abdominal system examination - trinity college, dublin · abdominal system examination subtitle —...
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Abdominal System Examination Subtitle — Calibri Regular 14pt
Presenter/s Name — Calibri Bold 14pt Title — Calibri Regular 14pt
Date 00/00/00
Trinity College Dublin, The University of Dublin
Resources
http://www.medicine.tcd.ie/clinical-skills/
Trinity College Dublin, The University of Dublin
Approaching the patient
Be kind
Be friendly
Smile
Introduce yourself clearly & simply
Confirm Patient details and ask how the patient would like to be addressed
Explain that you would like to write a few things down to help you remember the facts
Trinity College Dublin, The University of Dublin
Gloves should be warn only when….
• Examining any individual with exudative lesions or weeping dermatitis
• When handling blood-soiled or body fluid-soiled sheets or clothing
Trinity College Dublin, The University of Dublin
Preparation of the patient
• Have the patient empty their bladder before examination
• Have the patient lie in a comfortable, flat, supine position
• Have them keep their arms at their sides
• Before the exam, ask the patient to identify painful areas so that you can examine those areas last
• During the exam pay attention to their facial expression to assess for sign of discomfort
Trinity College Dublin, The University of Dublin
General Inspection
General Inspection Observe for: Distention Jaundice wasting Scratch marks visible scars pulsations Stomata Wounds Drains
Inspection Around The Bed
Observe for any IV cannula insitu Fluids NG tube Nutritional supplements
Trinity College Dublin, The University of Dublin
Inspect the hands
Inspect the Nails for
• Clubbing
• Koilonychia
• Leuconychia
Inspect the hands for
• Palmar erythema
• Dupuytren’s contractures
• Hepatic flap
Trinity College Dublin, The University of Dublin
Inspect the Arms
• Spider naevi (telangiectatic lesions)
• Bruising
• Wasting
• Scratch marks (chronic cholestasis)
Trinity College Dublin, The University of Dublin
Inspect the Face and Eyes
• Conjuctival pallor (anaemia)
• Sclera: jaundice, iritis
• Cornea: Kaiser Fleischer’s rings (Wilson’s disease)
• Xanthelasma (primary biliary cirrhosis)
• Parotid enlargement (alcohol)
Trinity College Dublin, The University of Dublin
Mouth
Breath (fetor hepaticus)
Lips
– Angular stomatitis
– Cheilitis
– Ulceration
– Peutz-Jeghers syndrome
Tongue
– Atrophic glossitis
– Leicoplakia
– Furring
– Thrush
Gums Gingivitis, bleeding Candida albicans Pigmentation
Trinity College Dublin, The University of Dublin
Inspect Neck and Chest
• Cervical lymphadenopathy
• Left supraclavicular fossa (Virchov’s node)
• Gynaecomastia
• Loss of hair
Trinity College Dublin, The University of Dublin
Physical Examination of the Abdomen
• Inspection
• Palpation
• Percussion
• Auscultation
Trinity College Dublin, The University of Dublin
Inspection of Abdomen
Distention
Herniae
Scars
Striae
Pulsations
Peristalsis
Distended veins
Stomata
Wounds/Dressing
Drains Image from http://residentnet.com/clinic2.htm
http://www.nhsdirect.wales.nhs.uk/
Trinity College Dublin, The University of Dublin
Abdominal Quadrants: Clinical Exam
Right Hypochondriac: liver, gallbladder, duodenum, right kidney and hepatic flexure of colon
Right Lumbar: ascending colon, lower half Right Kidney
Right iliac: Cecum, appendix, right ureter,
(in case of female, right ovary & tube)
Epigastric: Stomach, pancreas, liver, aorta,
Umbilical: omentum, mesentary, transverse colon,
Hypogastric: ileum, bladder
Left hypochondriac: Stomach, spleen, pancreas, left kidney,
Left Lumbar: small intestines, left kidney, descending colon
Left Iliac: descending colon, sigmoid colon (in case of female, left ovary & tube)
Image from http://www.harvard-wm.org/
Trinity College Dublin, The University of Dublin
Palpation
LIGHT PALPATION: First warm your hands by rubbing them together before placing them on the patient.
Abdominal wall depressed approximately 1 cm
Use pads of three fingers of one hand and a light, gentle, dipping maneuver to examine abdomen
DEEP PALPATION: Entire palm, Either one- or two handed technique is acceptable
Use palmar surface of fingers of one hand (greatest number of fingers) and a deep, firm, gentle maneuver to examine abdomen
Trinity College Dublin, The University of Dublin
Liver palpation
• Start in the RUQ,10 centimeters below the rib margin in the mid-clavicular line
• Place left hand posteriorly parallel to and supporting 11th & 12th ribs on right.
• Ask the patient to take a deep breath.
• You may feel the edge of the liver press against your fingers.
• Palpating hand is held steady while patient inhales
• Palpating hand is lifted and moved while the patient breathes out
Trinity College Dublin, The University of Dublin
Liver Enlargement
Moderate enlargement: • Leukemia, lymphomas, etc. • Fatty liver • Hemochromatosis • All marked causes
Marked enlargement: • Alcoholism • RHF • Carcinoma: metastases, or 1°
Minor enlargement: • Hepatitis • Cirrhosis • Metastatic dz • All marked, moderate causes
Trinity College Dublin, The University of Dublin
Palpation of Spleen
• Support lower left rib cage with left hand while patient is supine and lift anteriorly on the rib cage.
• Palpate upwards toward spleen with finger tips of right hand, starting below left costal margin.
• Have the patient take a deep breath.
Trinity College Dublin, The University of Dublin
Splenomegaly DDx
Sarcoidosis, amyloidosis
Sjogren's
Infectious: • CMV • IE, SBE • Lyme disease • Rheumatic fever • Malaria
Lymphoid: • Leukaemias • Lymphoma
DIC
Trinity College Dublin, The University of Dublin
Palpation of Kidneys
Right kidney
Place left hand posteriorly just below the right 12th rib, above the right iliac crest and not as far in as the spine and paravertebral muscles
As patient to take a deep breath
Palpate deeply with right hand on anterior abdominal wall while flexing upwards with fingers of the left. (balloting)
Lower pole can be felt in a few thin individuals or if enlarged
Left Kidney
Lean over patient, slide palm of left hand around and under into left renal angle
Please right hand on the left flank and ballot the left kidney( The left kidney is not normally palpable
Trinity College Dublin, The University of Dublin
Palpation of Aorta
Flat palm placed over the epigastrium to locate pulse
Press down deeply in the midline above the umbilicus
The aortic pulsation is easily felt on most individuals
Trinity College Dublin, The University of Dublin
Percussion
DIP joint of third finger (pleximeter) pressed firmly on the abdomen remainder of hand not touching the abdomen
LIVER: Start just below the right breast in a line with the middle of the clavicle. Percussion in this area should produce a relatively resonant note.
Continue downward until the sound changes once again. At this point, you will have reached the inferior margin of the liver.
Upper margin is noted by first dull percussion note
Lower margin is noted by first tympanitic note
Trinity College Dublin, The University of Dublin
Auscultation
Bowel sounds
Vascular sounds (bruits)
Friction Rubs
It is performed before percussion or palpation
Normal sounds are due to peristaltic activity.
Are bowel sounds present?
If present, are they frequent or sparse (i.e.quantity)?
What is the nature of the sounds (i.e.quality)?