abdominal examination

Abdominal Examination

• Expose the patient from the xiphisternum pubic symphisis. ( leave the genitalia covered until u want to examine them)

Regions of the abdomen:

• There are 9 regions in the abdomen divided by 2 horizontal lines and 2 vertical lines ( the midclaviclular lines)

Contents of each region:

• Lt. Hypochodrium:– Spleen– Lt. Kidney

• Rt. Iliac fossa:– Terminal ileum– Appendix– Ovaries (also in

LIF)

• Rt. Hypochodrium:– Liver– Rt. Kidney– Gall bladder

• Suprapubic area:– Urinary bladder

INSPECTION

• Shape of the abdomen• Movement of abdominal wall• Umbilicus• Surgical scars or dilated veins• Cautery marks• Striae• Hair distribution• Hernial orifices

Shape of the abdomen

• Normal• Schaphoid (sunken):

– Wasting– Starvation

• Distension: by the 5 Fs (Fat, Fluid, Fetus, Feces & Flatus)

Movement of abdominal wall

• Movement with respiration: normally present in normal people.

• Can be absent in peritonitis. (inflammation of the peritoneum)

• Visible peristalsis ( contractile movement of the intestines): usually absent.

Umbilicus

• Normally circular and inverted ( pushed inward)

• Look for any hernias

• Surgical scars: indicate the type of previous surgery according to their location in the abdomen.

• Dilated veins: indicate portal hypertension or obstruction of the inferior vena cava– Assess the direction of blood flow in the veins

if they are dilated.

Striae

• White striae:• Are due to fast changes in abdominal size

e.g. pregnancy, ascites, wt. loss.

• Purple striae: due to Cushing Syndrome.

Hair distribution

• Male hair distribution: is convex upward towards the umbilicus (like a triangle pointing upwards)

• Female hair distribution: is concave upwards (like a triangle pointing downwards).

Hernial orifices

• Assessed by asking the patient to cough which causes hernias to bulge outwards due to increased intra abdominal pressure.

PALPATION

• The patient abdominal wall muscles must be relaxed to be able to palpate the abdomen.

• Rub your hands if the are cold.• Ask the patient about any tender areas

and palpate them at the end of the examination.

1. Superficial Palpation

2. Deep Palpation & assessment of internal organs enlargement.( liver, kidney, spleen,……)

3. Dipping

1 -Superficial palpation

• Palpate the whole abdomen gently in a circular movement assessing for the following signs:– Tenderness: is pain on touching, – Rigidity: with tenderness they indicate

underlying inflammation (peritonitis)– Guarding– Superficial Masses:– temperature

2 -Deep palpation

• Press with your fingers during expiration, wait for the organ to move downwards during inspiration and touch your finger tips.

• Keep looking at the patient face ( for detecting tenderness.

• Rebound tenderness: press firmly then release suddenly induces pain this also indicates peritonitis

Masses

Asses for• Site ( location)• Size• Shape• consistency• Surface• Movement with respiration• Mobility ( movement)

• Upper & lower limits of the mass• Bimanually palpable or not

• Site: According to the site of the mass, its possible to define its most likely cause(s).

• Size: asses the diameters of masses by using your finger width (1 finger=2 cms)

• Consistency:– cystic: water filled balloon– Very soft: like jelly– Soft: like relaxed muscle– Firm: like the tip of the nose– Hard: like contracted muscle– stony hard: bone like

• Surface: smooth, irregular, nodular• Edge: sharp or rounded• Movement with respiration: liver, spleen,

kidney and gallbladder all move with respiration.

• Mobility.• Upper & lower limits of the mass: e.g. you

can’t get above an enlarged spleen.• Bimanually palpable or not: kidneys can

be bimanually palpable if enlarged.

• Palpation of the liver: start from the right iliac fossa moving to the right hypochondrium.

• When the liver is palpable percuss for its upper border as it may be displaced downwards.

• The edge of the Rt. Lobe of the liver can be palpable esp. in thin people.

Gall bladder

• Situated in the Rt. Hypochondrium• Normally not palpable.• If enlarged, then it can be felt as a smooth

globular swelling, • Moves with respiration.• Murphy’s Sign: sudden tenderness when

palpating for the gall bladder and asking the patient to take a deep breath.

Spleen• Lies in the Lt. hypochondrium.• It needs to be enlarged 2-3 times to be

palpable (below the costal margin)• Enlarges towards the Rt. Iliac fossa (RIF)• Method: palpate from RIF moving towards

Lt. hypochondrium using the same maneuver as the liver examination.

• Ask the pt. to take a deep breath.• Assess the spleen size below the costal

margin using the width of your fingers.

Kidneys

• Renal angle tenderness: can be +ve if there is an abscess or infection in the kidney (pyelonephritis)

• If enlarged the can be bimanually palpable.

• They move with respiration.

Differential diagnosis of Lt. Kidney and Spleen

feature Lt. Kidney Spleen

Direction of enlargement DownwardsTowards LIF

Downwards and mediallyTowards RIF

Notch Absent Present

Bimanually palpable Yes No

Can get above it?? Yes No

Percussion note above it Resonant( due to overlying gut)

Dull

Urinary bladder

• Not palpable when empty, when distended becomes palpable as a rounded swelling in the hypogastrium ( e.g. urine retention)

• Palpation of the mass induces desire to micturate.

3- Dipping

• Is a method to detect for organ enlargement when there is a large ascites.

• Done by making a quick press with your hand repeatedly which displaces fluid and if an organ is present it can be felt.

percussion

• Used to asses:

1.Organ diameter: e.g. Liver span

2.Detection of ascites.

Auscultation

• For:

1.Bowl sounds

2.Bruit

3.Friction rub

• Bowl sounds: best heard near to the Rt. Iliac fossa.

• Are normally audible every 5-10 seconds.• Note for frequency (frequent or infrequent)

and intensity( loud, absent or normal).• They can be loud and frequent in intestinal

obstruction.• They can be absent in paralytic ileus

• Bruit:• Is an abnormal sound that occurs due to

narrowing of arteries outside the heart ( if heard above the heart then it’s a murmur)

• Can occur in renal artery stenosis.

The normal abdominal examination

• Inspection: shape of the abdomen is normal, the abdominal wall is moving normally with respiration, umbilicus is central and of normal shape, no visible pulsation, or peristalsis, No surgical scars, cauttery marks( كي أو حجامة striae ,(عالماتor dilated veins.

• The pubic hair is of male distribution, hernial orifices are intact.

• Palpation: no rigidity or tenderness, no palpable viscera or masses palpable.

• Percussion: no fluid thrill & no shifting dullness.

• Auscultation: bowl sounds are 3-5 per minute, of normal intensity. No bruit or friction rub audible.