1

PD DEMO ABDOMEN BOUNDARIES -topography: expose from xiphoid process symphysis pubis -margins >Lower end of costal margin >ASIS >left and right midclavicular line (MCL) -px points with -entire hand: 4 equal quadrants -finger: 9 quadrants Region 2: above the stomach = epigastrium Organ: stomach - peptic ulcer disease, gastritis Regions 1&3: below costal margin/chondrium = R & L hypochondrium Organs (1): liver & gallbladder (3): spleen blood dyscrasias Region 5: umbilical region Regions 4&6: approximates the area of the lumbar vertebra = R & L lumbar Region 8: below the stomach = hypogastrium Above the pubis = suprapubic Organs: urinary bladdercystitis;uterus,fallopian tube Region 7&9: = R & L iliac At inguinal canal = R & L inguinal Organ (7): Appendix Examination of Abdomen Prepare the patient. Position = supine 2 pillows; 1 under the head and another (smaller) under the knees Expose: xiphoid symphysis pubis MD: R-handed = R side of the patient L-handed = L side of the patient if not indicated=right hand na agad Sit or stand = oblique view Palpation is the most difficult. INSPECTION SKIN Color: if same color arm & abdomen=produces too many melanocyte stimulating hormone; hyperpigmentation=Addisons or adrenal insufficiency Lesions: description & distribution Scar: from surgery or trauma; possibility of the scar to adhere to nearby bowel loop cause obstruction = post scarring adhesions SHAPE Flat Globular Scaphoid: anorexia nervosa, bulimia SYMMETRY Asymmetric=due to tumor/mass BULGING FLANKS & ABNORMAL BULGES ascites=fluid goes to the flanks, lulubog na yung flank pantay na sa pwet BLOOD VESSELS there should be none, if present: Dilated capillaries = spider angiomas Dilated veins = above umbilicus obstruction in superior mesenteric vein below umbilicus obstruction in inferior mesenteric vein UMBILICUS Flat Everted: 2 to umbilical hernia (congenital) Inverted inverted everted: below abdomen (+) mass=pushes the umbilicus outward

underneath epigastrium=abdominal aorta (+) pulsation anywhere else = abnormal PERISTALSIS contractions of the bowel loops to propel the contents from oral anal Bowel sound=gurgling sound to hear the BS, but not see the peristalsis MASS if (+) @ transverse colon: distal will be emptied; peristalsis stronger than usual=visible peristalsis= bad sign emergency! Operate! PULSATIONS AUSCULTATION -use diaphragm (stet) = BS are high frequency sound BOWEL SOUND anywhere, preferentially @ RLQ=gurgling sounds within 2-3 s Normoactive Hyperactive=high pitched, almost no interval Hypoactive=very soft, interval is very far/distant Absent=(-)BS for 5mins in at least 2 locations=abN obstruction: early=hyper; middle=hypo; late= absent = ileus = paralysis of the muscles that causes peristalsis BRUIT turbulent blood flow in the blood vessels flow = laminar Epigastrium area = abdominal aorta; if (+) = AAA R & L Paraumbilical area = renal arteries; if (+) congenital renal artery stenosis-very young HPN PERCUSSION -contents of abdomen are mostly gas = tympanitic -all 4 quadrants LIVER SPAN Normal value: 6-12cm Vertical landmark: RMCL 1. Start at the level slightly lower than the umbilicus, tympaniticdullness = lower border of liver rd th 2. Start at 3 or 4 ICS RMCL, from resonantdullness = upper border of liver SLEEN DULLNESS -at left hypochondrium -spleen=dull -base of the lungs=resonant -splenic flexure=tympanic Vertical landmark: LMAL Horizontal landmark: L 9, 10, 11 ICS Normal findings: no spleen dullness is percussed/ spleen dullness in any 1 ICS If 2 or 3 ICS =spleen is enlarged= abnormal PALPATION -ask if px feels any pain in the abdomen -area with pain examined LAST -if (-) pain: elicit tenderness= (+) pain if area is touched or pressed Ask patient to cough LIGHT (SUPERFICIAL)PALPATION -use tip of the fingers, palm on patients abdomen -dipping motion -1cm deep -dipglidedipglide (swift motion, dont lift palms)

kgdvibarra

-MUSCLE TONE/MASS/TENDERNESS Soft Firm Rigid=pag pinapalpate ndi bumibigay -voluntary: px is anxious, distract the px by asking him to breathe deeply or talk to him, normally abdomen softens. -involuntary: generalized peritonitis = bowel loop had ruptured tone of muscle (reflex) DEEP PALPATION Single handed (SH) assess if theres: MASS Double handed (DH) TENDERNESS (R) hand palpates, (L) hand pushes normally, the liver & spleen are not palpable BIMANUAL PALPATION -RUQ -palpate for LIVER & (R) KIDNEY 1. (R)hand parallel to rectus abdominis (pointing upwards, near costal margin), (L)hand at the back (last few ribs/thorax) 2. ask the patient to breathe through the abdomen, on expiration, (R)hand glides in then lift (L)hand diaphragm goes down, liver goes down, if something bumped (R) finger = abnormal; (-) palpation = ; if something hit the palm = kidney on bimanual palpation the liver & (R) kidney are NOT palpated HOOKING TECHNIQUE = liver -examiner faces towards the feet of the patient -both hands hooked at costal margin BIMANUAL PALPATION -LUQ -palpate for SPLEEN & (L) KIDNEY -(R)hand direct towards the spleen, other hand at (L)thorax/back of the patient (+): spleen is enlarged Mass at palm: (L) kidney MIDDLETON TECHNIQUE = spleen -(R)handed examiner moves to the LEFT side of the patient, hook fingers of both hands on costal margin, then feel for the spleen KIDNEY PUNCH Landmark: costovertebral angle-junction between ribs and spine -(R)handed: left palm @ CVA then punch -capsule is inflamed (+) pain receptors= painful patient complains of back pain, difficulty in urinating, blood-colored urine (-) kidney punch or CVA tenderness SPECIAL MANEUVERS Patients abdomen is globular, (+) ascites; to rule out, use: SHIFTING DULLNESS @ supine: tympanitic all throughout = fat Tympanitic then dull on dependent areas = ascites

Px on (R) Latl decubitus for 5 mins percuss: dull on dep. Side Then (L) Latl decubitus for 5mins percuss: dull on dep. Side the dullness have shifted from the R side to the L side FLUID WAVE -ask patient to place hands on the middle, ulnar aspect touching the abdomen (-): upon percussion, did not feel anything ATTRIBUTES MASS Size: small=pinch Large=ipitin between 2 hands then measure Location: ask px to lift head (muscle becomes rigid) Intraabdominal = less prominent Intramural = more prominent BALLOTEMENT -if with ascites: the mass will float -common with ovarian mass TENDERNESS = local peritonitis (+) during palpation: direct tenderness (+) upon removal of the palpating hand: rebound BLUMBERG = pain on the same site palpated ROVSING = pain away from the site of palpation referred pain: pathology is still@site of palpation JARRING TENDERNESS/ MARKLES px stands on tiptoes, then rest the toesshake abdomenpx touches tender area = (+) Markles sign PSOAS SIGN px lying down, press on the knee, ask px to elevate pressed knee psoas muscle contracts pulls the peritoneum = (+) if pain OBTURATOR SIGN px lying down, flex hip at right angle flex the knee at right angle internally rotate the leg obturator contract = pain MURPHYS SIGN -R hypochondrium pain = acute cholecystitis (+) rxn of px: inspiratory arrest

NOTES from Dr. Siocs lecture. also read PD MANUAL and BATES GOD BLESS!

kgdvibarra

PD PRACS GUIDE: ABDOMEN PREP PT 1. POSITION 2. EXPOSURE INSPECTION 1. SKIN color, lesion, scar 2. SYMMETRY 3. SHAPE flat/ globular/ scaphoid 4. BULGING FLANKS/ABN. BULGES 5. DILATED BV spider angiomas, veins 6. UMBILICUS flat/ inverted/ everted 7. PULSATION 8. PERISTALSIS 9. MASS AUSCULTATION 1. BS 2. BRUIT

normo/ hypo/ hyper/ absent epigastrium R/L paraumbilical

PERCUSSION 1. LIVER SPAN DULLNESS 2. SPLEEN DULLNESS ASCITES 1. SHIFTING DULLNESS 2. FLUID WAVE ASK PAIN TENDERNESS LIGHT PALPATION 1. CONSISTENCY 2. MASS 3. TENDERNESS

soft/ firm/ rigid

DEEP PALPATION 1. SH NO MASS 2. DH TENDERNESS BIMANUAL RUQ 1. LIVER HOOKING 2. (R) KIDNEY LUQ 1. SPLEEN MIDDLETON 2. (L) KIDNEY SPECIAL MANUEVER TENDERNESS SUPINE DIRECT REBOUND BLUMBERG ROVSING-PSOAS-OBT BALLOTMENT MURPHYS

STANDING MARKEL

kgdvibarra