Demonstration About Acute Demonstration About Acute AbdomenAbdomen
The History and Physical in The History and Physical in PerspectivePerspective
70%70% of diagnoses can be made based on of diagnoses can be made based on historyhistory alone. alone.
90%90% of diagnoses can be made based on of diagnoses can be made based on history and physical examhistory and physical exam. .
Expensive testsExpensive tests often confirm what is found often confirm what is found during the during the history and physicalhistory and physical. .
The Importence Of History The Importence Of History In Cases With Acute In Cases With Acute
AbdomenAbdomen
Personal HistoryPersonal History
Age: neonatal, childhood, adults, old Age: neonatal, childhood, adults, old ageage
SexSex
Special Habits: Smoking, Special Habits: Smoking, Alcoholism,..Alcoholism,..
History Of Presenting IllnessHistory Of Presenting Illness
Onset:Onset:
Appendicitis, rupture spleen, acute Appendicitis, rupture spleen, acute mesenteric ischaemiamesenteric ischaemia
Course:Course:
Perforated duodenal ulcer, ruptured Perforated duodenal ulcer, ruptured appendixappendix
Duration:Duration:
In seconds, minutes, hours, days….In seconds, minutes, hours, days….
(1) Analysis of patient complaint:(1) Analysis of patient complaint:
Exact onset Exact onset
Many conditions are precipitated by Many conditions are precipitated by exertion . It is important to know what the exertion . It is important to know what the patient was doing at the time of onset.patient was doing at the time of onset.
Fainting occurs with ectopic gestation, Fainting occurs with ectopic gestation, perforated GU/DU, a/c pancreatitis, perforated GU/DU, a/c pancreatitis, ruptured aortic aneurysm.ruptured aortic aneurysm.
Intestinal obstruction gradual in onset and Intestinal obstruction gradual in onset and culminates in crisisculminates in crisis
History Of Presenting IllnessHistory Of Presenting Illness
Analysis of patient complaint (cont.):Analysis of patient complaint (cont.):
Site of painSite of painCharacter of painCharacter of painIncreased byIncreased byDecreased byDecreased byRadiationRadiationReferralReferral
(2) Design your questions so as to find a (2) Design your questions so as to find a causecause for the patient complaint: for the patient complaint:
e.g.e.g.
If you suspect a complicated peptic ulcerIf you suspect a complicated peptic ulcer
If you suspect a renal colicIf you suspect a renal colic
If you suspect a portal pyaemiaIf you suspect a portal pyaemia
If you suspect a complicated herniaIf you suspect a complicated hernia
History Of Presenting IllnessHistory Of Presenting Illness
(3) Design your questions so as to find a (3) Design your questions so as to find a complicationcomplication for the patient complaint: for the patient complaint:
e.g.e.g.
Does a ruptured viscus lead to peritonitis??Does a ruptured viscus lead to peritonitis??
Does the irreducible hernia lead to Does the irreducible hernia lead to strangulation??strangulation??
Does the internal bleeding lead to shock??Does the internal bleeding lead to shock??
History Of Presenting IllnessHistory Of Presenting Illness
(4) Revision of other body systems(4) Revision of other body systems
Is there a contraindication to my proposed Is there a contraindication to my proposed surgery?surgery?
Is there a special precaution to be noticed?Is there a special precaution to be noticed?
Past HistoryPast History
Similar conditionsSimilar conditions
Major illness ( including drugs)Major illness ( including drugs)
Major trauma (including surgical trauma)Major trauma (including surgical trauma)
Blood transfusion, travel abroad, previous Blood transfusion, travel abroad, previous admissions to hospitalsadmissions to hospitals
Family historyFamily history
Similar conditions in the familySimilar conditions in the family
History of positive consanguinityHistory of positive consanguinity
Type of abdominal painType of abdominal pain
Visceral painVisceral pain Somatic painSomatic pain
Visceral painVisceral pain
This is pain is This is pain is dulldull, , poorly localizedpoorly localized, , and and difficultdifficult for for the patient to the patient to characterizecharacterize..
Somatic painSomatic pain
Sharp, bright, and Sharp, bright, and well localizedwell localized
Indicates Indicates involvement of involvement of parietal peritoneumparietal peritoneum or the or the abdominal abdominal wall itselfwall itself
Equipment for physical examinationEquipment for physical examination
Required Required Stethoscope Stethoscope
Tongue blades Tongue blades Penlight Penlight
Tape measure Tape measure Sphygmomanometer Sphygmomanometer Reflex hammer Reflex hammer Safety pins Safety pins
OptionalOptional GlovesGloves
Gauze padsGauze pads
Lubricant gel Lubricant gel
Nasal speculum Nasal speculum Turning forkTurning fork: : 128 Hz,512Hz128 Hz,512Hz
Pocket visual acuity Pocket visual acuity card card
Oto-ophthalmoscopeOto-ophthalmoscope
Important aspects of physical Important aspects of physical examination----physicianexamination----physician
Elegant appearanceElegant appearance
Decent mannerDecent manner
Kind attitudeKind attitude
Highly responsibilityHighly responsibility
Good medical Good medical moralsmorals
How to perform the physical How to perform the physical examination?examination?
Exposing only the Exposing only the area that are being area that are being examined examined
Offer a chaperone for Offer a chaperone for both sexes.both sexes.
Explain what you're Explain what you're going to dogoing to do
Sequential Sequential
Gloves should be worn when..Gloves should be worn when..
Examining any Examining any individual with individual with exudative lesionsexudative lesions or or weeping dermatitisweeping dermatitis
When handling When handling blood-soiledblood-soiled or or body body fluid-soiledfluid-soiled sheets sheets or clothingor clothing
General principles of examGeneral principles of exam
Good light Good light
Relaxed Relaxed patientpatient
Full exposure Full exposure of abdomenof abdomen
General principles of examGeneral principles of exam
Before the exam, ask Before the exam, ask the patient to the patient to identify identify painful areaspainful areas so that so that you can examine you can examine those areas lastthose areas last
During the exam pay During the exam pay attention to their attention to their facial facial expressionexpression to assess to assess for sign of discomfort for sign of discomfort
General principles of examGeneral principles of exam
If muscles remain If muscles remain tensetense, patient may , patient may be asked to be asked to rest rest feetfeet on table with on table with hipships and and knees knees flexedflexed
General examinationGeneral examination
Patient is alert, conscious, co-operative and Patient is alert, conscious, co-operative and oriented for time, place and person. oriented for time, place and person.
Special decubitus, average body weight Special decubitus, average body weight
Striking featuresStriking features
Vital signsVital signs
ColoursColours
What is CREST?scleroderma which is characterized by: Calcinosis; Raynaud's; Esophagus motility disorders; Sclerodactyly, Telangiectasia.
Peutz-Jeghers syndrome
Think Think AnatomicallyAnatomically
Think AnatomicallyThink Anatomically
When looking, When looking, listening, feeling and listening, feeling and percussing percussing imagine imagine what organs livewhat organs live in in the area that you are the area that you are examining. examining.
Landmarks of the abdominal wall,
Costal margin, umbilicus, iliac crest, anterior superior iliac spine, symphysis pubis, pubic tubercle, inguinal ligament, rectus abdominis muscle, xiphoid process.
Physical Examination of the Physical Examination of the Acute AbdomenAcute Abdomen
InspectionInspection Auscultation Auscultation Percussion Percussion Palpation Palpation Special Tests Special Tests
InspectionInspection
Very clearVery cleare.g. gunshotse.g. gunshots
Scars Scars
Appearance of the abdomenAppearance of the abdomen
Is Aortic Is Aortic pulsationpulsation? ?
Is it flat or Is it flat or Scaphoid Scaphoid ((Normally)?Normally)?
DistendedDistended? ?
If enlarged, does this If enlarged, does this appear appear symmetricsymmetric??
With With bulging or bulging or movingmoving??
Visible PulsationsVisible Pulsations
More conspicuous in the More conspicuous in the thin than in the fatthin than in the fat
Greater in the old than in Greater in the old than in the young.the young.
Increased in Increased in thyrotoxicosis, thyrotoxicosis, hypertension, or aortic hypertension, or aortic regurgitation)regurgitation)
In those with an aortic In those with an aortic aneurysm and tortuous aneurysm and tortuous aortaaorta
In those who have a In those who have a mass joining the aorta to mass joining the aorta to the anterior abdominal the anterior abdominal wall. wall.
Symmetrical in shapeSymmetrical in shape
Scaphoid or flat in young patients of normal weight
slightly full but not distended in older age group due to poor muscle tone or in subjects who are mildly overweight
Appreciation of abdominal contoursAppreciation of abdominal contours
Standing at the footStanding at the foot of of the table and looking up the table and looking up towards the patient's towards the patient's head. head.
Lower yourself until the Lower yourself until the
anterior abdominal anterior abdominal wallwall and ask the patient and ask the patient to breathe normally while to breathe normally while you are doing so. you are doing so.
Appearance of the abdomenAppearance of the abdomen
Global Global abdominal abdominal enlargement is enlargement is usually caused usually caused by by FsFs
(fat, fluid, flatus, (fat, fluid, flatus, food, foetus) food, foetus)
Appearance of the abdomenAppearance of the abdomen
Localized Localized enlargement enlargement probably distend probably distend GB space GB space occupyingoccupying lesion, lesion, hepatomegaly….hepatomegaly….
Appearance of the abdomenAppearance of the abdomen((Skin)Skin)
Abnormal Abnormal striastria
Umbilicus isUmbilicus is sunken sunken
StriaeStriae
Stretch marks are a Stretch marks are a light silver hue.light silver hue.
Pregnancy and obese Pregnancy and obese individualsindividuals
Cushing’s syndrome Cushing’s syndrome (more purple or pink).(more purple or pink).
Congenital naevus on the abdomenCongenital naevus on the abdomen
Appearance of the abdomenAppearance of the abdomen ( (Skin)Skin)
TattoosTattoosScars can be drawn on schematic diagrams of the abdomen (a picture is worth a thousand words).
Cullen’s signCullen’s sign
Ecchymosis Ecchymosis periumbilicallyperiumbilically. . (intraperitoneal (intraperitoneal hemorrhage hemorrhage ruptured ectopic ruptured ectopic pregnancy, pregnancy, hemorrhagic hemorrhagic pancreatitis..)pancreatitis..)
Grey-Turner’s signGrey-Turner’s sign
Ecchymosis of Ecchymosis of flanks. flanks. ((retroperitoneal retroperitoneal hemorrhage hemorrhage such as such as hemorrhagic hemorrhagic pancreatitis) pancreatitis)
Upward flow direction indicates IVC obstruction
Outward flow pattern from umbilicus in all directions ? Portal HTN
Evaluate venous return states
Place index finger side by side over a vein and press laterally, milking vein.
Release one finger and time refill, repeat with other finger. Venous return is in direction of faster filling.
Appearance of the abdomenAppearance of the abdomen
Areas which Areas which become more become more pronounced when pronounced when the patient the patient valsalvasvalsalvas are are often associated often associated with with ventral ventral herniashernias
Visible gastric PeristalsisVisible gastric Peristalsis
Gastric peristalsis is Gastric peristalsis is commonly seen in commonly seen in neonates with neonates with congenital congenital hypertrophic pyloric hypertrophic pyloric stenosisstenosis
Intestinal peristalsis in Intestinal peristalsis in partial and chronic partial and chronic intestinal obstructionintestinal obstruction
Colonic obstruction is Colonic obstruction is usually not manifest usually not manifest as visible peristalsis as visible peristalsis
Visible intestinal Visible intestinal PeristalsisPeristalsis
Appearance of the abdomenAppearance of the abdomen Patient's movement Patient's movement
Patients with Patients with kidney kidney stonesstones will frequently will frequently writhe on the writhe on the examination table, examination table,
unableunable to find a to find a
comfortablecomfortable positionposition
Appearance of the abdomenAppearance of the abdomen Patient's movement Patient's movement
Patients with Patients with peritonitisperitonitis prefer to lie prefer to lie
very stillvery still as any as any motion causes further motion causes further peritoneal irritation peritoneal irritation and pain. and pain.
Palpation Palpation
Abdominal Palpation Abdominal Palpation
Technique Technique
Light Light
Deep Deep
Liver edge Liver edge
Spleen tip Spleen tip
Kidneys Kidneys
Aorta Aorta
MassesMasses
Light PalpationLight Palpation
Light PalpationLight Palpation
First First warm your warm your handshands by rubbing by rubbing them together before them together before placing them on the placing them on the patient.patient.
Abdominal palpationAbdominal 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 PalpationLight Palpation
Mostly looking for Mostly looking for areas of areas of temprature, temprature, tenderness & rigidity.tenderness & rigidity.
Palpation Light palpation assesses
Muscle tone & Cutaneous hypersensitivity (suggests peritoneal irritation)
Palpation Light palpation assesses
Presence of superficial (intramural) masses is more prominent if patient raises their head ,Intra-abdominal mass is less prominent if patient raises their head
Deep PalpationDeep Palpation
Deep PalpationDeep PalpationUse palmar surface of fingers of one hand (greatest number of greatest number of fingers)fingers) and a deep, firm, gentle maneuver to examine abdomen
PalpationPalpation
Palpate deeply with Palpate deeply with finger finger padspads (do not (do not “dig in” with finger “dig in” with finger tipstips))
Deep PalpationDeep PalpationPalpate tender areas Palpate tender areas lastlast
Try to identify Try to identify abdominal abdominal massesmasses or or areas of areas of deep deep tendernesstenderness
Normal structure that may be Normal structure that may be palpablepalpable
Sigmoid colon Sigmoid colon
LiverLiver
KidneyKidney
Abdominal aortaAbdominal aorta
Iliac arteryIliac artery
Distended bladderDistended bladder
Gravid and non-Gravid and non-gravid uterus gravid uterus
Xyphoid processXyphoid process
spleen spleen
TendernessTenderness
If there is tenderness If there is tenderness determine the point of determine the point of maximum tendernessmaximum tenderness
Abdominal muscle spasmAbdominal muscle spasm
Voluntary guardingVoluntary guarding Tensing abdominal Tensing abdominal muscles due to muscles due to patient anxiety or patient anxiety or palpation to a painful palpation to a painful area area
Involuntary guardingInvoluntary guarding Muscular spasm or Muscular spasm or rigidity due to rigidity due to peritoneal peritoneal inflammationinflammationMay be localized May be localized (early appendicitis )or (early appendicitis )or diffuse (perforated diffuse (perforated bowel) bowel)
How to differentiate the two?
Voluntary guardingVoluntary guarding Tensing abdominal Tensing abdominal muscles due to muscles due to patient anxiety or patient anxiety or palpation to a painful palpation to a painful area area
Involuntary guardingInvoluntary guarding Muscular spasm or Muscular spasm or rigidity due to rigidity due to peritoneal peritoneal inflammationinflammationMay be localized May be localized (early appendicitis )or (early appendicitis )or diffuse (perforated diffuse (perforated bowel) bowel)
Board-like rigidityBoard-like rigidityIf abdominal wall is If abdominal wall is palpated as obviously palpated as obviously tense, even as tense, even as rigid rigid as a boardas a board..
Liver palpationLiver palpation
Standard Method Liver palpationStandard Method Liver palpation
Ask the patient to Ask the patient to take a take a deep breath.deep breath.
You may feel the You may feel the edge of the liver press edge of the liver press against your fingers. against your fingers.
Liver palpation Liver palpation ((Standard Method)Standard Method)
Palpating hand is Palpating hand is held steadyheld steady while while
patient inhalespatient inhales
Liver palpation Liver palpation ((Standard Method)Standard Method)
Palpating hand is Palpating hand is lifted and movedlifted and moved while the patient while the patient
breathes outbreathes out
Alternate Method Liver palpationAlternate Method Liver palpation
Stand by the patient's Stand by the patient's chest.chest.
"Hook""Hook" your fingers your fingers just below the costal just below the costal margin and press margin and press firmly. firmly.
HepatomegalyHepatomegaly
More than More than 1cm below1cm below the costal marginthe costal margin
How to differentiate How to differentiate hepatomegaly from hepatomegaly from ptosed liver (e.g. lax ptosed liver (e.g. lax ligaments)?ligaments)?
Spleen palpationSpleen palpation
Spleen palpation Spleen palpation
Support Support lower left rib lower left rib cagecage with left hand with left hand while patient is supine while patient is supine and and lift anteriorly on lift anteriorly on the rib cagethe rib cage. .
Spleen palpation Spleen palpation
Palpate Palpate upwards upwards toward spleentoward spleen with with finger tips of right finger tips of right hand, starting below hand, starting below left costal margin. left costal margin.
Have the Have the patient take patient take a deep breatha deep breath. .
Examination of Spleen (Palpation)
Kidney palpationKidney palpation
Kidney palpationKidney palpation
Place Place left hand left hand posteriorlyposteriorly just below just below the right 12th rib. Lift the right 12th rib. Lift upwards. upwards.
Palpate deeply with Palpate deeply with right hand on anterior right hand on anterior abdominal wall.abdominal wall.
Examination of Kidney
Patient take a Patient take a deep deep breath. breath.
Feel lower pole of Feel lower pole of kidneykidney and try to and try to capture it between capture it between your hands.your hands.
Examination of Kidney
Right kidney may be felt to slip between hands during exhalation
Special examSpecial exam
Abdominal examinationAbdominal examination
Special examSpecial exam
Murphy’s Sign Murphy’s Sign McBurney’s McBurney’s PointPointRovsing’s SignRovsing’s SignPsoas SignPsoas SignObturator Sign Obturator Sign
Rebound Rebound TendernessTendernessCostovertebral Costovertebral tendernesstendernessShifting DullnessShifting Dullness
Murphy’s Sign (acute cholecystitis)Murphy’s Sign (acute cholecystitis)
Examiner’s hand is at Examiner’s hand is at middle inferior border middle inferior border of liver.of liver.Patient is asked to Patient is asked to take take deep inspirationdeep inspiration..If positive patient will If positive patient will experience painexperience pain and and will will stop shortstop short of full of full inspirationinspiration
Acute CholecystitisAcute Cholecystitis
McBurney’s PointMcBurney’s Point
Localized tenderness Localized tenderness at the junction of at the junction of medial 2/3 and lateral medial 2/3 and lateral 1/3 of a line between 1/3 of a line between right anterior superior right anterior superior iliac spineiliac spine and and umbilicusumbilicus
McBurney’s Point (McBurney’s Point (Common CausesCommon Causes))
Appendicitis Incarcerated or Incarcerated or strangulated hernia strangulated hernia Ovarian torsion (twisted Ovarian torsion (twisted Fallopian tube) Fallopian tube) Pelvic inflammatory disease Abdominal abscess Hepatitis Diverticular disease Diverticular disease Meckel''s diverticulumMeckel''s diverticulum
Rovsing’s SignRovsing’s Sign
Patient will Patient will experience right lower experience right lower quadrant pain (in quadrant pain (in region of McBurney’s region of McBurney’s Point) when left lower Point) when left lower quadrant is palpated. quadrant is palpated.
Non-Classical AppendicitisNon-Classical Appendicitis
Iliopsoas SignIliopsoas Sign
Obturator SignObturator Sign
Iliopsoas SignIliopsoas Sign
Patient can lay on side and extend leg at the hip Patient can lay on side and extend leg at the hip or have patient lay on back and try to flex hip or have patient lay on back and try to flex hip against the resistance of examiner’s hand on against the resistance of examiner’s hand on thigh. If patient has an inflamed retro-cecal thigh. If patient has an inflamed retro-cecal appendix, this will produce pain. appendix, this will produce pain.
Iliopsoas SignIliopsoas Sign
Anatomic basis for Anatomic basis for the psoas sign: the psoas sign: inflamed appendix is inflamed appendix is in a retroperitoneal in a retroperitoneal location in contact location in contact with the psoas with the psoas muscle, which is muscle, which is stretched by this stretched by this maneuver. maneuver.
Obturator SignObturator Sign
Internally rotate right leg at the hip with the knee Internally rotate right leg at the hip with the knee at 90 degrees of flexion. Will produce pain if at 90 degrees of flexion. Will produce pain if inflamed appendix is in pelvis. inflamed appendix is in pelvis.
Obturator SignObturator Sign
Anatomic basis for Anatomic basis for the obturator sign: the obturator sign: inflamed appendix in inflamed appendix in the pelvis is in contact the pelvis is in contact with the obturator with the obturator internus muscle, internus muscle, which is stretched by which is stretched by this maneuver. this maneuver.
Rebound TendernessRebound Tenderness ((FFor peritoneal irritation)or peritoneal irritation)
WarnWarn the patient what the patient what you are you are about to doabout to do. .
Press deeplyPress deeply on the on the abdomen with your hand. abdomen with your hand.
After a moment, After a moment, quickly quickly release pressurerelease pressure. .
If it If it hurts more when you hurts more when you release,release, the patient has the patient has rebound tenderness. [rebound tenderness. [4] ]
Cost vertebral TendernessCost vertebral Tenderness (Often with renal disease)(Often with renal disease)
CompareCompare the the left left and right sides. and right sides.
PercussionPercussion
PercussionPercussion
Technique Technique
Liver Liver
SpleenSpleen
The two solid organs are percussable in the normal patientLiver: will be entirely covered by the ribs. Occasionally, an edge may protrude 1-2 cm below the costal margin.
Spleen: The spleen is smaller and is entirely protected by the ribs.
To determine the size of the liverTo determine the size of the liver
Measure the liver Measure the liver span by percussing span by percussing hepatic dullness from hepatic dullness from above (lung) and above (lung) and below (bowel).below (bowel). A A normal liver span is normal liver span is 6 6 to 12 cmto 12 cm in the in the midclavicular line.midclavicular line.
Spleen percussionSpleen percussion
Enlarged spleen Enlarged spleen produce a produce a dull dull tonetone, in the , in the left left upper quadrant upper quadrant percussionpercussion but but should then be should then be verified by verified by palpation.palpation.
AuscultationAuscultation
AuscultationAuscultation
BowelBowel sounds sounds
Vascular Vascular sounds (bruits)sounds (bruits)
Friction Friction Rubs Rubs
Auscultation for bowel soundsAuscultation for bowel sounds
Normal sounds are Normal sounds are
due to due to peristaltic peristaltic activityactivity..Peristalsis: A Peristalsis: A progressive progressive wavelike wavelike movementmovement that occurs that occurs involuntarily in hollow involuntarily in hollow tubes of the body. tubes of the body.
AuscultationAuscultation
Listening in Listening in one one spotspot is usually is usually sufficientsufficientListening for Listening for 15-20 15-20 or 30-60or 30-60 seconds secondsBowel sounds Bowel sounds cannot cannot be said to be absentbe said to be absent unless they are not unless they are not heard after listening heard after listening for for 3-5 minutes3-5 minutes. .
Three things about bowel Three things about bowel soundsound
Are bowel sounds Are bowel sounds present?present?
If present, are they If present, are they frequent or sparse frequent or sparse (i.e.quantity)? (i.e.quantity)?
What is the nature of What is the nature of the sounds the sounds (i.e.quality)? (i.e.quality)?
Bowel sound decreaseBowel sound decrease
Inflammatory Inflammatory processes of serosaprocesses of serosa
Inflammation of the Inflammation of the intestinal mucosaintestinal mucosa will cause will cause hyperactivehyperactive bowel bowel sounds. sounds.
Bowel sound increaseBowel sound increase
Auscultation for bowel soundsAuscultation for bowel sounds
What about What about intestinal intestinal obstruction??obstruction??
Splash SignSplash Sign
Splashing sound Splashing sound indicative of indicative of air or air or fluid in body cavity fluid in body cavity with shaking with shaking individualindividual: gastric : gastric outlet obstruction. outlet obstruction.
Auscultation for vascular sounds Auscultation for vascular sounds (bruits)(bruits)
AorticAortic (midline between (midline between umbilicus and xiphoidumbilicus and xiphoid
RenalRenal ( (two inches two inches superiorsuperior to and to and two two inches lateral toinches lateral to umbilicus)umbilicus)
Common iliac (Common iliac (midway midway between umbilicus between umbilicus and midpoint of and midpoint of inguinal ligamentinguinal ligament))
Venous Hum (rare)Venous Hum (rare)
Epigastric/umbilical Epigastric/umbilical areaarea. .
Soft hummingSoft humming noises noises in in systolic/diastolicsystolic/diastolic component. component.
Indicates Indicates collateral collateral between portal and between portal and venous systemsvenous systems as in as in hepatic cirrhosis. hepatic cirrhosis.
Friction rubs (rare)Friction rubs (rare)
Right and leftRight and left upper upper quandrants quandrants Grating sound with Grating sound with respiratory movementrespiratory movement Indicates Indicates inflammation of the inflammation of the capsule of the liver or capsule of the liver or spleen (spleen (infection or infection or infarctioninfarction). ).
THANK YOUTHANK YOU