sounds are 3-5 per minute. of normal intensity. No bruit or friction rub audible. no palpable viscera or masses palpable.

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