ABDOMINAL EXAMINATION ABDOMINAL EXAMINATION PALPATION 1 Ensure that

ABDOMINAL EXAMINATION

ABDOMINAL EXAMINATION PALPATION 1. Ensure that your hands are warm 2. Stand on the patient’s right side 3. Help to position the patient 4. Ask whether the patient feels any pain before you start 5. Begin with superficial examination 6. Move in a systematic manner through the abdominal quadrants 7. Repeat palpation deeply.

PALPATION Tenderness: discomfort for it’s site. and resistance to palpation. Note Voluntaryguarding- voluntary provoked by palpation. Rebound tenderness: patient released contraction due to pain feels pain when the hand is Tenderness + rigidity: perforated Palpable mass (enlarged viscus organ, faeces, tumour)

Palpation of liver Place both the hands flat on abdomen in the right sub costal region. Ask the patient to breath deeply. Edge of liver is felt moving downwards. Hepatomegaly is measured in cms below right costal margin.

Surface - soft and tender. Smooth, RHF Firm and regular. OBSTRUCTIVE JAUNDICE Hard, irregular painless. ADVANCED SECONDARY CA

Gall bladder Normal gall bladder can not be felt. Distended- palpated as firm smooth globular swelling, distinct borders lateral to rectus abdominus near the tip of 9 th intercostal margin. Painless gallbladder Jaundice in patient with Ca head pancreas or CBD obstruction due to malignancy. Mucocele. Carcinoma gall bladder.

MURPHY’S SIGN Pain in RUQ Inflammation of gallbladder (cholecystitis) Courvoisier'slaw states that in the presence of an enlarged gall bladder which is nontender and accompanied with jaundice, the cause is unlikely to be gallstones.

Palpation of spleen the spleen is not normallypalpable. It has to be enlarged to two or three times its usual size before it becomes palpable, and then is felt beneath the left subcostal margin. Enlargementtakes place in a superior and posterior direction beforeit becomes palpable subcostally. Once the spleen has become palpable, the direction of furtherenlargementis downwardsand towards the right iliac fossa

Start from the umbilicus. Keep your hand stationaryand ask the patient to breathe in deeply through the mouth. Feel for the splenic edge as it descends on inspiration(Fig. A) Move yourhand diagonally upwards towards the left hypochondrium 1 cm at a time between each breath the patient takes. Feel the costal margin along its length, as the position of the spleen tip is variable.

If you cannot feel the splenic edge, ask the patient to roll towards you and on to his right side; repeat the above. Palpate with your righthand, placing your left hand behind the patient'sleft lower ribs, pulling the ribcage forward(Fig. B). Feel along the left costal margin and percuss over the lateral chest wall to confirmor exclude the presence of splenic dullness

Palpation of kidney Left kidney The left hand is placed anteriorlyin the left lumbarregion and the right is placed posteriorlyin the left loin Ask the patient to take a deep breath in, press the right hand forwardsand the left hand backwards, upwards and inwards The left kidney is not usuallypalpable unless it is either low in position or enlarged.

Right kidney Place the right hand horizontallyin the right lumbar region anteriorly with the left hand placed posteriorly in the right loin. Push forwardswith the left hand, ask the patient to take a deep breath in, and press the right hand inwards and upwards The lower pole of the right kidney, is commonlypalpable in thin patients, and is felt as a smooth, rounded swelling which descends on

THE URINARY BLADDER Normallythe urinarybladder is not palpable. When it is full and the patient cannot empty it (retentionof urine), a smooth firmregular ovalshaped swelling will be palpated in the suprapubic regionand its dome (upper border) may reach as far as the umbilicus The fact thatthis swelling is symmetrically placed in the suprapubic regionbeneath the umbilicus, thatit is dull to percussion, and that pressure on it gives the patient a desire to micturate, together confirms such a swelling as the bladder

External genitalia ln surgical practice this is usually confined to examination of the male genitalia, since females with disorders of this region are managed by gynaecologists. The examination is best performed with the patient in the supine and standing position. Spermatic cord : - Beaded = B or T. B – -Matted= filarasis

Scrotum - Shape, symmetry and swelling - ln all cases both sides of the scrotum should be palpated - Back of the scrotum for T. B sinus - Starting with the healthy side, first with the patient standing & then in the recumbent position - Palpation of the epididymis(size, consistency, presence of sulcus, between it and the testis) - tunica vaginalis (early hydrocele detected by pinching test. i. e. you feel double layers)

Testis - Size - Consistency - Testicular sensation Penis -for ulcer or scar of chancre -external meatus (site, discharge by pressing the glans)

Hernial orifices Epigastric, paraumbilical inguinal femoral incisional

Back Don’t forget to examine the back for Pott's disease psoas abscess

DEFINING THE BOUNDARIESOF ABDOMINAL ORGANS AND MASSES Liver Start anteriorly, at the fourthintercostal space, where the note will be resonant over the lungs, and workvertically downwards. Over a normal liver, percussion will detect the upper border at abmen). The dullness extends down to the lower border at or just below the right subcostal margin, giving a normal liver vertical height of 12 -15 cm

Spleen Dullness extends from the left lowerribs into the left hypochondriumand left lumbar region. Urinary bladder The dullness on percussion, and clear differencefrom the adjacent bowel, provides reassurance that the swelling is cystic or solid and not gaseous. Other masses The boundaries of any localized swelling in the abdominal cavity, or in the walls of the abdomen, can sometimes be defined more accurately by percussion than palpation, as for the urinary bladder.

Fluid thrill Place the palm of your left hand flat against the left side of the abdomen and flick a finger of your righthand against the right side of the abdomen. If you feel a ripple against your left hand, ask an assistant to place the edge of their hand on the midline of the abdomen. This prevents transmissionof the impulse via the skin rather than through the ascites. If you still feel a ripple againstyour left hand, a fluid thrillis present (only detected in gross ascites).

Clinical features of marked abdominal Gross ascites swelling Dull in flanks Umbilicus everted and/or hernia present Shifting dullness positive Fluidthrill positive Large ovarian cyst Resonant in flank. Umbilicus, vertical and drawn up Large swelling felt arising out of pelvis which one cannot 'get below' Intestinal obstruction Resonant throughout. Colicky pain Vomiting. Recent cessation of passage of stool and flatus Increased and/or 'noisy'bowel sounds