Download - Physical Examinationgi
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HISTORY
ANDPHYSICAL
EXAMINATION
THEABDOMEN
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HISTORY
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History
Infants and young children may be erratic eaters
A toddler might eat insatiably or refuse to consume food
during a meal.
Toddlers and young children also tend to eat only a limitedvariety of foods.
Infancy and adolescence are periods of rapid growth; high
nutrient requirements for growth may be associated with
voracious appetites. Demonstration of age-appropriate growth on a growth
curve is reassuring
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History
The number, color, and consistency of stools can varygreatly in the same infant and between infants of similar
age.
The earliest stools after birth consist of meconium, a
dark, viscous material that is normally passed within the1st 48 hr of life.
normally passed within the 1st 48 hr of life.
With the onset of feeding, meconium is replaced by
green-brown transition stools, often containing curds,and, after 4-5 days, by yellow-brown milk stools.
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History
Stool frequency is extremely variable in normal infantsand can vary from none to 7 per day.
Breast-fed infants can have frequent small, loose stools
early (transition stools), and then after 2-3 wk can have
very infrequent soft stools
Some nursing infants mightnot pass any stool for 1-2 wk
and then have a normal soft
bowel movement.
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History
The color of stool has little significance except for thepresence of blood or absence of bilirubin products (white-
gray rather than yellow-brown).
The presence of vegetable matter, such as peas or corn, inthe stool of an older infant or toddler ingesting solids is
normal and suggests poor chewing and not malabsorption.
A pattern of intermittent loose stools, known as toddler'sdiarrhea, occurs commonly between 1 and 3 yr of age.
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PHYSICAL EXAMINATIONINSPECTION
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INSPECTION
Newborn lying supine (and, optimally, asleep)
abdomen is protuberant as a result of poorly developed
abdominal musculature
abdominal wall blood vessels and intestinal peristalsis areeasily noticeable
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INSPECTION What to look for?
Abnormalities? Ompalocoele- is a type of abdominal wall defect in which
the intestines, liver, and occasionally other organs remain outside of
the abdomen in a sac because of a defect in the development of
the muscles of the abdominal wall(exomphalos)
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INSPECTION
What to look for?Abnormalities?
Gastrochisis- intestines not covered by peritoneum
Scaphoid abdomen- associated with congenital diaphragmatic hernia
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INSPECTION
Newborn's umbilical cord Two thick-walled umbilical arteries and one larger but thin-walled
umbilical vein, which is usually located at the 12-o'clock position
May have a long cutaneous portion (umbilicus cutis), which is covered
with skin, or an amniotic portion (umbilicus amnioticus), which is covered
by a firm gelatinous substance Amniotic portion dries up and falls off within 2 weeks, whereas the
cutaneous portion retracts to be flush with the abdominal wall.
A single umbilical artery may be associated with congenital anomalies or
as an isolated anomaly (Patent urachus or Omphalitis)
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PATENT URACHUS AND OMPHALITIS
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INSPECTION
Inspect the area around the umbilicus for redness or swelling.
Bleeding? Any discharge?
Color should be translucent; greenish-yellow color suggest meconium staining
Umbilical granuloma at the base of the navel
-development of pink granulation tissue formed during the
healing process
Umbilical hernias are detectable at a few weeks of age (most disappear by1 year, nearly all by 5 years)
Umbilical hernias in infants-caused by a defect in the abdominal wall and can be up to 6
cm in diameter and quite protuberant with intra-abdominal
pressure.
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INSPECTION
In some normal infants
diastasis recti
-separation of the two rectus abdominis muscles, causing a
midline ridge, most apparent when the infant contracts the
abdominal muscles.
-benign-in most cases, it resolves during early childhood
-chronic abdominal distention may also
predispose to this condition
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INSPECTION
Older Children
Size and shape
Prominent vessels, Striae, Pulsations
Peristaltic movements
Umbilical hernia
Movement in relation to respiration
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INSPECTION
commonly have protuberant abdomens
most apparent when they are upright
Abdominal distention- measure Abdominal Circumference
(AC) An exaggerated pot-belly appearance may indicate
malabsorption from:
celiac disease
cystic fibrosisConstipation
aerophagia
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INSPECTION
FINDINGS CLINICAL IMPLICATIONSScaphoid or Flat Diaphragmatic hernia (new born)
Malnutrition
Full or Globular or
Protuberant
Normally seen infants and toddlers due to weak
abdominal musculature, relatively large abdominal
organs and lumbar lordosis
In other instances think of 5F-flat, flatus, feces, fluid , fetus
Peristaltic waves Normal in thin individuals
May signify pressence of obstruction as in pyloric
stenosis, intussusception
Distended veins In epigastric area may indicate obstruction of inferior
vena cava
In periumbilical areas-portal hypertension
Paradoxical abdominal
movements with breathing
Diaphragmatic paralysis or impending respiratory failure
in severe status asthmaticus
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PHYSICAL EXAMINATIONAUSCULTATION
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Auscultation
Done before palpation and percussion
May alter the results
Done to detect bowel sounds
Warm steth with palm of the hand
Diaphragm is used
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Auscultation
BOWEL SOUNDS
RLQ/Mid-abdomen
One spot is sufficient Character
Frequency
**Characteristics of BS are not diagnostic of specific conditions exceptHigh-Pitched = Obstruction/Gastroenteritis
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Auscultation
Important to observe BS change over a period of time
Bowel obstruction may progress to strangulation and
ischemia
Ischemia = BS may decrease
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Auscultation
BS are gurgling in nature
Episodically at 5-10 secs interval or longer
Infants and younger childer
10-30/min Adults
5-34/min
If BS are absent, auscultate again for 1-2min
before concluding so.
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Auscultation
Inactive bowel sounds
Infants on their first days of life
Extremely premature
Never fed for several days
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Auscultation
Scratch Test Place the diaphragm of stethoscope just above the right costal
margin at the midclavicular line
With your fingernail, lightly scratch the skin of the abdomen along the
midclavicular line
Move from below the umbilicus toward the costal margin
When your scratching finger reaches the liver's edge, you will hear a
change in the scratching sound
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Auscultation
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PHYSICAL EXAMINATIONPERCUSSION
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PERCUSSION
Newborn
NOT BEING DONE
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PERCUSSION
Older Children
Normally tympanitic except for areas of dullness
(solid organs like liver or full bladder)
TUMOR or FLUID- dullness on areas that are normally tympanitic
COLIC, INTESTINAL OBSTRUCTION, ILEUS- highly tympanitic
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PERCUSSION
WHY PERCUSS??
to detect presence of fluid in the peritoneal cavity
through 2 methods
FLUID WAVE
SHIFTING DULLNESS
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PERCUSSION
FLUID WAVE Palpate the flank of the abdomen with one hand and tap on
the opposite flank with fingers of the other hand
An aide or patient places his hand on the midline to obliteratethe feeling of stretching of the skin why may affect
transmission of fluid waves If present, will be felt by the patient.
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PERCUSSION
SHIFTING DULLNESS
Patient in supine
Percuss abdomen from midline to the right flank until
dullness is perceived
Mark the area of transition from tympanism to dullness
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PERCUSSION
SHIFTING DULLNESS
Then, ask the patient to roll over and lie at the right side atleast 30 seconds
After the fluid settled, percuss again from left to right flank
Mark the area of transition AREA OF DULLNESS WILL SHIFT UPWARD
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PERCUSSION
LIVER SPAN
Percuss along RMCL anteriorly with the pleximeter finger held
parallel to the ribs along intercostal pace using heavy percussion
Percuss downward until resonance shifts to dullness
Mark this as the UPPER BORDER OF THE LIVER
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PERCUSSION
LIVER SPAN
Percuss from RUQ moving upward along RMCL until dullness is
perceived and mark as the LOWER BORDER OF THE LIVER
(palapationas alternative)
Measure UPPER BORDER-LOWER BORDER
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PHYSICAL EXAMINATIONPALPATION
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Palpation
Supine with both lower extremities slightly flexed at kneesand hips
Position yourself on where your dominant hand for palpation
is at
Warm the hand before palpation Distract the child when palpating
Ask the patient to inhale slowly and deeply
Use flat side of fingers
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Palpation
Newborn Easily palpated when quiet
Stand at the right side of the infant
Left hand raising the legs Raise pelvis slightly
Right hand, finger pads are used topalpate
Start below the umbilicus on both sidesthen proceed towards the diaphragm
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Palpation
In Crying infant = place hand on the abdomen
Palpate when infant takes inspiration after
crying
With pain = ask where the pain is Start palpate away from the pain
Proceed gently to the painful area
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Palpation
Direct tenderness
Pain elicited on pressure
Visceral pain
Rebound tenderness
Pain is felt or greater on release
Peritoneal irritation
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Palpation
Patients who are unable to verbalize feelings/patients whotalks a lot
Observe facial expressions upon palpation
Wincing, grimacing, sudden crying
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Palpation
Detecting Organs and Masses
1. Location
2. Upper and lower borders
3. Attached to abdominal wall?4. Firm, hard, soft, cystic?
5. Movement during respiration
6. Movable?
7. Pulsations
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Palpation
Liver size
Below the right subcostal margin
Look for the lower liver edge
RLQ -> RMCL Hepatomegaly
Liver can be palpated over the epigastrium
extending to the left subcostal area
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Palpation
Infants and young children
Liver is normally palpable
Length along RMCL -> RSCM
0-6 months 3.0 3.5 cm
6 months - 4yrs 0 3 cm
4 -10 yrs < 2 cm
> 10 yrs < 1 cm
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Palpation
Spleen
Usually splenic tip is palpable as soft with
a sharp edge in infants
Supine, RLQ -> Left costal margin Right hand, Px inspires deeply
May use left hand for lifting flanks
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Palpation
Spleen Shorts Maneuver if spleen is not
palpable
Px lie in right lateral decubitus Examiners left hand placed over left lower
ribs on midscapular pushing spleen
forward Right hand palpates from RLQ -> LUQ
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Palpation
Spleen When palpable usually slides downward
during inspiration and upward during
expiration
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Palpation
Psoas Sign Place hand on px right knee
Ask px to flex right hip against resistance
Abdominal pain (+) sign
Indicative of appendicitis Obturator sign
Px raises right leg with flex knee then rotating
internallyAbdominal pain (+) sign suggests
appendicits
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Palpation
Anus Prepare child for the exam
Expose anus left lateral decubitus with
legs flexed against the abdomen What to look for?
1. Location
2. Patency
3. Fissures
4. Hemorrhoids
5. worms
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Palpation
Rectum Left lateral decubitus, right leg drawn up
into abdomen, head curled down
Use gloved index finger/little finger
Apply lubricant on finger/tip
What to look for?
1. Sphincter tone
2. Mass or impacted feces
3. tenderness
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THE CASEINTUSSUSCEPTION
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Case
Infant with Intussusception
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Intussusception
Intussusception occurs
when a portion of the
alimentary tract is
telescoped into anadjacent segment.
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Intussusception
It is the most common cause of intestinal obstructionbetween 3 mo and 6 yr of age and the most common
abdominal emergency in children
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Intussusception
Intussusceptions are most often ileocolic, less commonlycecocolic, and rarely exclusively ileal.
Intussusceptum leading invaginating segment
Intussuscipiensreceiving segment
Pulling of its mesentery along with it Constriction of the mesentery obstructs venous return
Engorgement of the intussusceptum follows, withedema, and bleeding from the mucosa leads to a bloody
stool, sometimes containing mucus. The apex of the intussusception can extend into the
transverse, descending, or sigmoid colon, even to andthrough the anus in neglected cases.
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Intussusception
Clinical Manifestations Sudden onset of severe paroxysmal colicky pain that recursat frequent intervals
Accompanied by straining efforts with legs and knees flexedand loud cries.
The infant may initially be comfortable and play normallybetween the paroxysms of pain; but if the intussusception isnot reduced, the infant becomes progressively weaker andlethargic.
A shocklike state with fever The pulse becomes weak and thready
The respirations become shallow and grunting, and the painmay be manifested only by moaning sounds.
I i
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Intussusception
Clinical Manifestations Vomiting occurs in most cases and is usually more frequent
in the early phase.
In the later phase, the vomitus becomes bile stained.
Stools of normal appearance may be evacuated in the 1stfew hours of symptoms.
Later, fecal excretions are small or more often do not occur,
and little or no flatus is passed.
Blood is generally passed in the 1st 12 hr, but at times notfor 1-2 days, and infrequently not at all
I t ti
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Intussusception
Clinical Manifestations
60% of infants pass a stool
containing red blood and
mucus, the currant jelly
stool.
I t ti
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Intussusception
Clinical Manifestations Some patients have only irritability and alternating or
progressive lethargy.
The classic triad (
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Intussusception
Inspection
Distended abdomen
Legs are drawn into the abdomen
Auscultation
Absent or diminished bowel sounds
Pecrussion Tender but ussually not done
Palpation
Sausage-shaped abdominal mass may be palpable in the right
upper quadrant or in the midepigastric area if the transversecolon is involved
Tender abdomen, with some guarding over the intussusceptionsite