Clinical Examination of Abdomen PDF

Clinical examination of abdomen Prof.dr.Gordana Kamceva Mihailova FMN – UGD, Shtip, 2023 SPECIAL PHYSICAL STATUS ABDOMEN PHYSICAL EXAMINATION OF ABDOMEN • The abdominal examination is performed as part of the comprehensive physical examination or when a patient presents with signs or symptoms of...

Clinical examination of abdomen Prof.dr.Gordana Kamceva Mihailova FMN – UGD, Shtip, 2023 SPECIAL PHYSICAL STATUS ABDOMEN PHYSICAL EXAMINATION OF ABDOMEN • The abdominal examination is performed as part of the comprehensive physical examination or when a patient presents with signs or symptoms of an abdominal disease process. • It involves the core examination skills in a particular sequence: inspection, auscultation, percussion, and palpation. • Additional procedures are used to detect serious abdominal pathology. • During the abdominal examination, pay careful attention to the patient’s comfort level or degree of distress. SURFACE ANATOMY Three Levels - Nine Quadrants : Epigastrium Right and left hypochondriac and epigastrium Mesogastrium Right and left lumbar (flank) and umbilical region Hypogastrium Right and left iliac and hypogastrium SURFACE ANATOMY In relation to the umbilicus of the 4 quadrants: Right and left upper quadrant Right and left lower quadrant INSPECTION  SHAPE (retracted, expanded, froggy), size,  LEVEL of the abdomen in relation to the chest, (in/above/below) Retracted abdomen (in weak asthenic persons) Еxpanded abdomen (in the obese, flatulent abdomen due to filling with intestinal gases, bubbling of the intestines (with motility), flatulence without movement in the abdomen (and without sounds - paralytic ileus), ascites (fluid in the peritoneum when following a protruding umbilicus), shiny skin (in cancers, heart failure, hypoproteinemia) INSPECTION  VISIBLE CHANGES: skin-stretch marks, rash, caput meduzae (visible venous drawing on the abdomen - in cirrhosis, obstruction of the inferior vena cava)  VISIBLE PERISTALTICS on the abdominal wall (normally it is not visible, it can be seen in the weak or in hyperperistalsis due to ileus)  RESPIRATORY MOBILITY (increased in lung and pleural diseases)  PRESENCE OF HERNIA (hernias): umbilical, inguinal, femoral AUSCULTATION With the patient supine, place your stethoscope diaphragm to the right of the umbilicus and do not move it. • Listen for up to 2 minutes before concluding that bowel sounds are absent. • Listen above the umbilicus over the aorta for arterial bruits Now listen 2–3 cm above and lateral to the umbilicus for bruits from renal artery stenosis. • Listen over the liver for bruits. • Test for a succussion splash; this sounds like a half-filled water bottle being shaken. Explain the procedure to the patient, then shake their abdomen by rocking their pelvis using both hands. Normal bowel sounds are gurgling noises from the normal peristaltic activity of the gut. They normally occur every 5–10 seconds but the frequency varies. Absence of bowel sounds implies paralytic ileus or peritonitis. In intestinal obstruction, bowel sounds occur with increased frequency and volume, and have a high-pitched, tinkling quality. Bruits suggest an atheromatous or aneurysmal aorta or superior mesenteric artery stenosis. A friction rub, which sounds like rubbing your dry fingers together, may be heard over the liver (perihepatitis) or spleen (perisplenitis). An audible splash more than 4 hours after the patient has eaten or drunk anything indicates delayed gastric emptying, as in pyloric stenosis. AUSCULTATION 1. PERISTALTICS (MOTILITY) OF THE INTESTINES: Normal - bubbling is heard, which is a consequece of liquid leakageand air in the intestines during peristaltic movements Enhanced with: mechanical ileus, diarrhea (acute enterocolitis), starvation Extinguished in: paralytic (adynamic) ileus, peritonitis AUSCULTATION 2. VASCULAR NOISES OF THE ABDOMEN: 1. A. renalis dex et sin - is heard 2cm above the umbilicus to the right and left of the medioclavicular line, with stenosis of the renal artery a systolic murmur is heard 2. Aorta abdominalis - it is heard vertically 2cm above the umbilicus at the level of the renal arteries (between them), in case of stenosis or aneurysm a systolic murmur is heard 3. A. iliaca dex et sin- are heard in the same vertical as the renal arteries on the line that joins the spina iliaca anterior superior, above the ligamentum inguinale pouparti 4. A. Femoralis dex et sin-are heard below the ligamentum inguinale pouparti in the same vertical as the renal and iliac arteries 5. Venous murmurs in cirrhosis of the liver - heard in the epigastrium or around the liver AUSCULTATION 3. RUBBING - occurs in the abdomen during inflammations or tumors: 1. Inflammation of the peritoneum (peritonitis) 2. Over the liver in case of inflammation of the hepatic capsule (abscess of the liver, echinococcal cyst, carcinoma of the liver when, in addition to rubbing, a noise is also heard) 3. Above the lien during infarction (in the right lateral position) PALPATION Ensure your hands are warm and clean.  If the bed is low, kneel beside it but avoid touching the floor to prevent infection.  Ask the patient to show you where any pain is and to report any tenderness during palpation.  Ask the patient to place their arms by their sides to help relax the abdominal wall.  Use your right hand, keeping it flat and in contact with the abdominal wall.  Observe the patient’s face throughout for any sign of discomfort.  Begin with light superficial palpation away from any site of pain.  Palpate each region in turn, and then repeat with deeper palpation.  Test abdominal muscle tone using light, dipping finger movements.  Describe any mass using the basic principles of palpation. Describe its site, size, surface, shape and consistency, and note whether it moves on respiration. Is the mass fixed or mobile?  To determine if a mass is superficial and in the abdominal wall rather than within the abdominal cavity, ask the patient to tense their abdominal muscles by lifting their head. An abdominal wall mass will still be palpable whereas an intra-abdominal mass will not.  Decide whether the mass is an enlarged abdominal organ or separate from the solid organs PALPATION  Superficial / Light  Deep  Moderate  Palpation of Specific Organs and Structures RULE - it is palpated against the place of pain! muscle defense (defans musculore), is a defensive reaction of the abdominal muscles during palpation of a painful abdomen, it can be local and diffuse. PALPATORY PAIN POINTS: A. PLEXALGIC: Xyphoid (ganglion xyphoideus) Epigastric (plexus celiacus-solar) Upper mesenteric (ganglion mesentericus superior) Lower mesenteric (ganglion mesentericus inferior) B. ORGANIC 1. Cystic point of projection of pain originating from the gallbladder - Murphy's point 2. Raumond's point-left umbilicus middle of the rib arch 2cm below-great curve of stomach) 3. Projection point of the appendix - Mc Barny's point, junction of the outer with the middle third of the line from the umbilicus to the anterior superior iliac spine (Blumberg's sign) 4. Bazy's points to the left and right of the umbilicus at 3 cm, kidney projection points 5. Points of projection of ureters - Landz - this point (junction of the external with the middle third of the line that joins the spina iliac anterior superior bilaterally). 6. Pyloro-duodenal-point (on the line of umbilicus with cystic point)-Obrascov's pointCourvoasie's sign - enlarged, tense, painless gallbladder + icterus (carcinoma of the head of the pancreas, DDg pleurisy) 7. Richter-Monro line Umbilicus with spina iliac anterior superior, junction of lateral with middle third is the point of abdominal puncture in ascites  PALPATION OF THE LIVER It is not normally palpable-bimanual palpation- palpation when lying on the left side  PALPATION OF THE SPLEEN It is not normally palpable-bimanual palpation- palpation when lying on the right side  PALPATION OF THE GALLBLADDER (according to Pronne's method, the gall point is palpated, and the patient inhales deeply or in the left lateral position)  MENSURATION Measurement of the volume of the abdomen at the level of the umbilicus and comparison on a daily basis, while monitoring the effect of diuretic therapy in the treatment of conditions accompanied by ascites PERCUSSION Percussion is used to assess the size and density of the organs in the abdomen and to detect the presence of fluid (as with ascites), air (as with gastric distention), and fluid-filled or solid masses. Percussion is used either independently or concurrently with palpation of specific organs and can validate palpatory findings. For simplicity, percussion and palpation are discussed separately. First percuss all quadrants or regions of the abdomen for a sense of overall tympany and dullness. Tympany is the predominant sound because air is present in the stomach and intestines. Dullness is heard over organs and solid masses. A distended bladder produces dullness in the suprapubic area. PERCUSSION Normal percussion tone: sonic/hypersonic percussion tone, tympatism of the stomach (Traube), intestines PERCUTORY DULLNESS may occur with: Tu mass in the abdomen, dullness of the liver and/or liver during their enlargement (size for pp, edges, surface, consistency is described), with ascites. INCREASED TYMPANISM occurs with: intestinal occlusion, flatulence in small (around the umbilicus) and/or large intestines (right and left colon-lumbar quadrants and hypochondrium). PERCUSSION 1. BOUNDARIES OF LIVER Normally the liver and spleen are not palpable enlarged below the costal archesIt is percussed on: the right medioclavicular line the LOWER EDGE OF THE LIVER (dullness) should be found, percussion starts from distal to proximal, or from lung sonority to distal.Mediasternal line - percussive dullness may be decreased (fulminant hepatitis, pneumoperitoneum, flatulence of the right colon) or increased (low diaphragm and COPD). 2. BOUNDARIES OF SPLEEN It lies under the left diaphragmatic dome behind the mid-axillary line. When splenomegaly is suspected, it is first percussed in the direction of the middle axillary line, and then star-shaped in all directions. SHIFTING DULLNESS • With the patient supine, percuss from the midline out to the flanks. Note any change from resonant to dull, along with areas of dullness and resonance. • Keep your finger on the site of dullness in the flank and ask the patient to turn on to their opposite side. • Pause for 10 seconds to allow any ascites to gravitate, then percuss again. If the area of dullness is now resonant, shifting dullness is present, indicating ascites. FLUID THRILL • If the abdomen is tensely distended and you are uncertain whether ascites is present, feel for a fluid thrill. • Place the palm of your left hand flat against the left side of the patient’s abdomen and flick a finger of your right hand against the right side of the abdomen. • If you feel a ripple against your left hand, ask an assistant or the patient to place the edge of their hand on the midline of the abdomen. This prevents transmission of the impulse via the skin rather than through the ascites. If you still feel a ripple against your left hand, a fluid thrill is present (detected only in gross ascites). ABDOMINAL STATUS - NORMAL FINDING Abdomen at the level of the chest, without visible changes, soft, painfully insensitive to light and deep palpation, liver and spleen are not palpated enlarged, a tympanic percussion tone is heard, preserved peristalsis is monitored by auscultation, without audible vascular noises. SPECIAL PHYSICAL STATUS UG SYSTEM INSPECTION  GENERAL INSPECTION position of the patient - color of skin and mucous membranes, deformities in the lumbar region (enlarged kidney in polycystic kidneys, or suprapubic globe in distended vesica urinaria), swellings: pale, doughy, cold and softtype of breathing, muscle spasms, genital organs in men and women PALPATION 1. PALPATION OF THE KIDNEY (bimanual palpation in the lumbar regions) It describes: position, size, consistency, tumefaction, mobility/fixation, painful tenderness; 2. PALPATORY PAIN POINTS 2.1. KIDNEY PAIN POINTS COSTO-VERTEBRAL PAIN POINT - located at the angle between the linea paravertebralis and the twelfth rib BONE-MUSCULAR PAIN POINT - located at the angle that forms the twelfth rib and the outer edge of the lumbosacral muscle mass (musculus erector spinae) (both are on the back) SUB-CIB PAIN POINT - located slightly outside the junction of the rib cage with the rectus abdominis muscle (on the front of the abdomen) 2.2. URETERAL PAIN POINTS BAZY's painful points - right and left at 3 cm from the umbilicus (right slightly above). They represent points of projection of the renal pyelons LANZ's points - are located in the projection of the junction of the middle with the outer thirds of the line passing through the two spinae iliacae anterior superior (these points correspond to the middle third of the ureters) Lower ureteral pain point - a projection where the ureters enter the vesica urinaria. It is determined by rectal or vaginal palpation 3. RECTAL EXAMINATION • Explain what you are going to do and why it is necessary, and ask for permission to proceed. Tell the patient that the examination may be uncomfortable but should not be painful. • Position the patient in the left lateral position with their buttocks at the edge of the couch, their knees drawn up to their chest and their heels clear of the perineum. • Put on gloves and examine the perianal skin, using an effective light source. • Look for skin lesions, external haemorrhoids, fissures and fistulae. • Lubricate your index finger with water-based gel. • Place the pulp of your forefinger on the anal margin and apply steady pressure on the sphincter to push your finger gently through the anal canal into the rectum. • If anal spasm occurs, ask the patient to breathe in deeply and relax. If necessary, use a local anaesthetic suppository or gel before trying again. If pain persists, examination under general anaesthesia may be necessary. 3. RECTAL EXAMINATION • Ask the patient to squeeze your finger with their anal muscles and note any weakness of sphincter contraction. Palpate systematically around the entire rectum; note any abnormality and examine any mass (Fig. 6.24). Record the percentage of the rectal circumference involved by disease and its distance from the anus. • Identify the uterine cervix in women and the prostate in men; assess the size, shape and consistency of the prostate and note any tenderness. • If the rectum contains faeces and you are in doubt about palpable masses, repeat the examination after the patient has defecated. • Slowly withdraw your finger. Examine it for stool colour and the presence of blood or mucus. PERCUSSION (pain sensitivity of the kidneys is examined) SUCCUSIO RENALIS normally negative when pathological it is quantified 1 +-3+ In distinction of splenomegaly and enlarged left kidney AUSCULTATION Renal arteries are auscultated (at 2-3 cm lateral from the umbilicus), normally no murmur is heard. In case of arterial hypertension, a systolic murmur is heard in the groin area, laterally or next to the umbilicus. In the presence of an arteriovenous fistula as a complication of renal biopsy, we listen a continuous murmur UGT STATUS - NORMAL FINDING Kidneys are not palpated enlarged, succussio renalis bilaterally negative, no pathological sounds are heard from the renal arteries. Genital organs without visible and palpable changes. LINKS • https://www.youtube.com/watch?v=PYAnF6GJY2I • https://www.youtube.com/watch?v=bK1GTLpL_F8 • https://www.youtube.com/watch?v=sv1Ri74Xc4s THANK YOU FOR YOUR ATTENTION