abdominal system examination - trinity college, dublin · abdominal system examination subtitle —...

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/






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


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


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


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


Inspect the hands

Inspect the Nails for

• Clubbing

• Koilonychia

• Leuconychia

Inspect the hands for

• Palmar erythema

• Dupuytren’s contractures

• Hepatic flap

http://www.youtube.com/watch?v=pAOWjYo-sX4


Inspect the Arms

• Spider naevi (telangiectatic lesions)

• Bruising

• Wasting

• Scratch marks (chronic cholestasis)


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)


Mouth

Breath (fetor hepaticus)

Lips

– Angular stomatitis

– Cheilitis

– Ulceration

– Peutz-Jeghers syndrome

Tongue

– Atrophic glossitis

– Leicoplakia

– Furring

– Thrush

Gums Gingivitis, bleeding Candida albicans Pigmentation


Inspect Neck and Chest

• Cervical lymphadenopathy

• Left supraclavicular fossa (Virchov’s node)

• Gynaecomastia

• Loss of hair


Physical Examination of the Abdomen

• Inspection

• Palpation

• Percussion

• Auscultation


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/


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/


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


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


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


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.


Splenomegaly DDx

Sarcoidosis, amyloidosis

Sjogren's

Infectious: • CMV • IE, SBE • Lyme disease • Rheumatic fever • Malaria

Lymphoid: • Leukaemias • Lymphoma

DIC


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


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


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


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)?

abdominal system examination - trinity college, dublin · abdominal system examination subtitle —...

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