Examination of the Abdomen

Examination of the AbdomenPWM Olly IndrajaniPEMERIKSAAN ABDOMENPersiapan Pemeriksaan Abdomen

Pasien dalam posisi supine dengan nyaman dan meletakkan bantal dibawah kepala, serta meletakkan tangan pasien di sisi badan atau di atas dada.Pemeriksa mencuci tangan dan membersihkan stetoskop dengan kapas alkohol. Inspeksi abdomen

Ingat 8 kuadran dari abdomen Lakukan pemeriksaan pada seluruh kulit abdomen, apakah tampak jaringan parut (bentuk dan lokasi), striae, dilatasi vena, rash, dan lesi lain. Perhatikan kontur abdomen (flat, rounded, protuberant, atau scaphoid), apakah abdomen tampak simetris, dan apakah tampak benjolan pada flank atau benjolan ditempat lain.

Pemeriksa berdiri di sebelah kanan pasien, Selama pemeriksaan memperhatikan wajah pasien apakah tampak kesakitan pada pemeriksaan tertentu.

AuscultationPlace the diaphragm of your stethoscope lightly on the abdomen. Listen for bowel sounds. Are they normal, increased, decreased, or absent? Listen for bruits over the renal arteries, iliac arteries, and aortaAuskultasi abdomen

Letakkan diafragma stetoskop secara hati-hati pada abdomen, dengarkan suara usus, kemudian catat hasilnya (normal, meningkat, menurun, negatif) dan karakternya (metallic sound, dll).Bila pasien hipertensi atau dicurigai adanya insufisiensi pada ekstremitas bawah, dengarkan bruit pada Aorta, A. iliaca dan A. femoralis. Percussion

Percuss in all four quadrants using proper technique. Categorize what you hear as tympanitic or dull. Tympany is normally present over most of the abdomen in the supine position. Unusual dullness may be a clue to an underlying abdominal mass.

Perkusi perut juga dipakai untuk evaluasi adanya cairan ascites, dengan cara: puddle sign, shifting dullness.Perkusi hepar: Liver spanLakukan perkusi ringan mulai dari Linea Medioclavicular (LMC) kanan setinggi sedikit di bawah umbilicus ke arah atas, dan tentukan batas bawah pekak hepar (perubahan dari timpani sampai berubah menjadi redup). Untuk menentukan batas atas hepar, lakukan perkusi di sepanjang LMC kanan mulai dari ICS II ke arah bawah (perubahan dari sonor menjadi redup). Kemudian ukur panjang liver span tadi dengan menggunakan penggaris. Normal liver span sepanjang 8-12 cm.Ingat !. Liver span tidak perlu diukur jika sudah ada pembesaran liver yang nyata kearah bawah.Liver span

Percuss downward from the chest in the right midclavicular line until you detect the top edge of liver dullness. Percuss upward from the abdomen in the same line until you detect the bottom edge of liver dullness. Measure the liver span between these two points. This measurement should be 6-12 cm in a normal adult.

LiverPerkusi Lien: Traubes space Untuk mengetahui adanya pembesaran lien kearah anterior, perlu dilakukan perkusi pada Traubes space. Normal Traubes space terdengar suara timpani, jika ada pembesaran lien terdengar redup. Ingat ! perkusi Traubes space tidak perlu dilakukan jika sudah ada pembesaran lien kearah bawah atau ada ascites yang cukup banyak. Why ?Palpasi ringan Sebelum palpasi, pasien diminta untuk menekuk kedua kaki agar dinding abdomen dalam posisi relaks sehingga memudahkan pemeriksaan.Letakkan tangan dan lengan bawah pada bidang yang sejajar (rata), dengan jari rata terletak pada permukaan abdomen. Palpasi permukaan abdomen dengan gerakan ringan dan lembut. Saat menggerakkan tangan dari satu tempat ke tempat lain, angkat sedikit saja dari kulit. Bergerak dengan lembut dan rasakan pada semua kuadran.Identifikasi adanya organ superfisial atau adanya masa dan adanya daerah yang nyeri atau memberikan tahanan terhadap tekanan tangan.

Palpasi dalam

PalpationGeneral PalpationBegin with light palpation. At this point you are mostly looking for areas of tenderness. The most sensitive indicator of tenderness is the patient's facial expression (so watch the patient's face, not your hands). Voluntary or involuntary guarding may also be present. Proceed to deep palpation after surveying the abdomen lightly. Try to identify abdominal masses or areas of deep tenderness. Palpation of the Liver

Standard MethodPlace your fingers just below the right costal margin and press firmly. Ask the patient to take a deep breath. You may feel the edge of the liver press against your fingers. Or it may slide under your hand as the patient exhales. A normal liver is not tender.

Palpasi hepar

Palpasi lien Secara Schuffner dan Hackett

Palpasi lien secara Schuffner dilakukan mulai dari SIAS kontralateral (kanan) melalui umbilikus sampai dengan arcus costae pada LMC kiri (Schuffner I - VIII). Palpasi lien secara Hackett dimulai dari daerah setinggi SIAS kiri sampai dengan arcus costae pada LMC kiri (Hackett I IV).

Splenic Dullness

Percuss the lowest costal interspace in the left anterior axillary line. This area is normally tympanitic. Ask the patient to take a deep breath and percuss this area again. Dullness in this area is a sign of splenic enlargementPalpation of the SpleenUse your left hand to lift the lower rib cage and flank. ++ Press down just below the left costal margin with your right hand. Ask the patient to take a deep breath. The spleen is not normally palpable on most individuals

HepatosplenomegalyHepatomegalyAuscultation liver Follow the inspection of the liver, as with the rest of the abdominal exam, with auscultation. Listen over the area of the liver for bruits or venous hums.Palpation of the AortaPress down deeply in the midline above the umbilicus. ++ The aortic pulsation is easily felt on most individuals. A well defined, pulsatile mass, greater than 3 cm across, suggests an aortic aneurysm.

Rebound TendernessThis is a test for peritoneal irritation. ++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 tendernes Costovertebral Tenderness

CVA tenderness is often associated with renal disease. ++Warn the patient what you are about to do. Have the patient sit up on the exam table. Use the heel of your closed fist to strike the patient firmly over the costovertebral angles. Compare the left and right sides.

Shifting Dullness

This is a test for peritoneal fluid (ascites). ++Percuss the patient's abdomen to outline areas of dullness and tympany. Have the patient roll away from you. Percuss and again outline areas of dullness and tympany. If the dullness has shifted to areas of prior tympany, the patient may have excess peritoneal fluid. Shifting Dullness

This maneuver is performed with the patient supine.Percuss across the abdomen as for flank dullness, with the point of transition from tympany to dullness noted.The patient then is rolled on his/her side away from the examiner, and percussion from the umbilicus to flank area is repeated.Positive test: When ascites is present, the area of dullness will shift to the dependent site. The area of tympany will shift toward the top. Note: The shift in zone of tympany with position change will usually be Psoas Sign

This is a test for appendicitis. ++Place your hand above the patient's right knee. Ask the patient to flex the right hip against resistance. Increased abdominal pain indicates a positive psoas sign.

Obturator Sign

This is a test for appendicitis. ++Raise the patient's right leg with the knee flexed. Rotate the leg internally at the hip. Increased abdominal pain indicates a positive obturator sign.

Technique: AscitesBulging FlanksWith the patient supine, the examiner visually observes whether the flanks are pushed outward (presumably by large amounts of ascitic fluid) Positive test: simply the presence of bulging flanks Note: A patient with an obese abdomen may also have flanks that bulge, although the fat of obesity extends further posterior than fluid in the peritoneum.

The patient is examined in the supine position.Direct percussion is done over the abdomen, from the umbilicus to the flanks.The location of the transition from tympany to dullness is noted.Positive test: Percussion note is tympanitic over the umbilicus and dull over the lateral abdomen and flank areas Flank DullnessFluid Wave

Have the patient lying supine.The patient or an assistant places one or both hands (ulnar surface of hand downward) in a wedge-like position into the patient's mid abdomen, applying with slight pressure.The examiner places the fingertips of one hand along one flank, and with the other hand firmly gives a sharp tap along the opposite flank.Positive test: The examiner is able to detect "a shock wave" of fluid moving against the fingertips pressed along the flank, as the fluid is pushed from one side of the abdomen to the other by the force of the tap along the opposite flank.

Palmar erythemaSpider angiomata - most commonly on the trunk and upper extremitiesCaput medusae (dilated venous pattern over the right upper abdomen)SkinFluid Overload:

Peripheral edemaNote: edema in ascites due to liver or heart disease is usually confined to the lower extremities only; if present also in upper extremities and hands, consider renal disease and nephrotic syndrome.Jugular venous distension (see JVP below)Pulmonary crackles (suspect CHF)Cardiac S3Positive hepatojugular reflux (link to neck veins module associated examination segment for description of exam maneuver)Peripheral edema