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Gloves Gauze pads Lubricant gel Nasal speculum Turning fork: 128 Hz,512Hz Pocket visual acuity card Oto-ophthalmoscope
bed Exam with right hand Head just a little elevated Ask the patient to keep the mouth partially open and breathe gently
Think Anatomically
Think Anatomically
When looking, listening, feeling and percussing imagine what organs live in the area that you are examining.
Left Lower Quadrant (LLQ) Sigmoid colon (in case of female, left ovary & tube)
Epigastric Area
Stomach, pancreas (head and body), aorta
Inspection
Abdominal examination
Symmetrical in shape
slightly full but not distended in older age group due to poor muscle tone or in subjects who are mildly overweight
An aortic aneurysm
Palpable mass Patient feeling of pulsation On rare occasions, a lump can be visible.
An aortic aneurysm
1 in 10 men over 65 may have some enlargement of the abdominal aorta. About 1 in 100 will have a large aneurysm requiring surgery.
Striae
Stretch marks are a light silver hue. Pregnancy and obese individuals Cushings syndrome (more purple or pink).
Cullens sign
Ecchymosis periumbilically. (intraperitoneal hemorrhage ruptured ectopic pregnancy, hemorrhagic pancreatitis..)
Grey-Turners sign
Ecchymosis of flanks. (retroperitoneal hemorrhage such as hemorrhagic pancreatitis)
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hernias
Visible Pulsations
More conspicuous in the thin than in the fat Greater in the old than in the young. Increased in thyrotoxicosis, hypertension, or aortic regurgitation) In those with an aortic aneurysm and tortuous aorta In those who have a mass joining the aorta to the anterior abdominal wall.
Gastric peristalsis is commonly seen in neonates with congenital hypertrophic pyloric stenosis
Intestinal peristalsis in partial and chronic intestinal obstruction Colonic obstruction is usually not manifest as visible peristalsis
comfortable
position
Auscultation
Abdominal examination
activity.
Peristalsis: A pregressice wavelike movement that occurs involuntarily in hollow tubes of the body.
pathognomonic
for any particular process.
Auscultation
1.Diaphragm of stethoscope used 2.Skin depressed to approximately 1 cm
Auscultation
3.Listening in one spot is usually sufficient 4.Listening for 15-20 or 30-60 seconds
5.Bowel sounds cannot be said to be absent unless they are not heard after listening for 3-5 minutes.
Splash Sign
Splashing sound indicative of air or fluid in body cavity with shaking individual: normal in s stomach.
Bruits
Bruits confined to systole do not necessarily indicate disease.
Rubs Rubs-Rubs
Liver Spleen Cardiac Pulmonary
Percussion
Abdominal examination
Percussion
Technique Liver Spleen
Percussion (technique)
DIP joint of third finger (pleximeter) pressed firmly on the abdomen remainder of hand not touching the abdomen
Percussion (technique)
Striking hand should move only at the wrist, with only little more than force of gravity
Percussion (technique)
Middle finger of striking hand (plexor) should knock the pleximeter firmly, with a strong note
Spleen percussion
Enlarged spleen produce a dull tone, in the left upper quadrant percussion but should then be verified by palpation.
Palpation
Abdominal examination
Abdominal palpation
To palpate four quadrants superficially from LLQ
counterclockwise
Light Palpation
Light Palpation
First warm your hands by rubbing them together before placing them on the patient. Abdominal wall depressed approximately 1 cm
Abdominal 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
Light Palpation
Mostly looking for areas of tenderness Tenderness is a physical exam finding a reflex occurs (muscle splinting, wide eyes, moaning, teeth gritting).
Deep Palpation
Palpation (deep)
Entire palm Either one- or two handed technique is acceptable
Deep Palpation
Use palmar surface of fingers of one hand (greatest number of fingers) and a deep, firm, gentle maneuver to examine abdomen
Palpation
Palpate deeply with finger pads (do not dig in with finger tips)
Deep Palpation
Palpate tender areas last Try to identify abdominal masses or areas of deep tenderness
Palpation (deep)
Push as deeply as patient will allow without significant discomfort
Abdominal mass
Intra abdominal masses or enlargements of the liver, gallbladder or spleen Abdominal wall mass
Paraumbilical node
Visceral pain
This is pain that arises from an organic lesion or functional disturbance within an abdominal viscus (dull, poorly localized, and difficult for the patient to characterize).
Somatic pain
Painful lesion of the skin Sharp, bright, and well localized Indicates involvement of parietal peritoneum or the abdominal wall itself
Tenderness
If there is tenderness determine the point of maximum tenderness and its distribution
Board-like rigidity
If abdominal wall is palpated as obviously tense, even as rigid as a board, board-like rigidity is so called. Is caused by the spasm of abdominal muscle due to peritoneal irritation.
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Liver palpation
Liver palpation
Another method of palpating the liver uses the radial border of the index finger. In this method the anterior hand is placed flat on the anterior abdominal wall with fingers parallel to the costal margin
Hepatomegaly
More than 1cm below the costal margin An exception is a congenitally large right lobe of the liver Severe, chronic emphysema
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Ballotable sign
Spleen palpation
Spleen palpation
Seldom palpable in normal adults. Causes include COPD, and deep inspiratory descent of the diaphragm.
Spleen palpation
Support lower left rib cage with left hand while patient is supine and lift anteriorly on the rib cage.
Spleen palpation
Palpate upwards toward spleen with finger tips of right hand, starting below left costal margin. Have the patient take a deep breath.
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Kidney palpation
Kidney palpation
Place left hand posteriorly just below the right 12th rib. Lift upwards. Palpate deeply with right hand on anterior abdominal wall.
Examination of Kidney
Patient take a deep breath. Feel lower pole of kidney and try to capture it between your hands.
Examination of Kidney
Examination of Aorta
Examination of Aorta
Press down deeply in the midline above the umbilicus. The aortic pulsation is easily felt on most individuals.
Examination of Aorta
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.
Examination of Aorta
Special exam
Abdominal examination
Special exam
Murphys Sign McBurneys Point Rovsings Sign Psoas Sign Obturator Sign
Re bound Tenderness Costovertebral tenderness Shifting Dullness Fluid wave
McBurneys Point
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.
Rovsings Sign
Patient will experience right lower quadrant pain (in region of McBurneys Point) when left lower quadrant is palpated.
Non-Classical Appendicitis
Iliopsoas Sign
Patient can lay on side and extend leg at the hip or have patient lay on back and try to flex hip against the resistance of examiners hand on thigh. If patient has an inflamed retrocecal appendix, this will produce pain.
Iliopsoas Sign
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.
Obturator Sign
Internally rotate right leg at the hip with the knee at 90 degrees of flexion. Will produce pain if
Obturator Sign
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.
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Shifting Dullness
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Fluid wave