final acute abdominal examination demo

Demonstration About Acute Demonstration About Acute AbdomenAbdomen

The History and Physical in The History and Physical in PerspectivePerspective

70%70% of diagnoses can be made based on of diagnoses can be made based on historyhistory alone. alone.

90%90% of diagnoses can be made based on of diagnoses can be made based on history and physical examhistory and physical exam. .

Expensive testsExpensive tests often confirm what is found often confirm what is found during the during the history and physicalhistory and physical. .

The Importence Of History The Importence Of History In Cases With Acute In Cases With Acute

AbdomenAbdomen

Personal HistoryPersonal History

Age: neonatal, childhood, adults, old Age: neonatal, childhood, adults, old ageage

SexSex

Special Habits: Smoking, Special Habits: Smoking, Alcoholism,..Alcoholism,..

History Of Presenting IllnessHistory Of Presenting Illness

Onset:Onset:

Appendicitis, rupture spleen, acute Appendicitis, rupture spleen, acute mesenteric ischaemiamesenteric ischaemia

Course:Course:

Perforated duodenal ulcer, ruptured Perforated duodenal ulcer, ruptured appendixappendix

Duration:Duration:

In seconds, minutes, hours, days….In seconds, minutes, hours, days….

(1) Analysis of patient complaint:(1) Analysis of patient complaint:

Exact onset Exact onset

Many conditions are precipitated by Many conditions are precipitated by exertion . It is important to know what the exertion . It is important to know what the patient was doing at the time of onset.patient was doing at the time of onset.

Fainting occurs with ectopic gestation, Fainting occurs with ectopic gestation, perforated GU/DU, a/c pancreatitis, perforated GU/DU, a/c pancreatitis, ruptured aortic aneurysm.ruptured aortic aneurysm.

Intestinal obstruction gradual in onset and Intestinal obstruction gradual in onset and culminates in crisisculminates in crisis


Analysis of patient complaint (cont.):Analysis of patient complaint (cont.):

Site of painSite of painCharacter of painCharacter of painIncreased byIncreased byDecreased byDecreased byRadiationRadiationReferralReferral

(2) Design your questions so as to find a (2) Design your questions so as to find a causecause for the patient complaint: for the patient complaint:

e.g.e.g.

If you suspect a complicated peptic ulcerIf you suspect a complicated peptic ulcer

If you suspect a renal colicIf you suspect a renal colic

If you suspect a portal pyaemiaIf you suspect a portal pyaemia

If you suspect a complicated herniaIf you suspect a complicated hernia


(3) Design your questions so as to find a (3) Design your questions so as to find a complicationcomplication for the patient complaint: for the patient complaint:

e.g.e.g.

Does a ruptured viscus lead to peritonitis??Does a ruptured viscus lead to peritonitis??

Does the irreducible hernia lead to Does the irreducible hernia lead to strangulation??strangulation??

Does the internal bleeding lead to shock??Does the internal bleeding lead to shock??


(4) Revision of other body systems(4) Revision of other body systems

Is there a contraindication to my proposed Is there a contraindication to my proposed surgery?surgery?

Is there a special precaution to be noticed?Is there a special precaution to be noticed?

Past HistoryPast History

Similar conditionsSimilar conditions

Major illness ( including drugs)Major illness ( including drugs)

Major trauma (including surgical trauma)Major trauma (including surgical trauma)

Blood transfusion, travel abroad, previous Blood transfusion, travel abroad, previous admissions to hospitalsadmissions to hospitals

Family historyFamily history

Similar conditions in the familySimilar conditions in the family

History of positive consanguinityHistory of positive consanguinity

Type of abdominal painType of abdominal pain

Visceral painVisceral pain Somatic painSomatic pain

Visceral painVisceral pain

This is pain is This is pain is dulldull, , poorly localizedpoorly localized, , and and difficultdifficult for for the patient to the patient to characterizecharacterize..

Somatic painSomatic pain

Sharp, bright, and Sharp, bright, and well localizedwell localized

Indicates Indicates involvement of involvement of parietal peritoneumparietal peritoneum or the or the abdominal abdominal wall itselfwall itself

Equipment for physical examinationEquipment for physical examination

Required Required Stethoscope Stethoscope

Tongue blades Tongue blades Penlight Penlight

Tape measure Tape measure Sphygmomanometer Sphygmomanometer Reflex hammer Reflex hammer Safety pins Safety pins

OptionalOptional GlovesGloves

Gauze padsGauze pads

Lubricant gel Lubricant gel

Nasal speculum Nasal speculum Turning forkTurning fork: : 128 Hz,512Hz128 Hz,512Hz

Pocket visual acuity Pocket visual acuity card card

Oto-ophthalmoscopeOto-ophthalmoscope

Important aspects of physical Important aspects of physical examination----physicianexamination----physician

Elegant appearanceElegant appearance

Decent mannerDecent manner

Kind attitudeKind attitude

Highly responsibilityHighly responsibility

Good medical Good medical moralsmorals

How to perform the physical How to perform the physical examination?examination?

Exposing only the Exposing only the area that are being area that are being examined examined

Offer a chaperone for Offer a chaperone for both sexes.both sexes.

Explain what you're Explain what you're going to dogoing to do

Sequential Sequential

Gloves should be worn when..Gloves should be worn when..

Examining any Examining any individual with individual with exudative lesionsexudative lesions or or weeping dermatitisweeping dermatitis

When handling When handling blood-soiledblood-soiled or or body body fluid-soiledfluid-soiled sheets sheets or clothingor clothing

General principles of examGeneral principles of exam

Good light Good light

Relaxed Relaxed patientpatient

Full exposure Full exposure of abdomenof abdomen


Before the exam, ask Before the exam, ask the patient to the patient to identify identify painful areaspainful areas so that so that you can examine you can examine those areas lastthose areas last

During the exam pay During the exam pay attention to their attention to their facial facial expressionexpression to assess to assess for sign of discomfort for sign of discomfort


If muscles remain If muscles remain tensetense, patient may , patient may be asked to be asked to rest rest feetfeet on table with on table with hipships and and knees knees flexedflexed

General examinationGeneral examination

Patient is alert, conscious, co-operative and Patient is alert, conscious, co-operative and oriented for time, place and person. oriented for time, place and person.

Special decubitus, average body weight Special decubitus, average body weight

Striking featuresStriking features

Vital signsVital signs

ColoursColours

What is CREST?scleroderma which is characterized by: Calcinosis; Raynaud's; Esophagus motility disorders; Sclerodactyly, Telangiectasia.

Peutz-Jeghers syndrome

Think Think AnatomicallyAnatomically

Think AnatomicallyThink Anatomically

When looking, When looking, listening, feeling and listening, feeling and percussing percussing imagine imagine what organs livewhat organs live in in the area that you are the area that you are examining. examining.

Landmarks of the abdominal wall,

Costal margin, umbilicus, iliac crest, anterior superior iliac spine, symphysis pubis, pubic tubercle, inguinal ligament, rectus abdominis muscle, xiphoid process.

Physical Examination of the Physical Examination of the Acute AbdomenAcute Abdomen

InspectionInspection Auscultation Auscultation Percussion Percussion Palpation Palpation Special Tests Special Tests

InspectionInspection

Very clearVery cleare.g. gunshotse.g. gunshots

Scars Scars

Appearance of the abdomenAppearance of the abdomen

Is Aortic Is Aortic pulsationpulsation? ?

Is it flat or Is it flat or Scaphoid Scaphoid ((Normally)?Normally)?

DistendedDistended? ?

If enlarged, does this If enlarged, does this appear appear symmetricsymmetric??

With With bulging or bulging or movingmoving??

Visible PulsationsVisible Pulsations

More conspicuous in the More conspicuous in the thin than in the fatthin than in the fat

Greater in the old than in Greater in the old than in the young.the young.

Increased in Increased in thyrotoxicosis, thyrotoxicosis, hypertension, or aortic hypertension, or aortic regurgitation)regurgitation)

In those with an aortic In those with an aortic aneurysm and tortuous aneurysm and tortuous aortaaorta

In those who have a In those who have a mass joining the aorta to mass joining the aorta to the anterior abdominal the anterior abdominal wall. wall.

Symmetrical in shapeSymmetrical in shape

Scaphoid or flat in young patients of normal weight

slightly full but not distended in older age group due to poor muscle tone or in subjects who are mildly overweight

Appreciation of abdominal contoursAppreciation of abdominal contours

Standing at the footStanding at the foot of of the table and looking up the table and looking up towards the patient's towards the patient's head. head.

Lower yourself until the Lower yourself until the

anterior abdominal anterior abdominal wallwall and ask the patient and ask the patient to breathe normally while to breathe normally while you are doing so. you are doing so.


Global Global abdominal abdominal enlargement is enlargement is usually caused usually caused by by FsFs

(fat, fluid, flatus, (fat, fluid, flatus, food, foetus) food, foetus)


Localized Localized enlargement enlargement probably distend probably distend GB space GB space occupyingoccupying lesion, lesion, hepatomegaly….hepatomegaly….

Appearance of the abdomenAppearance of the abdomen((Skin)Skin)

Abnormal Abnormal striastria

Umbilicus isUmbilicus is sunken sunken

StriaeStriae

Stretch marks are a Stretch marks are a light silver hue.light silver hue.

Pregnancy and obese Pregnancy and obese individualsindividuals

Cushing’s syndrome Cushing’s syndrome (more purple or pink).(more purple or pink).

Congenital naevus on the abdomenCongenital naevus on the abdomen

Appearance of the abdomenAppearance of the abdomen ( (Skin)Skin)

TattoosTattoosScars can be drawn on schematic diagrams of the abdomen (a picture is worth a thousand words).

Cullen’s signCullen’s sign

Ecchymosis Ecchymosis periumbilicallyperiumbilically. . (intraperitoneal (intraperitoneal hemorrhage hemorrhage ruptured ectopic ruptured ectopic pregnancy, pregnancy, hemorrhagic hemorrhagic pancreatitis..)pancreatitis..)

Grey-Turner’s signGrey-Turner’s sign

Ecchymosis of Ecchymosis of flanks. flanks. ((retroperitoneal retroperitoneal hemorrhage hemorrhage such as such as hemorrhagic hemorrhagic pancreatitis) pancreatitis)

Upward flow direction indicates IVC obstruction

Outward flow pattern from umbilicus in all directions ? Portal HTN

Evaluate venous return states

Place index finger side by side over a vein and press laterally, milking vein.

Release one finger and time refill, repeat with other finger. Venous return is in direction of faster filling.


Areas which Areas which become more become more pronounced when pronounced when the patient the patient valsalvasvalsalvas are are often associated often associated with with ventral ventral herniashernias

Visible gastric PeristalsisVisible gastric Peristalsis

Gastric peristalsis is Gastric peristalsis is commonly seen in commonly seen in neonates with neonates with congenital congenital hypertrophic pyloric hypertrophic pyloric stenosisstenosis

Intestinal peristalsis in Intestinal peristalsis in partial and chronic partial and chronic intestinal obstructionintestinal obstruction

Colonic obstruction is Colonic obstruction is usually not manifest usually not manifest as visible peristalsis as visible peristalsis

Visible intestinal Visible intestinal PeristalsisPeristalsis

Appearance of the abdomenAppearance of the abdomen Patient's movement Patient's movement

Patients with Patients with kidney kidney stonesstones will frequently will frequently writhe on the writhe on the examination table, examination table,

unableunable to find a to find a

comfortablecomfortable positionposition

Appearance of the abdomenAppearance of the abdomen Patient's movement Patient's movement

Patients with Patients with peritonitisperitonitis prefer to lie prefer to lie

very stillvery still as any as any motion causes further motion causes further peritoneal irritation peritoneal irritation and pain. and pain.

Palpation Palpation

Abdominal Palpation Abdominal Palpation

Technique Technique

Light Light

Deep Deep

Liver edge Liver edge

Spleen tip Spleen tip

Kidneys Kidneys

Aorta Aorta

MassesMasses

Light PalpationLight Palpation


First First warm your warm your handshands by rubbing by rubbing them together before them together before placing them on the placing them on the patient.patient.

Abdominal palpationAbdominal palpation

Use pads of three fingers of one hand and a light, gentle, dipping maneuver to examine abdomen

Palpation (light)

Any areas of pain or tenderness are reserved for evaluation at the end of the exam


Mostly looking for Mostly looking for areas of areas of temprature, temprature, tenderness & rigidity.tenderness & rigidity.

Palpation Light palpation assesses

Muscle tone & Cutaneous hypersensitivity (suggests peritoneal irritation)

Palpation Light palpation assesses

Presence of superficial (intramural) masses is more prominent if patient raises their head ,Intra-abdominal mass is less prominent if patient raises their head

Deep PalpationDeep Palpation

Deep PalpationDeep PalpationUse palmar surface of fingers of one hand (greatest number of greatest number of fingers)fingers) and a deep, firm, gentle maneuver to examine abdomen

PalpationPalpation

Palpate deeply with Palpate deeply with finger finger padspads (do not (do not “dig in” with finger “dig in” with finger tipstips))

Deep PalpationDeep PalpationPalpate tender areas Palpate tender areas lastlast

Try to identify Try to identify abdominal abdominal massesmasses or or areas of areas of deep deep tendernesstenderness

Normal structure that may be Normal structure that may be palpablepalpable

Sigmoid colon Sigmoid colon

LiverLiver

KidneyKidney

Abdominal aortaAbdominal aorta

Iliac arteryIliac artery

Distended bladderDistended bladder

Gravid and non-Gravid and non-gravid uterus gravid uterus

Xyphoid processXyphoid process

spleen spleen

TendernessTenderness

If there is tenderness If there is tenderness determine the point of determine the point of maximum tendernessmaximum tenderness

Abdominal muscle spasmAbdominal muscle spasm

Voluntary guardingVoluntary guarding Tensing abdominal Tensing abdominal muscles due to muscles due to patient anxiety or patient anxiety or palpation to a painful palpation to a painful area area

Involuntary guardingInvoluntary guarding Muscular spasm or Muscular spasm or rigidity due to rigidity due to peritoneal peritoneal inflammationinflammationMay be localized May be localized (early appendicitis )or (early appendicitis )or diffuse (perforated diffuse (perforated bowel) bowel)

How to differentiate the two?

Voluntary guardingVoluntary guarding Tensing abdominal Tensing abdominal muscles due to muscles due to patient anxiety or patient anxiety or palpation to a painful palpation to a painful area area

Involuntary guardingInvoluntary guarding Muscular spasm or Muscular spasm or rigidity due to rigidity due to peritoneal peritoneal inflammationinflammationMay be localized May be localized (early appendicitis )or (early appendicitis )or diffuse (perforated diffuse (perforated bowel) bowel)

Board-like rigidityBoard-like rigidityIf abdominal wall is If abdominal wall is palpated as obviously palpated as obviously tense, even as tense, even as rigid rigid as a boardas a board..

Liver palpationLiver palpation

Standard Method Liver palpationStandard Method Liver palpation

Ask the patient to Ask the patient to take a take a deep breath.deep breath.

You may feel the You may feel the edge of the liver press edge of the liver press against your fingers. against your fingers.

Liver palpation Liver palpation ((Standard Method)Standard Method)

Palpating hand is Palpating hand is held steadyheld steady while while

patient inhalespatient inhales

Liver palpation Liver palpation ((Standard Method)Standard Method)

Palpating hand is Palpating hand is lifted and movedlifted and moved while the patient while the patient

breathes outbreathes out

Alternate Method Liver palpationAlternate Method Liver palpation

Stand by the patient's Stand by the patient's chest.chest.

"Hook""Hook" your fingers your fingers just below the costal just below the costal margin and press margin and press firmly. firmly.

HepatomegalyHepatomegaly

More than More than 1cm below1cm below the costal marginthe costal margin

How to differentiate How to differentiate hepatomegaly from hepatomegaly from ptosed liver (e.g. lax ptosed liver (e.g. lax ligaments)?ligaments)?

Spleen palpationSpleen palpation

Spleen palpation Spleen palpation

Support Support lower left rib lower left rib cagecage with left hand with left hand while patient is supine while patient is supine and and lift anteriorly on lift anteriorly on the rib cagethe rib cage. .

Spleen palpation Spleen palpation

Palpate Palpate upwards upwards toward spleentoward spleen with with finger tips of right finger tips of right hand, starting below hand, starting below left costal margin. left costal margin.

Have the Have the patient take patient take a deep breatha deep breath. .

Examination of Spleen (Palpation)

Kidney palpationKidney palpation

Kidney palpationKidney palpation

Place Place left hand left hand posteriorlyposteriorly just below just below the right 12th rib. Lift the right 12th rib. Lift upwards. upwards.

Palpate deeply with Palpate deeply with right hand on anterior right hand on anterior abdominal wall.abdominal wall.

Examination of Kidney

Patient take a Patient take a deep deep breath. breath.

Feel lower pole of Feel lower pole of kidneykidney and try to and try to capture it between capture it between your hands.your hands.

Examination of Kidney

Right kidney may be felt to slip between hands during exhalation

Special examSpecial exam

Abdominal examinationAbdominal examination

Special examSpecial exam

Murphy’s Sign Murphy’s Sign McBurney’s McBurney’s PointPointRovsing’s SignRovsing’s SignPsoas SignPsoas SignObturator Sign Obturator Sign

Rebound Rebound TendernessTendernessCostovertebral Costovertebral tendernesstendernessShifting DullnessShifting Dullness

Murphy’s Sign (acute cholecystitis)Murphy’s Sign (acute cholecystitis)

Examiner’s hand is at Examiner’s hand is at middle inferior border middle inferior border of liver.of liver.Patient is asked to Patient is asked to take take deep inspirationdeep inspiration..If positive patient will If positive patient will experience painexperience pain and and will will stop shortstop short of full of full inspirationinspiration

Acute CholecystitisAcute Cholecystitis

McBurney’s PointMcBurney’s Point

Localized tenderness Localized tenderness at the junction of at the junction of medial 2/3 and lateral medial 2/3 and lateral 1/3 of a line between 1/3 of a line between right anterior superior right anterior superior iliac spineiliac spine and and umbilicusumbilicus

McBurney’s Point (McBurney’s Point (Common CausesCommon Causes))

Appendicitis Incarcerated or Incarcerated or strangulated hernia strangulated hernia Ovarian torsion (twisted Ovarian torsion (twisted Fallopian tube) Fallopian tube) Pelvic inflammatory disease Abdominal abscess Hepatitis Diverticular disease Diverticular disease Meckel''s diverticulumMeckel''s diverticulum

http://www.medicineonline.com/conditions/redirect.html?encyID=9674





Rovsing’s SignRovsing’s Sign

Patient will Patient will experience right lower experience right lower quadrant pain (in quadrant pain (in region of McBurney’s region of McBurney’s Point) when left lower Point) when left lower quadrant is palpated. quadrant is palpated.

Non-Classical AppendicitisNon-Classical Appendicitis

Iliopsoas SignIliopsoas Sign

Obturator SignObturator Sign


Patient can lay on side and extend leg at the hip Patient can lay on side and extend leg at the hip or have patient lay on back and try to flex hip or have patient lay on back and try to flex hip against the resistance of examiner’s hand on against the resistance of examiner’s hand on thigh. If patient has an inflamed retro-cecal thigh. If patient has an inflamed retro-cecal appendix, this will produce pain. appendix, this will produce pain.


Anatomic basis for Anatomic basis for the psoas sign: the psoas sign: inflamed appendix is inflamed appendix is in a retroperitoneal in a retroperitoneal location in contact location in contact with the psoas with the psoas muscle, which is muscle, which is stretched by this stretched by this maneuver. maneuver.


Internally rotate right leg at the hip with the knee Internally rotate right leg at the hip with the knee at 90 degrees of flexion. Will produce pain if at 90 degrees of flexion. Will produce pain if inflamed appendix is in pelvis. inflamed appendix is in pelvis.


Anatomic basis for Anatomic basis for the obturator sign: the obturator sign: inflamed appendix in inflamed appendix in the pelvis is in contact the pelvis is in contact with the obturator with the obturator internus muscle, internus muscle, which is stretched by which is stretched by this maneuver. this maneuver.

Rebound TendernessRebound Tenderness ((FFor peritoneal irritation)or peritoneal irritation)

WarnWarn the patient what the patient what you are you are about to doabout to do. .

Press deeplyPress deeply on the on the abdomen with your hand. abdomen with your hand.

After a moment, After a moment, quickly quickly release pressurerelease pressure. .

If it If it hurts more when you hurts more when you release,release, the patient has the patient has rebound tenderness. [rebound tenderness. [4] ]

Cost vertebral TendernessCost vertebral Tenderness (Often with renal disease)(Often with renal disease)

CompareCompare the the left left and right sides. and right sides.

PercussionPercussion

PercussionPercussion

Technique Technique

Liver Liver

SpleenSpleen

The two solid organs are percussable in the normal patientLiver: will be entirely covered by the ribs. Occasionally, an edge may protrude 1-2 cm below the costal margin.

Spleen: The spleen is smaller and is entirely protected by the ribs.

To determine the size of the liverTo determine the size of the liver

Measure the liver Measure the liver span by percussing span by percussing hepatic dullness from hepatic dullness from above (lung) and above (lung) and below (bowel).below (bowel). A A normal liver span is normal liver span is 6 6 to 12 cmto 12 cm in the in the midclavicular line.midclavicular line.

Spleen percussionSpleen percussion

Enlarged spleen Enlarged spleen produce a produce a dull dull tonetone, in the , in the left left upper quadrant upper quadrant percussionpercussion but but should then be should then be verified by verified by palpation.palpation.

AuscultationAuscultation


BowelBowel sounds sounds

Vascular Vascular sounds (bruits)sounds (bruits)

Friction Friction Rubs Rubs

Auscultation for bowel soundsAuscultation for bowel sounds

Normal sounds are Normal sounds are

due to due to peristaltic peristaltic activityactivity..Peristalsis: A Peristalsis: A progressive progressive wavelike wavelike movementmovement that occurs that occurs involuntarily in hollow involuntarily in hollow tubes of the body. tubes of the body.


Listening in Listening in one one spotspot is usually is usually sufficientsufficientListening for Listening for 15-20 15-20 or 30-60or 30-60 seconds secondsBowel sounds Bowel sounds cannot cannot be said to be absentbe said to be absent unless they are not unless they are not heard after listening heard after listening for for 3-5 minutes3-5 minutes. .

Three things about bowel Three things about bowel soundsound

Are bowel sounds Are bowel sounds present?present?

If present, are they If present, are they frequent or sparse frequent or sparse (i.e.quantity)? (i.e.quantity)?

What is the nature of What is the nature of the sounds the sounds (i.e.quality)? (i.e.quality)?

Bowel sound decreaseBowel sound decrease

Inflammatory Inflammatory processes of serosaprocesses of serosa

Inflammation of the Inflammation of the intestinal mucosaintestinal mucosa will cause will cause hyperactivehyperactive bowel bowel sounds. sounds.

Bowel sound increaseBowel sound increase

Auscultation for bowel soundsAuscultation for bowel sounds

What about What about intestinal intestinal obstruction??obstruction??

Splash SignSplash Sign

Splashing sound Splashing sound indicative of indicative of air or air or fluid in body cavity fluid in body cavity with shaking with shaking individualindividual: gastric : gastric outlet obstruction. outlet obstruction.

Auscultation for vascular sounds Auscultation for vascular sounds (bruits)(bruits)

AorticAortic (midline between (midline between umbilicus and xiphoidumbilicus and xiphoid

RenalRenal ( (two inches two inches superiorsuperior to and to and two two inches lateral toinches lateral to umbilicus)umbilicus)

Common iliac (Common iliac (midway midway between umbilicus between umbilicus and midpoint of and midpoint of inguinal ligamentinguinal ligament))

Venous Hum (rare)Venous Hum (rare)

Epigastric/umbilical Epigastric/umbilical areaarea. .

Soft hummingSoft humming noises noises in in systolic/diastolicsystolic/diastolic component. component.

Indicates Indicates collateral collateral between portal and between portal and venous systemsvenous systems as in as in hepatic cirrhosis. hepatic cirrhosis.

Friction rubs (rare)Friction rubs (rare)

Right and leftRight and left upper upper quandrants quandrants Grating sound with Grating sound with respiratory movementrespiratory movement Indicates Indicates inflammation of the inflammation of the capsule of the liver or capsule of the liver or spleen (spleen (infection or infection or infarctioninfarction). ).

THANK YOUTHANK YOU

final acute abdominal examination demo

Documents