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In The Name Of God

In The Name Of God. THE ABDOMINAL EXAMINATION. Dr. N Aletaha M.D. General principles of exam. State of exam Good light Relaxed patient Full exposure of abdomen. Equipment Needed A Stethoscope . General principles of exam. The patient should have an empty bladder .

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In The Name Of God

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  1. In The Name Of God

  2. THE ABDOMINAL EXAMINATION Dr. N Aletaha M.D

  3. General principles of exam • State of exam • Good light • Relaxed patient • Full exposure of abdomen • Equipment Needed • A Stethoscope

  4. General principles of exam • The patient should have an empty bladder. • The patient should be lying supine on the exam table and appropriately draped.

  5. General principles of exam • The examination room must be quiet to perform adequate auscultation and percussion. • The patient should have keep his arms at his sides or folded on the chest. • The patient should be positioned so that the abdominal muscles are relaxed. 

  6. It is important that the patient is • 1) lying flat • 2) have their arms at their sides • 3) have a pillow

  7. The patient should be undraped so that the abdomen is visible from the nipples to at least the anterior superior iliac spines.

  8. Before the exam, ask the patient to identify painful areas so that you can examine those areas last • Watch the patient's face for signs of discomfort during the examination • Use warm hand, warm stethoscope, and have short finger nails. • Approach the patient slowly and deliberately explainingwhat you will be doing.

  9. General principles of exam • Stand right side of the bed • Exam with right hand • Ask the patient to keep the mouth partially open and breathe gently

  10. INSPECTION • PALPATION • PERCUSSION • AUSCULTATION • Different order for abdoman exam • INSPECTION • AUSCULTATION • PERCUSSION • PALPATION

  11. If the patient is ticklish or frightened Initially use the patients hand under yours as you palpate. When patient calmsthen use your hands to palpate. • Watch the patient’s face for discomfort.

  12. Use the appropriate terminology to locate your findings: • Right Upper Quadrant (RUQ) • Right Lower Quadrant (RLQ) • Left Upper Quadrant (LUQ) • Left Lower Quadrant (LLQ) • Midline: • Epigastric • Periumbilical • Suprapubic

  13. The abdomen is commonly divided using a quadrant system.  • R and L Upper quadrants • R and L Lower quadrants

  14. Another system divides the abdomen into 9 areas: • R and L hypochondria • R and L lumbar • R and L inguinal • Epigastric • Umbilical • Suprapubic

  15. Useful landmarks for the abdomen • The midclavicular line

  16. Think Anatomically • Describe relevant anatomy and physiology as it pertains to the examination of the abdomen

  17. Right upper quadrant • Liver • Gallbladder • Pylorus • Duodenum • Pancreas(head) • Right kidney • Hepatic flexure of colon

  18. Right lower quadrant • Cecum • Appendix • Ascending colon • Small intestine • Right ovary and tube

  19. Left upper quadrant • liver (left lobe ) • spleen • Stomach • pancreas (body, tail) • left kidney • splenic flexure of colon

  20. Left lower quadrant • Sigmoid colon • Descending colon • Small intestine • Left ovary and tube

  21. Right hypochondrial liver gallbladder right kidney hepatic flexure of colon right lumber ascending colon jejunum right kidney right iliac cecum appendix right ovary and tube

  22. Epigastricliver (left lobe) pylorus duodenum omentumtransverse colon the head and body of pancreas umbilical duodenum jejunum ileum mesentery abdominal aorta lymph node omentumhypogastricbladder uterine ureter

  23. Left hypochondrial spleen stomach splenic flexure of colon pancreas (tail part ) left kidney left lumber descending colon jejunum ileum left iliac sigmoid colon left ovary and tube

  24. Landmarks of the abdominal wall • Costal margin, umbilicus, iliac crest, anterior superior iliac spine, symphysis pubis, inguinal ligament, rectus abdominis muscle, xiphoid process.

  25. (physical exam of other site) • INSPECTION • PALPATION • PERCUSSION • AUSCULTATION • LAB TEST

  26. Physical Examination of the Abdomen • Inspection • Auscultation • Percussion • Palpation • Special Tests

  27. Inspection • Inspection is always an important first step in any physical examination. Look at the abdominal contour and note any asymmetry. Record the location of scars, rashes, or other lesions.

  28. Inspection • The patient should be inspected for signs of liver disease.  Such as palmarerythema, Dupitran's contracture, jaundice etc.  • One can look for bulging flanks from the foot of the bed.

  29. Inspection • Look for scars, striae, hernias, vascular changes, lesions, or rashes. • Look for movement associated with peristalsis or pulsations. • Note the abdominal contour. Is it flat, scaphoid, or protuberant?

  30. Look for abnormal mass around the umblicus Sister Mary Joseph's Nodule

  31. Auscultation • Unlike other regions of the body, auscultation comes before percussion and palpation (the sounds may change after manipulation). Record bowel sounds as being present, increased, decreased, or absent. Auscultation

  32. Auscultation • Place the diaphragm of your stethoscope lightly on the abdomen. • Listen for bowel sounds. Are they normal, increased, decreased, or absent? • Listen for bruits over the renal arteries, iliac arteries, and aorta. • Each quadrant can be auscultated for bruits.

  33. Auscultation • Bruits confined to systole do not necessarily indicate disease. • Don't be fooled by a heart murmur transmitted to the abdomen.

  34. Auscultation • Normal bowel sounds occur every 5-10 seconds.  • 1.Listening in one spot is usually sufficient • 2.Listening for 15-20 or 30-60 seconds • 3.Bowel sounds cannot be said to be absent unless they are not heard after listening for 3-5 minutes.

  35. Auscultation • Listen at least for 2 minutes at one area before concluding absence • Listen at 3 areas • Absent BS = paralytic ileus or peritonitis

  36. Percussion • Percussion • Tympany is normally present over most of the abdomen in the supine position. • Unusual dullness may be a clue to an underlying abdominal mass.

  37. Percussion • Liver Span • Measure the liver span by percussinghepatic dullness from above (lung) and below (bowel) in the R mid-clavicular line . A normal liver span is 10-12 cm (male) or 8-10 (female) in the midclavicular line.

  38. Percussion • Liver Span • Percussdownward from the chest in the right midclavicular line until you detect the top edge of liver dullness. • Percussupward 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 8-12 cm in a normal adult.

  39. Percussion • Splenic Enlargement • To detect an enlarged spleen, percuss the lowest interspace in the left anterior axillaryline. • Ask the patient to take a deep breath and repeat. • A change from tympany to dullness suggests splenic enlargement.

  40. Palpation Palpation • 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. • Voluntary or involuntary guarding may also be present.

  41. Deep Palpation • Deep Palpation • Proceed to deep palpation after surveying the abdomen lightly. Try to identify abdominal masses or areas of deep tenderness.

  42. Palpation • Begin palpation away from any area of pain (as identified from the history), and do the painful area last. Palpate all 4 quadrants using both light and deep palpation. • Abdominal aortic aneurysms may present as a pulsatile mass in in the epigastric or periumbilical regions.

  43. Palpation of the Liver • To palpate the liver edge, place your fingers just below the costal margin and press firmly. Ask the patient to take a deep breath. • You may feel the edge of the liver press against or slide under your hand. A normal liver is not tender.

  44. Palpation of the Liver • Alternate Method for Liver Palpation • An alternate method for palpating the liver uses hands "hooked" around the costal margin from above. The patient should be instructed to breath deeply to force the liver down toward your fingers.

  45. Palpation of the Aorta • The aorta is easily palpable on most individuals. You should feel it pulsating with deep palpation of the central abdomen. An enlarged aorta may be a sign of an aortic aneurysm.

  46. Palpation of the Spleen • Press down just below the left costal margin with your right hand while asking the patient to take a deep breath. It may help to use your left hand to lift the lower rib cage and flank. The spleen is not normally palpable on most individuals.

  47. Kidney palpation • Bimanual (balloting) • Place left hand posteriorly just below the right 12th rib. Lift upwards. • Palpate deeply with right hand on anterior abdominal wall.

  48. Kidney palpation • Patient take a deep breath. • Feel lower pole of kidney and try to capture it between your hands.

  49. Special Tests • These tests are useful in special situations: • Rebound Tenderness • Costovertebral Angle Tenderness • Shifting Dullness • Fluid wave

  50. Rebound Tenderness • This is a test for peritoneal irritation. Palpate deeply and then quickly release pressure. If it hurts more when you release, the patient has rebound tenderness.

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