zemariam

 Be a detective!
 Think about what all could cause this
presentation.
 What are risk factors?
 Exposing only the
area that are being
examined
 Offer a chaperone
for both sexes.
 Explain what you're
going to do
 Sequential
 The examiner should
continue speaking to
the patient

 Showing care to his

disease and answer
to patient’s questions
 Examining any
individual with
exudative lesions
or weeping
dermatitis
 When handling
blood-soiled or
body fluid-soiled
sheets or clothing
 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 or folded on
the chest
 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
 Use warm hand,
warm stethoscope,
and have short
finger nails
 Approach the
patient slowly and
deliberately
explaining what you
will be doing
 Stand right side of the
bed (tradition-depends
on patient, room, and
situation)
 Exam with right hand
(again, it depends)
 Head just a little
elevated
 Ask the patient to keep
the mouth partially
open and breathe
gently
 If muscles remain
tense, patient may
be asked to rest feet
on table with hips
and knees flexed
 Take a spare bed
sheet and drape it
over their lower
body such that it
just covers the
upper edge of their
underwear
 If the patient is
ticklish or
frightened,
initially use the
patient’s hand under
yours as you palpate
 When patient calms
then use your hands
to palpate.
 Watch the patient’s
face for discomfort.
 When looking,
listening, feeling
and percussing,
imagine what organs
live in the area that
you are examining.
 liver, gallbladder,
duodenum,
right kidney
and hepatic
flexure of
colon
 Cecum,
appendix (in
case of
female, right
ovary & tube)
 Sigmoid
colon (in
case of
female, left
ovary &
tube)
 Stomach,
spleen, left
kidney,
pancreas (tail),
splenic flexure
of colon
 Stomach,
pancreas
(head and
body), aorta
 Costal margin,
umbilicus, iliac
crest, anterior
superior iliac spine,
symphysis pubis,
pubic tubercle,
inguinal ligament,
rectus abdominis
muscle, xiphoid
process.
Inspection
Auscultation
Percussion
Palpation
Special Tests
 Is Aortic pulsation?
 Is it flat or Scaphoid
(Normally)?
 Distended?
If enlarged, does this
appear symmetric?
 With bulging or
moving?
 Global
abdominal
enlargement is
usually caused
by air, fluid, or
fat.
 Localized
enlargement,
probably distended
GB space occupying
lesion,
hepatomegaly….
 Palpable mass
 Patient feeling of
pulsation
 On rare occasions, a
lump can be visible.
 Abnormal venous
patterns
 Abnormal
discoloration
 Umbilicus is
sunken
 Stretch marks are a
light silver hue.
 Pregnant and obese
individuals
 Cushing’s syndrome
(more purple or
pink).
 Tattoos
 Scars
 Ecchymosis,
periumbilical.
(intraperitoneal
hemorrhage
ruptured ectopic
pregnancy,
hemorrhagic
pancreatitis..)
 Ecchymosis
of flanks.
(retroperitone
al
hemorrhage
such as
hemorrhagic
pancreatitis)
Upward flow direction indicates IVC obstruction
Outward flow pattern from umbilicus in all directions ? Portal HTN
 Areas which become
more pronounced
when the patient
valsalvas are
often associated
with ventral
hernias
 More conspicuous in  In those with an aortic
the thin than in the fat aneurysm and tortuous
 Greater in the old than aorta
in the young.  In those who have a
 Increased in mass joining the aorta
thyrotoxicosis, to the anterior
hypertension, or aortic abdominal wall.
regurgitation)
 Visible intestinal Peristalsis

 Gastric peristalsis is Intestinal peristalsis in

commonly seen in partial and chronic
neonates with intestinal obstruction
congenital Colonic obstruction is
hypertrophic pyloric usually not manifest
stenosis as visible peristalsis
 Patients with kidney
stones will
frequently writhe on
the examination
table, unable to
find a
comfortable
position
 Patients with
peritonitis prefer to
lie very still as
any motion causes
further peritoneal
irritation and pain.
Abdominal examination
 It is performed before percussion
or palpation
 Normal sounds are
due to peristaltic
activity.
 Peristalsis: A
pregressive wavelike
movement that
occurs involuntarily
in hollow tubes of
the body.
 Listening for 15-60
seconds
 Bowel sounds
cannot be said to be
absent unless they
are not heard after
listening for 3-5
minutes.
 Are bowel sounds
present?
 If present, are they
frequent or sparse
(i.e.quantity)?
 What is the nature of
the sounds
(i.e.quality)?
 Inflammatory
processes of the
serosa
 After abdominal
surgery
 In response to
narcotic analgesics
or anesthesia.
 Inflammation of the
intestinal mucosa
will cause
hyperactive bowel
sounds.
 Processes which
lead to intestinal
obstruction initially
cause frequent
bowel sounds,
referred to as
"rushes."
 “Rushes"
means as the
intestines
trying to force
their contents
through a tight
opening.
 “Rushes" is followed
by decreased sound,
called "tinkles," and
then silence.
 Bruitsconfined
to systole do
not necessarily
indicate
disease.
Aortic (midline
between umbilicus
and xiphoid
Renal (two inches
superior to and two
inches lateral to
umbilicus)
Common iliac
(midway between
umbilicus and
midpoint of inguinal
ligament)
 Presence of a bruit
on the renal artery
would lend
supporting evidence
for the existence of
renal artery stenosis.
Abdominal examination
 Resonance (heard over lung tissue)
 Tympany (heard over most of abdomen)
 Dullness (heard over solid organs)
 Flatness (heard over muscle)
 DIP joint of third
finger (pleximeter)
pressed firmly on
the abdomen
remainder of hand
not touching the
abdomen
 Strikinghand
should move
only at the
wrist, with only
little more than
force of gravity
 Middle finger
of striking
hand (plexor)
should knock
the pleximeter
firmly, with a
strong note
 Tympanitic
(drum-like)
sounds
produced by
percussing
over air filled
structures.
 Dull sounds that
occur when a solid
structure (e.g.
liver) or fluid (e.g.
ascites) lies
beneath the region
being examined.
 Midclavicular
line is noted
 Second
intercostal
space is noted
 Liver:
Covered by the ribs.
Edge may protrude
1-2 centimeter
below the costal
margin.
 Spleen:
smaller and
protected by the
ribs.
 Percuss
hepatic dullness
from above (lung)
and below (bowel).
 Normal liver span =
6 to 12 cm in the
midclavicular line.
 Start just below the
right breast in a
line with the
middle of the
clavicle.
 Percussion here
should produce a
resonant note.
 As you move your
hand down you will
percuss over the
liver, which will
produce a duller
sound.
 Continue
downward until the
sound changes
once again.
 This is the inferior
margin of the liver.
 Upper margin is
noted by first dull
percussion note
 Lower margin is
noted by first
tympanitic note
Percussion at Castell’s Spot
 Castell’s Spot identified
Left anterior axillary line identified
Left lower costal margin identified
 Percussion at Castell’s Spot while patient
inhales and exhales deeply

Dull tone indicates

possible splenomegaly
 Enlarged spleen:
produces a dull
tone, in the LUQ
Abdominal examination
 Technique  Spleen tip
 Light  Kidneys
 Deep  Aorta
 Liver edge  Masses
 Topalpate four
quadrants
superficially
from LLQ
counterclockwise
 First warm your
hands by rubbing
them together
before placing them
on the patient.
 Abdominal wall
depressed
approximately 1 cm
 Any areas of pain or
tenderness are
reserved for
evaluation at the
end of the exam
 Tenderness (muscle
splinting, wide eyes,
moaning, teeth
gritting).
 Muscle tone,
Cutaneous
hypersensitivity
(suggests peritoneal
irritation)
 Superficial mass
(intramural): more
prominent with head
raised
 Intra-abdominal
mass: less
prominent with head
raised
 Use palmar surface
of fingers
 Deep, firm, gentle
maneuver
 Use finger pads (do
not “dig in” with
finger tips)
 Palpate tender areas
last
 Try to identify
abdominal masses
or areas of deep
tenderness
 When deep
palpation is difficult,
examiner may want
to use left hand
placed over right
hand to help exert
pressure
 Sigmoid colon  Distended bladder
 Liver  Gravid and non-
 Kidney gravid uterus
 Abdominal aorta  Xyphoid process
 Iliac artery  spleen
 Intra abdominal
masses or enlarged
liver, gallbladder or
spleen
 Abdominal wall
mass
 will shift down with
inspiration and back
with expiration.
 (not true of masses
within the
abdominal wall or
retroperitoneal
structures).
 Pain from an organic
lesion or functional
disturbance within an
abdominal viscus
(dull, poorly
localized, and
difficult for the
patient to
characterize).
 Painful lesion of the
skin
 Sharp, bright, and
well localized
 Indicates
involvement of
parietal peritoneum
or the abdominal
wall itself
 Voluntary guarding Involuntary guarding
Tensing abdominal Muscular spasm or
muscles due to rigidity due to
patient anxiety, peritoneal
ticklishness, or inflammation
toprevent palpation  May be localized
to a painful area (early appendicitis
)or diffuse
(perforated bowel)
 Abdominal wall is
tense, even as rigid
as a board.
 Caused by the
spasm of abdominal
muscle due to
peritoneal irritation.
 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.
 Palpatinghand
is held steady
while patient
inhales
 Palpating hand
is lifted and
moved while
the patient
breathes out
 Stand by the
patient's chest.
 "Hook" your fingers
just below the costal
margin and press
firmly.
 If you press the liver,
you will find the
dilated jugular vein
becomes more
bulged or distended,
as from the
enlargement of liver
passive congestion
resulted from right
failure.
 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.
 Seldom palpable in
normal adults.
 Press down deeply
in the midline above
the umbilicus with
flat palm.
 The aortic pulsation
is easily felt on most
individuals.
 Hands then oriented
vertically on either
side of midline with
distal fingers at level
of pulsation; equal
pressure applied
until pulsation is
palpated
A well defined, pulsatile mass, greater than
cm across, suggests an aortic aneurysm.
 Murphy’s  Re bound
Sign Tenderness
 McBurney’s
 Costovertebral
Point tenderness
 Rovsing’s
Sign  Shifting
 Psoas Sign Dullness
 Obturator  Fluid wave
Sign
 Examiner’s hand is
at middle inferior
border of liver.
 Patient is asked to
take deep
inspiration.
 If positive patient
will experience pain
and will stop short
of full inspiration
Hepatitis, subdiaphragmatic
abscess Cholecystitis
 Localized
tenderness Just
below midpoint of
line between right
anterior iliac crest
and umbilicus.
 Heel strike, riding
over bumps in road
while driving,
coughing, will
produce pain.
 Appendicitis
 Incarcerated or
strangulated hernia
 Ovarian torsion
(twisted Fallopian tube)
 Pelvic inflammatory
disease
 Abdominal abscess
 Hepatitis
 Diverticular disease
 Meckel''s diverticulum
 Patient will
experience right
lower quadrant pain
(in region of
McBurney’s Point)
when left lower
quadrant is
palpated.
 Iliopsoas Sign

 Obturator Sign
Patient lies on side, extends leg at the hip
or lies on back, flexes hip against resistance
of examiner’s hand on thigh.
Inflamed retrocecal appendix pain
 Anatomic basis for
the psoas sign:
inflamed appendix is
in a retroperitoneal
location in contact
with the psoas
muscle, which is
stretched by this
maneuver.
 Internally rotate right leg at the hip with the
knee at 90 degrees of flexion. Will produce
pain if inflamed appendix is in pelvis.
 Anatomic basis for
the obturator sign:
inflamed appendix
in the pelvis is in
contact with the
obturator internus
muscle, which is
stretched by this
maneuver.
 Warn the patient what
you are about to do.
 Press deeply on the
abdomen with your
hand.
 After a moment, quickly
release pressure.
 If it hurts more when
you release, the patient
has rebound
tenderness. [4]
 Use the heel of
your closed fist to
strike the patient
firmly over the
costovertebral
angles.
 Compare the left
and right sides.
 Patient rolled
slightly toward the
examined side;
movement of the
dull point medially is
described as
“shifting dullness”
and suggests ascites