Abdominal Examination Slides PDF

ABDOMINAL EXAMINATION Dr. Andres Aranda, MD, Nephrology. CSD Objectives: • At the end of the class students should: • Correctly execute the abdominal examination. • Integrate the medical questioning with the physical examination findings. Introduction: Bates' Guide to Physical Examination and H...

ABDOMINAL EXAMINATION Dr. Andres Aranda, MD, Nephrology. CSD Objectives: • At the end of the class students should: • Correctly execute the abdominal examination. • Integrate the medical questioning with the physical examination findings. Introduction: Bates' Guide to Physical Examination and History Taking, 13e • The physical examination of the abdomen is the key step in the evaluation of abdominal complaints such as pain, distension, enlarged organs, or masses. • The goal is to correlate the information obtained in the medical interview (direct and indirect) with the findings during the examination, to integrate them with laboratory and imaging studies to make a correct diagnosis Anatomy: • The abdomen, or the abdominopelvic cavity, lies between the thoracic diaphragm and the pelvic diaphragm and contains two continuous cavities, the abdominal cavity and the pelvic cavity. • For descriptive purposes, the abdomen is traditionally divided by imaginary lines either in quadrants (no pain/nonpathological). • Or nine sections/segments, which may help us locate and or identify more precisely where the problem is. • Both are correct. Bates' Guide to Physical Examination and History Taking, 13e Anatomy: Anatomy: Anatomy: Bates' Guide to Physical Examination and History Taking, 13e Retro – peritoneum: • The kidneys are retroperitoneal (posterior) organs. • The ribs protect their upper poles. • The costovertebral angle (CVA), formed by the lower border of the 12th rib and the transverse processes of the upper lumbar vertebrae. Bates' Guide to Physical Examination and History Taking, 13e Pelvic cavity. Bates' Guide to Physical Examination and History Taking, 13e Physical examination: Bates' Guide to Physical Examination and History Taking, 13e • Systemic findings related to gastro intestinal diseases Bates' Guide to Physical Examination and History Taking, 13e Inspection: • Skin: including temperature. • Color: note any bruises, erythema, or jaundice. • Scars: Describe or diagram their location. • Striae: Old silver striae or stretch marks are normal. • Dilated veins: A few small veins may be visible normally. • Rashes or ecchymoses • The umbilicus: Observe its contour and location and any inflammation or bulges suggesting a ventral hernia. • The contour of the abdomen: Is the abdomen symmetric? • Peristalsis • Pulsations Bates' Guide to Physical Examination and History Taking, 13e Inspection: • Expose the abdominal cavity from the nipple line to the pubic symphysis. • The patient should have an empty bladder. • From the right side of the bed, inspect the surface, contours, and movements of the abdomen. • Watch for bulges or peristalsis. • Try to sit or bend down so that you can view the abdomen tangentially. • Ask the patient to point the exact location of the pain. Bates' Guide to Physical Examination and History Taking, 13e Auscultation: • Auscultate before performing percussion or palpation, maneuvers which may alter the characteristics of the bowel sounds. • Auscultate for bruits. • Normal sounds consist of clicks and gurgles, occurring at an estimated frequency of 5 to 34 per minute, Absent bowel sounds? Auscultate for at least 2 mins. • Prolonged gurgles of hyperperistalsis from “stomach growling,” called borborygmi. Bates' Guide to Physical Examination and History Taking, 13e Percussion: • Helps you assess the amount and distribution of gas in the abdomen, viscera, and masses that are solid or fluid-filled, and the size of the liver and spleen. • Percuss the abdomen lightly in all four quadrants to determine the distribution of: • Tympany usually predominates because of gas in the GI tract, • Dull areas suggest an underlying mass or enlarged organ. This observation will guide subsequent palpation. • Briefly percuss the lower anterior chest above the costal margins. • On the right, you will usually find the dullness of the liver; on the left, the tympany that overlies the gastric air bubble and the splenic flexure of the colon Bates' Guide to Physical Examination and History Taking, 13e Liver percussion: • Liver size and shape can be estimated by percussion and palpation. • Measure the vertical span of liver dullness in the right mid clavicular line. • Starting at a level well below the umbilicus in the RLQ (in an area of tympany, not dullness), percuss upward toward the liver. • Identify the lower border of dullness in the midclavicular line. • Next, identify the upper border of liver dullness. • Starting at the nipple line, percuss downward in the midclavicular line until lung resonance shifts to liver dullness. Bates' Guide to Physical Examination and History Taking, 13e Spleen percussion: • Percuss the left lower anterior chest wall roughly from the border of cardiac dullness at the 6th rib to the anterior axillary line and down to the costal margin, an area termed Traube space. • Starting at a level well below the umbilicus in the RLQ (in an area of tympany, not dullness), percuss upward toward the spleen. Bates' Guide to Physical Examination and History Taking, 13e Percussion of the kidneys: • Place the ball of one hand in the CVA and strike it with the ulnar surface of your fist. • Use enough force to cause a perceptible but painless jar or thud. Bates' Guide to Physical Examination and History Taking, 13e Palpation: • Light Palpation. Gentle palpation aids detection of abdominal tenderness, muscular resistance, and some superficial organs and masses. • It also reassures and relaxes the patient. • Palpate after asking the patient to exhale, which usually relaxes the abdominal e patient. Bates' Guide to Physical Examination and History Taking, 13e Deep palpation: • Deep palpation is usually required to delineate the liver edge, the kidneys, and abdominal masses. • Tell the patient to bend the knees, and mouth breathe with jaws wide open, while exhaling palpate (gently) the patient. • Identify any masses, note their location, size, shape, consistency, tenderness, pulsations, and any mobility with respiration or pressure from the examining hand. • Correlate your findings from palpation with their percussion notes. Bates' Guide to Physical Examination and History Taking, 13e Liver palpation: • Place your left hand behind the patient, parallel to and supporting the right 11th and 12th ribs and adjacent soft tissues below. • Remind the patient to relax on your hand. By pressing your left hand upward, the patient’s liver may be felt more easily by your examining hand. • On inspiration, the liver is palpable about 3 cm below the right costal margin in the midclavicular line. • Hook technique: • Stand to the right of the patient’s chest. • Place both hands, side by side, on the right abdomen below the border of liver dullness. • Press in with your fingers and up toward the costal margin. Ask the patient to take a deep breath. • The liver edge is palpable with the fingerpads of both hands. Bates' Guide to Physical Examination and History Taking, 13e Spleen palpation: • With your left hand, reach over and around the patient to support and press forward the lower left rib cage and adjacent soft tissue. • With your right hand below the left costal margin, press in toward the spleen. • Begin palpation low enough so that you can detect an enlarged spleen. • Ask the patient to take a deep breath. • Try to feel the tip or edge of the spleen as it comes down to meet your fingertips Bates' Guide to Physical Examination and History Taking, 13e Kidney palpation: • The kidneys are retroperitoneal and usually not palpable, but learning the techniques for examination helps you distinguish enlarged kidneys from other organs and abdominal masses. • They may be palpable, especially when the patient is thin and the abdominal muscles are relaxed. • Left kidney: Move to the patient’s left side. Place your right hand below and parallel to the 12th rib. Lift with your left hand, trying to displace the kidney anteriorly. Place your left hand gently in the LUQ, lateral and parallel to the rectus muscle. • Ask the patient to take a deep breath. At the peak of inspiration, press your left hand firmly and deeply into the LUQ, just below the costal margin • Right kidney: Use your left hand to lift up from the back, and your right hand to feel deep in the RUQ Bates' Guide to Physical Examination and History Taking, 13e Aorta palpation: • Press firmly deep in the epigastrium, slightly to the left of the midline, and identify the aortic pulsations. • Assess the width of the aorta by pressing deeply in the upper abdomen with one hand on each side of the aorta. • Detection of pulsations is affected by abdominal girth and the diameter of the aorta Bates' Guide to Physical Examination and History Taking, 13e Bibliography: • BATES Guide to Physical Examination and history taking. Twelfth edition. Chapter 11: The abdomen. Page 449-483. • Macleod's Clinical Examination, 6, 105-132 The gastrointestinal system. ClinicalKey https://bibliodig.uag.mx:2113/#!/content/book/3-s2.0B978032384770400006X?scrollTo=%23hl0001934 • Perfecting the Gastrointestinal Physical Exam Findings and Their Utility and Examination Pearls. Emerg Med Clin N Am 39 (2021) 689–702 https://bibliodig.uag.mx:2113/service/content/pdf/watermarked/1s2.0-S0733862721000675.pdf?locale=en_US&searchIndex= Thank you for your attention. CSD Department