Abdominal examination

ABDOMINAL EXAMINATION

Daniel Eshetu

1

2

Out line

• Introduction

• Inspection

• Auscultation

• Palpation

• Percussion

• Interpretation

3

Introduction

• Basic topography

– Nine Vs four quadrant of the abdomen

– Reminder: Please note the anatomical location of each abdominal organs in each quadrant

4

Anatomical areas

5

Anatomical areas

6

Introduction cont…• General principle

The patient relaxed and comfortable in supine position

Use relaxation techniques if neededHead supported with pillowKeep the supinated arm by patient sides, warm hands

• Requirements:Insure good illuminationFull exposure of the abdomen( from xipisternum to

upper thigh)Be on the right side of the patient

7

Proper exposure for examination

8

INSPECTION

• Shape and contour, flank fullness, – Scaphoid/flat /distended: reference will be the level of

the abdomen between sternum and symphysis pubis

• Symmetry• Discoloration

– Striae: • Whitish in pregnancy• Pinkish in Cushing syndrome

– Localized hyper-pigmentation: Cullen’s sign, Grey-turner’s sign

• Peristalsis, pulsations,

9

Inspection cont…• Distended vessels:

– Normal direction of flow: above the umbilicus upward and below the umbilicus downward.• Portal hypertension-veins draining away from the umbilicus• IVC obstruction - reversal of flow in the lower abdomen – i.e

draining towards the umbilicus

• Umbilicus– Direction of slit: normally inverted – Horizontal slit, eversion– Swelling– Discoloration– Nodule around or signs of inflammation

• Hernia sites

10

Causes of distension

• Gross distension (5 F)

• Fluid

• Flatus

• Feces

• Fetus

• Fat

• Localized distension

– Loculated fluid

–Mass

–Hernia

–Organomegaly

– Impacted feces

11

Gross abdominal distension

12

Localized distension

13

14

Abdominal auscultation

15

Auscultation cont…

• Bowel sounds: four quadrant– Normal range 4-35/min, every 2-5 sec

– Hypoactive: eg. Peritonitis

– Hyperactive: eg. Obstruction

• Bruits:– Over enlarged organ

– Renal artery: few cm above the umbilicus lateral at the edge of rectus abdominus.

– Aneurysmal

16

Auscultation cont…

• Venus hum:

– Heard over collateral veins disappear by hard pressing with stethoscope unlike bruit

– Not localized to systole only unlike bruit

– May disappear with changing position unlike bruit

• Friction rub:

– seen in infarction, sub-capsular hemorrhage and inflammation of spleen or liver

17

Palpating the abdomen

18

Palpation cont….• Step 1: ask for any pain and location.

• Step 2: – Start superficial palpation away from the site.

– If none proceed with anticlockwise move starting from the LLQ :

– look for tenderness, temperature, mass, rigidity, guarding, pulsation

• Step 3: – Deep palpation starting from the LLQ.

– Examine the Left large bowel, Spleen, Epigsatrium, Liver, RUQ, suprapubic and periumblical,

• Step 4: Bimanual palpation for both kidneys

• Step 5: Flank fullness and fluid thrill, Succusion splash

19

Liver topography• Upper border:

– Rt lobe: 5th rib, 2 cm medial to the rt MCL and 1 cm below the rt nipple.

– Lt lobe: at 6th rib and Lt MCL, 2 cm below the lt nipple.

• Lower border:

– Rt: 9th costal margin

– Lt: 8th costal margin diagonally

– Crosses md way b/n the xyphi and umbilicus

• Edge moves 1-3cm by inspiration.

20

GB surface marking

21

Palpation of spleen

22

Cephalocaudad length of 13cm and width of 7cm

Techniques of spleen examination

• Bimanual palpation

• Ballottement

• Palpation from above (Middleton maneuver)

• Percussion

23

• Spleen– Size, direction of

growth– Notch– Above the mass– Bimanual palpability– Consistency– Tenderness– Friction rub– Bruit– Ballotable

2424

Examining the kidneysBimanual palpation

25

Eliciting fluid thrill

26

PERCUSSION

• Starting from the epigastrium umbilical suprapubic rt/lt lumbar region.

• Look for:

– Tympanicity

– Dullness-

• Direct and shifting

• Total vertical liver span(TLS= 10 ±2) . (8-12)

• Splenic percussion

27

Percusing the abdomen

28

Splenic percussionDelineating the spleen by Percussion

• Traube’s semilunar space – 6th rib superiorly, lt mid axillary line laterally and

costal margin inferiorly.

– Normal percussion note medial to lateral is resonant.

• Nixon’s method: – lower border of pulmonary resonance at Lt

posterior axillary percus diagonal 90 degree to mid lt costal margin

– Normal 6-8cm. If > 8 cm= splenomegaly

29

Shifting dullness

30

Digital rectal examination

• Rotate finger 360 degree• Assess-tone of sphincter and anal

musculature, irregularity and thickening of anal canal

• Feel prostate gland (male) and cervix (females)• Look for mucus, blood, pus on finger

31

Characterizing a pathology

• Organomegaly

• Specific mass

• Specific pathologies

Location, estimated size, shape, edge, surface regularity, consistency, tenderness, Mobility, pulsatility

32

Distinguishing Lt. kidney from spleen

• Inspection:– Kidney has less marked movement than spleen

with inspiration– Direction of growth: kidney grow down and

vertically• Palpation:

– Bimanually palpable: for kidney– Presence/absence of notch: Kidney has no notch – Getting above the mass: kidney, not for spleen

• Percussion: – Kidney may have overlying colonic resonance

33

INTERPRETATION

• Signs of acute abdomen

• Cystic lesion

• Mass

• Organomegaly

• Bowel pathologies

34

Intra peritoneal excess fluid- Ascites:(When exceeds 500ml)

Sensitive: (for ruling out)

• Absence of:

– Increase in abd. girth

– Flank fullness

– Flank dullness

– Shifting dullness

– fluid thrill

Specific (for ruling in)

Presence of:

– Fluid thrill (90%)

– Shifting dullness

35

Conclusion

• Make sure that basic requirements fulfilled.

• Use the four physical examination techniques– Inspection

– Auscultation

– Palpation

– Percussion

• Describe and/characterize abnormalities properly.

• Interpretation of physical finding is mandatory

36

Habesha Entertainment

• Like us on

• facebook.com/habeshaentertainment101

• follow me @danieleshetu99

• Habesha Entertainment

• http://habeshaentertainment.blogspot.com

37