Good morning..

My name is Prof. Kamal Bani Hani, Dean of the school of Medicine, Prof. of G.I surgery, and
oncosurgeon
Today we will talk about the abdominal examination, and this is very important topic for all the
specialties; the pediatrics, surgery and the internal medicine. There is no harmony of teaching in
faculties of medicine, so it depends on the background of your educators, so, you will find
different methods of abdominal examination
When you go to practice you will face different protocols of abdominal examination, my
advice to you is to stick with what I will present today! These will go with you not only for
the 4th year but with the 5th, 6th, through your practice till your death
Our presentation today will be comprehensive, from A-Z, so for the sake of your clinical practice
and for the sake of examinations; the OSCE examination in the 4th, 5th and 6th year I want you to
depend on these lectures only!..
I will provide you with Microsoft word document for this lecture so,,, "you will not need to
write it", at the end of the lecture each of you will take a copy of this lecture, the
PowerPoint show will be published on the website of the faculty so any can download it..
The prof. also talked about the groups' distribution for the fourth year, he said this subject won't
be discussed anymore, before we started the introductory course we've given all of you chances
to form and be in minor group of 3, and based on these 3s we've made the larger groups
distribution. So, dont ask any of the dean's assistants to change your groups unless that is "top
urgent", the student must come to me and I will see.
He also stressed on the attendance; "your are not studying Geography!!, this is medicine" so part
of the knowledge is taken from the educators, and the rest depends on the initiative of yours, so
forget about the modules and all of what was in the 1st three years.. being a doctor depends on a
large extent to the contact between you and the patients, "every patient is a textbook", you are
excused all the time to take history, doing clinical examinations, "the more you see patients, the
more a distinguished doctor you will be"

Now, let's begin the abdominal examination. But before starting just a reminder of some
we draw two vertical imaginary lines passing through the mid-clavicle,
anatomical
(mid-clavicular lines) going and crossing the mid-inguinal point ..
basics;
we have also two horizontal imaginary lines one's called a
trans-pyloric, and the other one passes between the 2 iliac
crests, and the two divide the abdomen into 3 regions; upper,
middle and lower. So by the 4 lines (the vertical and the
horizontal lines) the abdomen will be divided into 9regions

Each of the 9 regions has a specific name, will be used in

describing the location of a mass, lesion incision, so you
will not say in the abdomen. Theyare ( 1epigastric, 2left and
3
right hypochondriac, 4right and 5left lumbar, 6umbilical,
7
left and 8right iliac, and 9hypogastric or suprapupic region.
This is very important for you for the differential diagnosis (ddx.), you as a physician; you need
to take a good history, do good examination, reach a differential dx., a point dx. And treat the
patient..
Ex. If a patient complained from pain in the righthypochondriac region, your mind goes
toward the biliary system (bladder and liver), could be a cholecystitis, whereas if the pain in
the lefthypochondrium you think about splenic region , if the pain in the leftflank
(lumbar)region you think about left kidney pain or left ureteric colic, if it was in the epigastric
region you might think about the stomach.
Try to use diagrams in case recording, when you write history and when you perform an
abdominal examination.
Ex. If I see a history sheet you draw abdomen
like this, and here is initialpain; that means in
this patient the abdominal pain started in the
umbilical region and then later, the pain went
to the right iliac fossa, when you examined this
patient there was a tender area (means when
you touch the area, the patient feels pain),
{hence; pain is a symptom, while tenderness is
a sign}. When you put your hand on the right
iliac fossa, it was not only tender, the patient
himself tried to do spasm of the muscles in the
right iliac fossa

cuz he knows when you press more he will have more pain, so to prevent this pain he tries to
have this spasm.. this spasm we call it Guarding.
So,, this case is Acute appendicitis (no written things, only diagram told you this is acute
appendicitis)..
>> when you study, you will know that the appendicitis pain begins in the umbilicus and after
6-36 hours the pain shifts to the right iliac fossa, so you will see signs of tenderness and
guarding in the right iliac fossa, you do WBCs count, you will find leukocytosis, dont do other
investigations, take your patient to the OR and remove his appendix.
Guarding: voluntary spasm of the muscles
This isanothercasehistory; in (1) the patient has
epigastric tenderness, and he has a
hepatomegaly, in (2) the patient has
splenomegaly.
The normal spleen reaches down to the costal
margin, so this is enlarged spleen. Using
diagrams is very important in surgery.

(1)
Normally, only the liver edge is palpable, the lower
pole of the right kidney esp in thin female person- is
normally palpable, you may find a mass in the left
hypochondrium, this could be just hard feces in the
colon, the colon if it was distended and due to the
rectus abdominis muscle when the urinary bladder is
full, you can feel it!!

Thiswasanintroductionofabdominalexamination

(2)

Now, we will start doing an abdominal examination

Start the abdominal examination with your patient lying flat on his back, arms by his sides..
- Firm couch or mattress (so your patient stays straight not bent).
-

Head of the patient supported by 1-2 pillows to make him comfortable.

- There should be a very Good light (and the best light in the world is the sunlight) so, if
there was any curtains covering the window, remove them so you can see the physical
signs in your patient, if the patient has jaundice (yellowish discolouration of the sclera and
skin), or pigmentation or spider naevi you will see them.
- Very important your hands should be Warm esp. in winter months, otherwise this would
annoy the patient and initiates spasms. So, the best is to warm up your hand [try rubbing
them till they become warm before touching the patient]

Stand on the patient's right side (you dont examine abdomens from the left side).
-

Good exposure (from the nipple to mid thigh): this is very important for many reasons, 1st
why do we expose the nipple, we want to examine the abdomen?! Topographically, the area
bellow the nipple actually is in part with the abdominal cavity, when you studied anatomy,
we have the costal margin and the lower ribs they cover the spleen and the liver, the
abdominal cavity is larger than what it appears because we have the diaphragm separates
the chest and the abdomen (this diaphragm is approximately at level of the 5th intercostals
space.
2nd reason is when you expose the trunk, you may find physical signs on the chest wall
reflects abdominal pathology. For example if somebody has a chronic liver disease, there
may be a red spot on his trunk (a spot of headnotes size), this spot might be what we call
the CampbelldeMorganspot !! ( this spot is a normal finding in elderly, when your patient
[above 60 yo] you are examining and you found
such spot) now if you press on this spot with your finger, it doesn't
disappear, then this is a Campbell de Morgan spot But If you
found a spot and radiated lines arising from it (similar to a spider
web) and you pressed on it and it disappeared and reappeared
after few seconds this means this is a capillary, this reflects a
chronic liver disease. This one is called a "Spider naevus" .
Campbell is normal finding whereas Spider naevi
are found in chronic liver diseases, those 2 are found on the chest! So we need to expose it..
..
Another example, is when you expose a male's chest and found his breast is enlarged in
which is called gynecomastia, this could reflects a chronic liver disease, or testicular
pathology or the patient is taking iatrogenic oestrogens. So, these signs are important and
you will not see them unless u expose the chest!

Why do we go to the mid thigh? Because the scrotum and the genitalia are part of the
abdominal examination. Ex. A 10 years old boy comes to the hospital complaining of sever
lower abdominal pain [e.g. pain in the right iliac fossa], you examine him and there is no
tenderness, no guarding and then you say this is not acute appendicitis so you send him
home!!. Because you sent this patient home, he would pay the price of his life due to your
ignorance, this pain could be a testicular pain!. This pain was due to testicular torsion,
assuming he was biking his bicycle, this will give pain in the testicle or referred pain in the
abdomen; may be the boy doesn't tell you about the pain in the testicle and just he tells
you about the pain in the right iliac fossa. You didnt examine his scrotum, because if you
did, you would see a swelling and very tender swelling. After few hours, will become black
and the patient will need orchiectomy. Why all this? Because you didnt examine his
scrotum!!
Another ex. a patient (m/f) might come to you with severe abdominal pain, abdominal
distension, vomiting, and constipation. You examine his abdomen, though was soft but
there is distension, NO tenderness, so you discharge him; next day, the patient comes to
the ER because he had strangulated hernia, you didnt remove his trousers, didnt examine
his scrotum to detect the hernia and this hernia was incarcerated and strangulated, and you
didnt diagnose that..!
>> there must be a good exposure; there is no successful examination without enough
exposure.
>> ideal exposure is to the mid-thigh , but for socialreasons in our country, may be its
embarrassing for the patient to expose.
>> the minimum we accept is to expose an area called "groin" (is the area immediately
above and immediately below the inguinal ligament )

Inguinal ligament: is the ligament connecting the anterior superior iliac spine
(ASIS) to the pubic tubrcle

hernia above the ligament is inguinal, and below it, is femoral, so if you expose the groin at
least you will discover if there is a femoral or inguinal hernia and the second is in two types:
(1)directinguinalhernia.
(2) indirect inguinal hernia.

Abdominal Examination Proper

It is in 4 phases:

1) Inspection phase.

2) Palpation phase.

3) Percussion phase.

4) Auscultation phase.

Now, some of the books, they put auscultation as 2nd phase esp. Brouce. The idea behind is
they propose that percussion may disturb the bowl sounds so you will not hear. the prof.
described this as ridiculous and silly!!. In JUST we follow this sequence in examination.
Please Notice: you will deal with many instructors and everyone of those will
teach you in a different way than the other so, plz stick to this!

1)

Inspection: my way of teaching is:

1- introduceyourself (I'm Dr. Sameh /:-), 4th year medical student, going to examine your
abdomen),
2- takepermissionfortheprocedure. [these two steps are your 1st two marks in the
exams in surgery and in the internal medicine ]. Ex. hey sir whats your name? Abo
Khaled, I'm dr. Osama, 4th year MS and I like to examine your abdomen.
Ex.

..

You are not allowed to a touch a patient or take history from a patient, or examine and
prescribe a medication without his permission, (an actual conscious consent). Ex. someone with
gastric CA and you told him you must have a surgery, and he refuses this option, then you dont
do it!.
Another ex. are patients named "Jehova-patients", in their religion its prohibited to have any
blood transfusion.! So if one of them had a traffic accident, ruptured spleen and his Hb became
5 , he needs urgent blood transfusion, if you transfuse and he lived he might bring a legal action
against you ending with you in a Jail
3I go to the foot of the bed , stand there, from here and
after you expose the area of examination, You comment on 4
things [nothing more, nothing less]:
a- Look at the contour of the abdomen; and this in
turn takes a possibility of one of three:
1)flatabdomen, 2)distendedabdomen,
3)scaphoid (like a spoon); the distention may be due to
obesity, gas, or might be due to fluid (ascites), huge tumor and the tumors that could reach 15 Kgs
are the ovarian tumors; you think she is pregnant, and at the end its a tumor!!
-whatmakestheabdomenscaphoidinshape? Usually by terminal illnesses like
esophageal CA as a result of sever weight loss.
b- after you comment on the contour of the abdomen, look at the abdominal movement
with respiration; ask yourself is the abdomen is moving with respiration? If not, this is a
catastrophic sign in surgery!!!!

>>> usually indicates peritonitis or perforatedviscus (ex. perforated stomach,

duodenum or colon) meaning there is a catastrophe. This is a very serious sign.
c- We comment on the umbilicus ; look at the umbilicus, it is central and is inverted.
If it wasnt central, this means there was a surgeon changed something with it.
Also, if it was everted, that means we have high intra- abdominal pressure; could
be ascites distension, tumor or could be an umbilical or periumbilical hernia

w
till now; we've talked about 4 types of hernia: femoral, inguinal (direct and
indirect), umbilical and pericumblical types of hernia.

d- Is to look at the symmetry of the abdomen; when you stand at the foot of the
bed, look at the abdomen, normally the abdomen is symmetrical, and no bulges.
Now lets imagine a patient who is lying on his back, he has a bulge in the left
hypochondrium and another one in the right hypochondrium>> still the
abdomen is symmetrical, but this is a pathology!
So, you finish these four steps while you are at the foot side of the bed, Nowyoushifttothe right
side of the patient and complete your inspection..
Asasummary; I warm up my hands>> I introduce myself>> I take permission to do the
examination >>I expose the abdomen>> go to the foot of the bed>>and comment on 4
things: 1) the abdomen is flat, 2)moving with respiration, 3)the umbilicus is central and
inverted and 4)the abdomen is symmetrical and with no bulges..
In books, you will not find any of them describing the examination like this, so I want you to
focus upon what I'm telling..
When you come to the right side of the patient you start to comment about:
1)

skinlesions; no warts, no molds, and no erythaema.

Then, you comment on the 2)hair; look at the abdominal hair esp on the suprapubic area,
what form it is, (when commenting on a normal male: you should say, NORMAL MALE HAIR
DISTRIBUTION), if you say "normal hair distribution" you will get half a mark! Why? Because
if a girl comes to you and she has abdominal hair, this is abnormal; think about adrenal
tumor. Its very serious to find adrenal tumor and hair on a female's abdomen, you need to
investigate, "so dont forget the gender in this distribution".
3) then Look for dilated veins on the abdominal wall, because normally you
dont have dilated veins on the abdominal wall, -remember till now we are
inspecting and didnt touch-.
Dilated linear
superfacial
veins caused
by IVC
blockage

- There are two types of veins which can reflect abnormal abdominal
examination; the 1st type is called "Caput Medusae" like a sun and its
radiations from its centre.. when you look at the umbilicus, you will find
radiating tortuous veins around the umbilicus and this reflects Portal
Hypertension.
Youknowthat; liver receives 70% of the blood from the portal vein and
only 30% from the hepatic arteries, when there is a blockage in the
portal vein, it's pressure will rise up from 10 to 40 and portosystemic
shunts start to form. As results from these shunts, oesophageal
varices, haemorrhoids, and the oesophageal ones might rapture
>>haematemesis

Caput medusa,
secondarily to
portal
hypertension

>> so, if u noticed them, you will say he has caput medusa, and if he has no caput you will
say, he has no caput medusa?. One would ask, if there is no ,why to mention there is no? in
medicine and especially in history taking, the negative equals the positive! Ex. we can describe
dr. Osama in 2 ways; one, is excellent, hard worker, gets good marks .. or I can say, Osama,
I've never seen him got bad marks, he never hits anybody these are positive information in
negative style!.
Another ex. you became a resident in surgery and I'm a consultant staying at home enjoying
my time and you phoned me sayin: I've admitted a patient with abdominal pain; this abdomen
is soft, lax, no tenderness, no rigidity and no guarding I would tell you let him there to the
morning what can I do for him?
But when you tell me; his abdomen is rigid, I would tell you prepare the O.R. I'm coming.
- The 2nd type is the veins in the peripheral abdomen, you see them attheperiphery like
dilated veins, thisreflectsinferiorvenacavaobstruction!!. If you see the abdomen of the
patient, you will see like snakes drawn on the patient, at the peripheral abdomen going
toward the chest, you can diagnose IVC obstruction.
The two types of dilated vessels have distinct characteristics in addition to their different
location, form and causation;
- One of these is the blood flow in the veins; in portal hypertension (PH) the blood flow is
away from the umbilicus while in case of IVC obstruction the blood flow is from downward
>> upward,

and we can confirm this >>>>> as follows:

bring two index fingers>> put them on the dilated vein>> fix the upper index
finger,>> press on the lower finger while moving it downward and empty the
vein>> remove your lower finger suddenly>> iftherewasimmediatere-filling, then
thebloodflowiscomingdownward UPWARD. do the same thing in the opposite
direction..! thisiscalled"emptyingtest"

4)

lookattheepigastricregionofthepatient, - be sure to look at the region horizontally sitting

on your knees for e.g. (your vision is parallel to the body), dont look at it while standing!!
Remember you are now at the right side of the patient.
This is done for the aim of finding pulsations, they could be a normal finding in a thin
patient, because here is the aorta!. Because he is thin, we can see his aortic
pulsation coming to the abdominal wall, so this is normal

his kind of pulsation is called "Transmitted Pulsations".

What are the causes of the transmitted pulsations?

1)thin patient,
2) there may be a tumor on the normal aorta so the normal
pulsation of the aorta are transmitted through this tumor and comes to the Ant.
Abdominal wall, so it could reflects a gastric CA or pancreatic CA
Thereisanothertypeofpulsationscalled"expansilepulsations" , remember the 1st
was
"transmitted pulsations" and we said they can be normal and sometimes could be
abnormal!

Remember: the aorta begins as ascending aorta, then arch of aorta thoracic aorta
(descending aorta) and abdominal (descending aorta) ending with the bifurcation to form the
two common iliac arteries.

The expansile reflects abdominalaorticaneurysm

(AAA).
If this aorta has been distended and dilated, we call it
"aneurysm". After this aneurysm became more than 5.5
cm, it ruptures ..!

>> If the rupture was Anteriorly, sudden death!, if

posteriorly, he might continue for 4, 5 or 6 hours,,,,,
Remember, we have the peritoneum in the abdominal cavity, it can contain the
aortic aneurysm rapture and the internal hemorrhage can be contained to certain
limit..
if you leave the patient with post. Ruptured AAA without urgent intervention, the patient
willbelost.So, take him immediately to the OR take 5 blood unites with you, and if u were
good surgeon, the survival rate is 50%.

How can we judge if this pulsation is expansile or transmitted pulsations? This can be
done in the "palpation phase" of the abdominal physical examination.

In the palpation phase, to detect the AAA, I bring my two hands, I put them close to the
rectus abdominis muscle, around the area of pulsation, (usually between the xiphoid process
and the umbilicus, because below this region, is the bifurcation point!, when you surround
the aneurysm, you will see that your hands, they approximate and separate. How many
times? 7o times and these are because of the pulsations.

The aortic aneurysm is found in many people, but we do nothing for them unless it
approaches 5 cm, but we can do an elective surgery to prevent a future rupture,
Usually detected incidentally while you are examining the patient's abdomen..
. Now, the patient with ruptured aneurysm comes to you in the ER complaining of
epigastric pain, you measure his BP and you find it 70/20! -Very hypotensive-, and
tacycardiac.
Any artery in the body could have aneurysm, radial artery aneurysm for example, a
female patient come to you having a swelling in the wrist joint on the radial side (DDx.
Either a ganglion, or radial artery aneurysm). How could I palpate it? Simply, similar to
the aortic one, but her with my two index fingers, if expansile pulsations were seen,
then its a radial artery aneurysm.
Another type is the popliteal aneurysm, (in this area the DDx. Of the swelling Is either:
ruptured baker cyst or popliteal artery aneurysm). You let the patient lie on his
abdomen and examine this swelling (again, by two index fingers).

:D enbs6oo; Whats the most common peripheral artery aneurysm? Thepoplitealartery

aneurysm
one of the MSQs will come in the exam so you will have just 99 unknown
questions :p

Themostcommonaneurysmthatrupturesinpregnancy is the Splenic A. A., so if

diagnose a lady with it, we operate before any expected pregnancy.

we

5)

commentonanyvisibleperistalsis, normally, we dont see peristalsis in the abdomen.

Inathinpatientwithsmallintestineobstruction, try to ask the patient to contract his abdomen
so you can see the peristalsis. If this peristalsis was central, you will diagnose the patient
having small bowl obstruction.
If the patient have a gastric output obstruction, - in the pylorus- this could be secondary
to gastric CA or peptic ulcer. Here in this case, you will not find central peristalsis;
theystartfromtheleftcostalmargingoingtothemidlineandcrossing
it, you diagnose
the patient Gastric output obstruction . Now the issue depends on the history;
ifthehistoryisshort (period of compliance) think about CA and if
long history, think
about a peptic ulcer.

Pyloric obstruction is of two types: 1) oneisacquired2ndarytopepticulcerorCA,

2)theotheriscongenital (the baby is born with fibrosis in the duodenum and there is
obstruction in the first inch of the 1st part of duodenum started from the pylorus. So,
the baby when born, in his 2 first weeks, he is fine. And in his 3rd week, his mom tells
you when I feed him, the newborn vomits; and this vomiting is fired to a distance of 2
metres "is projectile"
our next question is; what was the colour of his vomit? She will tell you, its
milk!, no greenish discolouration [greenish colour come from the bile] and
this obstruction is above the bile releasing source.

Remember: the sphincter of oddi is in the posteriomedial aspect of the 2nd

part of duodenum and our obstruction is above this level.
hen, you take this child, put him on the couch, you will find the distention in
his upper abdomen only. (the distended part is the stomach only!), while if the
obstruction was caused by imperforate anus, the distension will be generalized
involving the whole abdomen. Look for pulsations in his abdomen, you will find
waves of peristalsis going from the left costal margin and crossing the midline.

astric outlet obstruction.

haracteristically, in this baby, if you look carefully in the abdomen, you will find
olivelikemassintherighthypochondrium. This is the hypertrophied pylorus.
In the adult, you will notseethismass. The similarities between the pyloric obstruction
in adults and the congenital hypertrophic stenosis are; 1)the distention
oftheupperabdomen and 2)theperistalsisfromtheleftcostalmargin
tothemidline.
In the baby you will find olive-like mass, while in adults you dont see because of the
thick muscles covering the abdomen.

4)

lookforanyscarsintheabdomen; the scars are two types:

1-cauterymarks: you might see patients whom were cauterized in their childhood, this could
indicates a chronic disease!!!
2-surgicalscars: resulted from new or old operations, you need to describe them,

f the patient has a scar in the right

hypochondrium running from the middle and
obliquely in the right hypochondrium, you will
describe it as " oblique right subcostal incision "
and when you become more experienced in
surgery, you will call it "Kocher incision"
according to the name of the surgeon described
it-. anyhow, this incision is used for open "
cholecystectomy " or for liver surgery.

f you find bilateral oblique subcosal incision

(double Kocher incision or roof top approach
(Chevron Incision)), we call it roof-top incision
like if you want to do pancreatic surgery.

f I wanted to operate on the hiatus, I would do

a "Mercedes Benz" incision.

may find a supra-pubic incision, this is

called "Caesarian incision", for caesarian
section.

e might find an incision above the groin, we

call it inguinal incision, done for inguinal
hernias.
e see also, an upper midline incision, or
lower midline incision, in emergency
surgeries or GI surgery.
So each incision indicates something..

1. Kocher: Biliary or hepatic procedures. May be

extended across to a left subcostal incision to
give useful access to the stomach and
pancreas.
2. Midline : General access. Usually skirts the
umbilicus. Quick and bloodless.
3. McBurney :Appendicectomy. Muscle layers
are split, rather than cut.
4. Battle :Appendicectomy. No longer used
because it produces an ugly scar and
sometimes incisional hernia. Often seen in
older patients therefore.
5. Lanz :Appendicectomy. A better cosmetic
result than McBurney

ou can also notice an incision begins from

behind in the flank and runs all the way in the
lumbar region toward the umbilicus. This is
called "Ratherford-Morison incision" used for
kidney and ureter surgery.

6. Paramedian : General access. Left or right

according to requirements.

ou might see an incision lateral and parallel to

the rectus abdominis muscle "para-rectal

8. Rutherford Morison Access to sigmoid colon

and pelvis, particularly if the midline is very
scarred from previous surgery.

7. Transverse : General access. Almost always

used in infants, and often in adults.

9.

suprapubic: caserian section Access to

bladder, uterus, Fallopian tubes and ovaries.
Good cosmetic result but gives no access
outside the pelvis. (notice: not all of them mentioned by
the prof.)

incision" "macvide incision" used specifically for the femoral hernia (we reach it
from above) and when there is special type of hernia (hernia lateral to the rectus
abdominis muscle" called "bagalian hernia".
When, we said look for skin lesion, we said look for scars,
striae are very important,
What are striae? Suppose a pregnant woman, after she gives
birth, look at her abdomen, you will find striae, sometimes a
pregnant woman may have something called lineanigra (a
black line appears in previous pregnant
woman or a pregnant at the present time).

Linea Nigra

Striae could occur as a result of corticosteroids as a

result of adrenal tumor, or iatrogenic corticosteroids, or after sever weight loss.
The warts, haemangiomas, I talked about the CampbelldeMorganspot, linea nigra,
erythaema ambigan
Erythaema ambigan: you find patients have chronic
abdominal pain, they bring a hot water containing
canteen and they put them on their abdomens
-

Grey Turner's sign, petaechiae (caused by

thrombocytopaenia).. and Cullen's sign
Cullen's sign: a blue discolouration around the umbilicus. now if you boxed "Samer" on his eye :D, you will see him

Abdominal striae

later, with blue eye surroundings, called "black eye" indicates a haematoma-, so if the
patient has a specific type of pancreatits (haemorrhagic pancreatits), blood will
escape from the pancreas- (retroperitoneally)- and when the area is filled with blood,
some of the of it will extravasate from the extraperitoneal space to the peritoneal
cavity. Now when the patient lies down, the blood will accumulate in the abdomen till
it reaches the surface of the liver, with the falciform ligament (between the liver and
the umbilicus)
it diffuses and will appear around the
umbilicus. Some of this blood will
extravasate to the flank and give you
a blue discolouration in the
flank.this is called "Grey Turner's
sign"
Both indicates Haemorrhagic
pancreatitis.

Grey Turner's and Cullen's signs

In this Lecture; I will mention 4

yyyy TTTTuuuurrrrnnnneeeerrrr''''ssss ssssiiiiggggnnnn:::: Seen above..

>>Fatal Mistakes in Medicine <<

At school, when 10 questions came to you, and you answered 9 of them, you'd
get (9/10); BUT in medicine this is not the case!; you might have 10 questions,
you answered 9 and your mark would be 35/100 . Why? Because the one you
didnt answer, your PATIENT paid his entire life a price for it (remember the
case of the testicular torsion at the beginning of the lec)

- If you do one of these 4 mistakes in the exam, you may fail your
exam

Never, Ever finish an inspection of the abdomen

without inspecting for hernia.
You ask your patient to cough once or twice, there are more than 36 types of hernia; but
look for only 4 areas[the most common ones],
what are the most common sites?
1) The groin, covers 3 types of hernia: 1) femoral hernia,
3)indirect inguinal hernia.
2) the umbilicus, covers 2 typpes of hernia:
hernia.

2) direct ingunal hernia,

1) umbilical hernia.

2) periumbilical

3)

the epigastric region: the epigastric hernia.

4)

atthescars: when the patient coughs, inspect any scar protrusion " incisional hernia"

>> these are the 4 most common sites and their associated hernias. These are the last thing

Panoramic view: the ability of looking at the 4 regions at once while the
patient is coughing. So, you dont as the patient to cough 16 times!!! Very
terrible ..

One last thing to do is; to put your hand on the patient's forehead (build some
resistance) and ask him to lean forward (from supine position to sitting) [against the
built mild resistance] and you inspect the abdominal region, if there was a bulge, then
"this is called "divarication of rectus

3 characteristics of a surgeon:
1] ladys' hand; gently touches the tissues.
2] lion heart: upon his decision, patients life
swings
3] eagle eye: ex. when you look at the
abdomen he looks as its a one area from the
nipple to the mid thigh all spots

..
..

.. .

..

Regarding the scars ; it is important to examine them during the

inspection phase, as some patients may forget to mention them in the
history-taking phase, the next step is to go to the right side of the
patient's bed and ask him to cough, during that, keep watching the scar, if
you see any plugging , that is called "incisional hernia".

ncisionalhernia : any plugging in a scar's site , EXCEPT in one case;

When you have a patient that had a previous inguinal hernia surgery
(a groin incision) , now if the patient coughs and gets a hernia, we will
call this hernia a "recurrent hernia" not an incisional hernia!! , WHY??
Incisional hernia can be the patient's factor, or the surgeon's factor ; if
the patient is
obese, anemic, diabetic, has vit C deficiency, has protein deficiency ,
develops a wound infection or if the surgery's technique was wrong ;
any one of those factors can cause an incisionalhernia, but if one
patient had a second inguinal hernia after managing a one before, this
is 100% the surgeon's fault!! So we call it then a recurrenthernia!!

NOTES:
egarding the books required ; Mcloed's is more used for
internalmedicine and Brow's is more used for surgery, but for the
"abdominal examination", this is ENOUGH!!
r the OSCE exams; once the doctors couldnt find enough pictures of
patients' cases from KAUH , they scan pictures from Brow's and use them
in the surgery exam!!
egarding the OSCE exam; you have only 5mins for each station; so the
question wont be "do an abdominal examination for this patient!!", it will
be for ex. : "perform the inspection phase for this patient, palpation or
auscultation!!"

>> By this, we finished the inspection phase from A-Z, and now we will move to
the next phase:

Palpation phase :
- There are 3 sub-phases for
palpation ; 1- Superficial
palpation.
2- Deep palpation.

3- Palpation for organomegaly.

1- Superficial palpation :

efore you start, make sure that your hands are warm.

tart at the point most remote from the site of abdominal pain

So the first thing you do is asking the patient about the site of pain,
and for ex. Let us assume that we have a patient that has an acute
appendicitis; so he will tell you that the pain is in the right iliac fossa..
(plz concentrate well now!!!!)
>> All the drs who will teach you in surgery and internal medicine will tell
you to start palpation from the opposite side of the pain; BUT this is
absolutely WRONG!!! , as you have to start from the "neighboring area", not
from the "oppositearea"!!

>> Now, recall the nine regions of the abdomen;

lets assume that the patient has a pain in the right
iliac fossa region ("X") , though, you put your hand
on the supra-pubic region (neighboring, "star") , and
start palpation superficially (following the arrows
beside), until you end in the area where he told you
he has pain in, if he shouts; you say : "there is a
superficial tenderness in the right iliac fossa region".
>> Use the palmar aspect of your fingers, NOT the tips!!

NOTE : almost 60% of medical students

perform the palpation in a wrong way; as
they use what we call :
the "Jumping technique" ; which is useless!!, what you need to do
is gentle,rolling movements.

>> Now, lets see what will happen if we follow the

opinion that say "start from the opposite area"; if the
patient has a pain in the right iliac fossa ("X"), then
we will start from the left iliac fossa ("star") and
continue following the pattern seen beside until
ending in the tender area!!
You can notice that the neighboring area (the
supra pubic area, "circle") in this case were
not examined!!, so to make sure that you
examined the whole 9 regions, start from the
neighboring area (above or below the tender
area).

hen you do superficial palpation, you have to answer 3

ques%ons: 1- Are there superficialmasses??
2- Is there superficialtenderness??
3- What is the status of themuscletone of the patient's abdomen??
For ex. There is moderate tenderness in the left iliac fossa region with
no superficial masses!!

egarding the abdomen's muscletone; it will take

one of 3 choices : a- Soft and lax : which is the
normal abdomen.
b- Gaurding : which is a voluntary muscle spasm that is performed by the
patient, done to
minimize the doctor's pressure on the tender area, to avoid the pain,
and this indicates local peritonitis.
c- Board-like rigidity : this indicates peritonitis, which usually
indicates a perforated viscus; which is a catastrophe and needs
an immediate emergent operation.
This sign is a very serious sign in surgery (in addition to the sign we
talked about before;
the non-moving abdomen in inspection) , and this is involuntary and
generalized, and whatever is in the abdomen (hepatomegaly,
spleenomegaly, ..) you wont feel it!!

For ex. There is a tenderness in the supra-pubic region, no superficial

masses and the abdomen is soft and lax!!

2- Deep palpation :------

-------

t is the same as the superficial palpation ; firstly, go to the neighboring

area of the pain, but when you do the gentle rolling movement, do it more
deeply, and here you have to answer 2 questions :
a- Are there deepmasses??
b- Is there deeptenderness??

>> Muscle tone can not be assessed by the deep palpation; only by the
superficial palpation, and if the patient has a board-like rigidity, you wont be
able to perform the deep palpitation!!

3- Palpation for Organomegaly :

-------

>> We have 3 organs in the abdomen which we need to discover; Liver,

Spleen and Kidney.

Palpation for the Liver:

here are 2 ways to examine the liver ;

I)- To use the hand vertically.

II)- To use the hand horizontally, which is the
best way to adapt yourself to use!!

Put your fingers on the right iliac fossa.

>> a very important point to pay attention to, is that the tips of your
fingers must NOT be on the midline of the abdomen; they should be
lateral to therectusabdominismuscle (about 4 cms away from the
midline).
Ask the patient to take breath ; with each inspiration, your hand should
go up, until it
reaches the liver if it is enlarged.
>> normally, the loweredge of the liver is palpable.
>> if the liver is enlarged, we say for ex. The liver is enlarged about 3
ngers below the costal margin., at this stage, you are allowed to
approximate the level of enlargement by the number of fingers that
separates the lower edge of the liver and the coastal margin.
>> If you find a liver, describe the followings :
he edge of the liver is normally sharp; if you feel it and find it rounded ,
this is a diseased liver!!
he surface of the liver is normally smooth; if you feel it and find it nodular,
this is either
cirrhosis or a metastatic cancer.
n pushing on the liver; if it is tender, we say that there is tenderness in
the liver, and the most common cause for a tender liver is "viral hepatitis"
nd

, the 2 most common cause is "congested heart failure" ; normally, the

blood leaves the liver through the hepatic veins to the inferior vena cava
and then to the right side of the heart, now when the pump of the heart is
failed, the blood will start to accumulate in the liver, which causes the
liver to become congested!! But this wont cause pain, the pain is because
the liver is surrounded by a capsule (Glisson's capsule), and the
congestion inside a capsule will cause pain.

 he consistency of the liver ; if you find it stony-like, this is cancer, if you

find it cystic, this is a cystic lesion in the liver, and it could be rubbery.
Size, Edge , Surface, Tenderness and Consistency.

xamination of the liver is one-hand technique; so if you see in any book the
other hand on the patient's loin, remember that this hand is doing nothing; It
is just for support!!

NOTE: Many information can be obtained by a simple hand-shake between the

patient and the physician ; such as knowing if the patient's hand is warm or
cold , whether it is sweaty or not, and this can promote a good relationship
between the two.

Palpation for the Spleen:

You always examine the spleen from

therightiliacfossa.
he spleen is covered under the left costal
th
th
margin ; it is normally hidden under the 9 , 10
th
and 11 ribs (not by the lower 3 ribs);
>> So normally you can not feel the spleen, and
once
you
spleen
is 3 Imes more than its normal size.
Ask the patient to take breath , and with each inspiration your hand goes
up.

Q- Why do you ask the patient to take breath while examining the liver and
the spleen?
Because both the liver and the spleen are intra-peritonealorgans ;
and whenever the patient takes a breath, those organs will descend
to your examining hand!!

>> If you find a mass, pay attention to the following characteristics to

decide whether this mass is a spleen or not:
he spleen has a notch ; it is like the fist of the hand , and this is characteristic
of the spleen.
th
th
th
he spleen is tightly and closely applied to the 9 , 10 and 11 ribs ;
firstly you will feel the lower border of the spleen, when go up, you will
feel a notch, after that, put your hand vertically, and try to go above this
mass, if it is the spleen, you will not be able to go above it, as it is closely
applied to the costal margin.
t descends2-3cmswitheachbreath.
NOTE: Near the spleen we have the kidney; if the
kidney is enlarged : 1- It has nonotch
2- We cangoaboveit
3- It doesntdescend2-3cmswithbreathing , because it is a retro-peritoneal

If we have 100 paIents with spleenomegaly, in 90% of them the spleen

will go toward the right iliac fossa, in the remaining 10% (esp. in
children), when the spleen enlarges, it goes toward the leJ iliac fossa,
and that is why we start from the right iliac fossa, as in 90% of cases
the spleen will go toward that direction.

Palpation for the Kidney:

It is a bi-manual technique; you need both hands to examine the kidney.

>> There are 3 areas in medicine which are
examined by 2 hands ; I)- The sub-mandibular area.
II)- The female pelvic
organs. III)- The kidney.

How do we examine the kidney?? (examining the left kidney)

Bring your left hand and put it on the back of the patient (on the
lumbar region) and the right hand on the front (if you are right
handed).
th
>> Your liKle nger of the leJ hand should touch the 12 rib (pararrel to
it) from behind,
and the Ip of it should be 2-3 cms away from the midline of the back,
because we have the erectusspinaemuscle that covers the midline of the
back, in the same way the rectus abdominis muscle covers the midline of
the abdomen.
Use the right hand from the front , and examine the kidney
between the two hands; the 2 hands are acIve (bi-manual
technique).

>> If you find a mass between the two hands, then :

1-

The lower hand begins doing "pushing" and the upper hand is
"receiving" ; and this is called "Ballottement procedure".

>> NOTE: if we want to examine the rightkidney, the index finger of the
left hand must
th
touch the 12 rib.

th

There is a 4 type of palpation, which is a very specific type, that is

not done unless the history or the previous phases of abdominal
examination suggest this.

** A patient came to you, and you made inspection, palpation and palpation for
hepatomegaly for him, but in the history he told you that he is complaining of
severe pain in the right hypochondrium radiating to the interscapular region ,
and to the tip of the shoulder, associated with nausea and vomiting; this is a
typical history for AcuteCholecystitis ; so you do a specific test called :
" Murphys sign "

Murphyssign :
>> Some drs do it in a similar way to the liver test ; and when their hands reach
the gall bladder (below the right costal margin, midway between the
xiphisternum and the flank), they ask the patient to take a deep breath, if he
could; that means he doesnt have acute cholecystitis, but if the breath was
arrested (to avoid pain) , that means the patient has acute cholecystitis .
Positive Murphy's sign is the cessation of the breath in the middle of
the inspiration
-

Our dr has another way to do it ; he brings his thump and place it on the
th

angle of the (V) shape made by the costal margin (on the 9 rib), and
asks the patient to take a breath; if he could, that means he doesnt have
acute cholecystitis, and if he has, the inspiration will be arrested in the
middle!!!
>> Murphy's sign is not pain ; it is the cessation of the breathing
in the middle of inspiration.

alpationforvisceralpulsation(expansilepulsation)

, which

is not done unless the history suggests it.

The pelvic organs are examined fromupwardtodownward ; to take

the bladder as an ex. , if you feel it at the level of the umbilicus, that
indicates a full bladder!!

In the case of a female with a swelling that reaches the umbilicus, you
say : "this female is pregnant, and the fetus age is 24 weeks" ; the age

of the fetus is measured by determining how many fingers the edge of

the uterus is ascended above the supra-pubic area !!

** Whenyounishpalpation, make sure that you make the following steps;

ring your both hands and put them on the groin region (above and below
the inguinal ligament; to examine for both the inguinal and femoral
hernia), and then ask the patient to cough, if anything hit your finger,
you say : "there is a palpable impulse on coughing" which means >>
HERNIA !!
ut your hand on the epigastric region , and then ask the patient to cough.

ut your hand on the umbilicus and ask the patient to cough, to

examine for umbilical hernia.
ut your hand on any incision, and then ask the patient to cough, to
examine for any incisional hernia.
Groin, Epigastric region, Umbilicus and any Incision.

Never , ever finish palpation without palpating for

hernias!!!

- When you find a mass during palpation (whether it is superficial or deep),

you have to describethismass, and masses are described in medicine
by answering the followings : 1- The site of the mass ; ex. a mass in the
epigastric region.
2- The size of the mass ; ex. approximately 4 x 5 cms.
3- The shape of the mass ; ex. oval shape.
4- The color and temperature of the mass; whether the color of the
overlying skin has changed or not, and whether it is hot or cold; if
it is very hot, that means there is an abscess.
5- Whether it is tender or not.
6- Whether the mass is mobile or not (against the overlying skin
and the underlying structures) ; if it is fixed, you have to think
about malignancy.
7- The consistency of the mass; whether it is soft, cystic, rubbery or stony.
8- The surface texture of the mass; whether it is smooth or nodular.
9- The edge of the mass; whether it is well-defined or ill-defined, sharp or
rounded.
10- The surrounding swellings; ex. if you have a hard mass in the upper
cervical area, that appears with swallowing , this indicates thyroid
cancer, so you must go to the surrounding area, and look for
associated swellings, such as hard lymph nodes, that may contain
metastatic cancer.

Percussion phase :
-

Use your wrist in the hummeringaction.

The 1 thing you have to do in percussion is : the general tympanic notch

of the abdomen

st

to locate the most tympanic area.

-

The largest content of the abdomen is the small bowels; the colon is
1.5 m, you have also the liver, the spleen and the stomach, and 6 ms of
small bowels!!
Inside the small bowels, there is a digestive fluid and some gases , if there
is fluid
surrounding those small bowels, we call it ascites, if there is a mass we call
it tumor.

Most of the ilium is located in front of the umbilicus, though, to decide if

the patient is having fluids or tumors, we have to locate the area of
maximum gases, which is usually in the center, in the umbilical region,
so ;
Bring your left hand , and put it over the umbilical region .
By the middle finger of the right hand, start to do hummering on the
middle finger of the left hand.
By this, we can determine if the area is tympanic or dull ;
ympanicarea : indicates the presence of gases or air in that area.

ullarea : indicates the presence of a hard mass in that area.

Go 360 degrees around the umbilicus to determine the site of the most
tympanic area.

Put you left hand vertically in the midline, with your middle finger
being on the most tympanic point, that you locate by the general
tympanic notch of the abdomen.
Start the hummering action, while moving your leJ hand laterally
about 1 cm, aJer each tympanic area you find, until you reach a dull
area!
Note : all the normal abdomen is tympanic ; there is no dull areas as a
normal person does not have fluid outside!!

ercussion for Ascites :

>> In a patient with ascites; when we reach the area where the fluid is
accumulating, that area will be dull, and because we examine the patient in the
supine position; we will find the fluid in the sides of the abdomen, not in the
center!!

Start hummering, when you reach the dull area, do NOT remove your
finger from that point, and ask the patient to lie on his other side of the
point you are putting your finger on without removing your finger.
Wait for 30 secs, to let all the uid that was in the area under your
nger, to go to the other side

Press again on the point you are putting your finger on; you will find it
become tympanic after it was dull!
Do not remove your finger!! and start hummering again toward the
opposite side, until you reach the dull area ; and this is called
"ShiftingDullness";
>> This indicates ascites ; and it is actually a very sensitive test for
ascites ; if it was +ve, the patient has fluids in his abdomen.

Anothertestforascitesisthistest :
Ask the patient to bring his hand,
and put it on the center of his
abdomen (keep in your mind that the
patient is lying on his back).
Bring your left hand, and put it on the
patient's left flank.
With your middle finger of the right
hand, flick on the patients right flank
>> If you feel a thrill reaching your left hand, that
indicates ascites; as you are pushing the fluids with your right finger
towards the left side, and for that, we need somehow a strong flick to
push the fluid.
- Note: we ask the patient to put his hand in the middle of his abdomen,
to prevent the
wave from being lost through the abdominal fat, and to make sure that
the fluid is the one which moves.
This test is called : "Transmissionthrill".

When you suspect that a patient has ascites, there are 2opinions :

I)- Internalmedicinedoctors say : "begin with the shifting dullness test

(SDT)".

II)- Surgeons say : "begin with the transmission thrill test (TTT)"; as TTT is
less sensitive than SDT; so if the patients shows a +ve TTT, there is no
need to do SDT, while ve TTT doesnt

exclude ascites, and we do SDT; the more sensitive test!! , also,

performing SDT may cause pain and discomfort to the patient, so if he
shows a +ve TTT, we dont perform SDT!!
Notes : (some terms used in the palpation phase)

Tenderness : pain felt by the patient, when pushing on a certain area.

Rebound tenderness: the pain felt by the patient immediately after the
doctor removes his hand from a certain area, which usually indicates
peritonitis ;
When the doctor removes his hand, the inflamed organ touches the
parietal peritoneum, which is the one sensitive to pain.
Rovsing's sign : pressing or deep palpation of the left iliac fossa ,
causes pain in the right iliac fossa, which indicates acuteappendicitis;
The old explanation : when you push on the left iliac fossa, the gases in
the descending
colon will move upward, then through the transverse colon, to
descend through the descending colon then through the cecum, to
irritate the inflamed appendix causing pain.
The modern explanation : pushing on the left iliac fossa will move the
bowels' loops that will push the inflamed appendix, causing pain.
Blumberg's sign (cross rebound tenderness) : when the doctor
pressesthenremoves his hand from the left side of the pt, the pt feels
pain in the right side (the dr said that he will ask us about Blumberg's
sign in the final exam; so make sure that you can differentiate between
Blumberg's sign and Rovsing's sign; as in Rovsing's , the pain is felt
when pushing on the left side, and in Blumberg's, the pain is felt after
removing the hand from the left side!!)

ercussion to determine the Liver's span :

-

Always start from upwardtodownward.

Put your finger in the supra-sternal notch of the paIent , go 2 cms
below it, where you will find the angle of Louis, then go to the right ,
nd
to the 2 intercostal space.
From the middle of the clavicle, descend with your nger, unIl you
nd
nd
reach the 2 intercostals space; so your nger will be now in the 2
intercostals space at the mid- clavicular line ; place your finger
there horizontally.
Start percussion using the middle finger of the other hand, it will be
"resonant"; which is the same as "tympanic" definition, used in the
abdomenal examination.
rd
Place your nger in the space below (3 intercostals space) and do
percussion, then the
th
4 , .. until you reach a "dull" area, that means you have reached the
upper edge of the liver.
Ask the patient to put his finger in that space, and not to remove it.

Put your finger in the right iliac fossa, lateral to the rectus abdominis
muscle, and start percussion upward, you will find it tympanic until
you reach the lower edge of the liver, it will become dull!! Then ask
the patient to replace another finger at that point!!
Use a meter (like that used by the tailor) to measure the distance
between the patient's
2 ngers, and that will be the paIent's liver's span.

Make sure you bring a meter with you, in addition to the other
instruments, to the rounds!!

There are many values for the normal liver span; but the number required
from you, is from 6-12 cms.
Q- If the liver span is 5.9 cm, is it normal or abnormal??
A- In medicine, when we have a range , "!! ; " so
anything outside the range is "abnormal", and in the same way
you can not say that a lady is
"approximately pregnant" you can not say "a liver is approximately
enlarged!!" ; be
precise!! , 5.9 is not between 6-12 , so 5.9 is abnormal!!

There are 74 causes for the hepatomegaly, and for the

decreasedliverspan , there are only 5 causes, which are :

1- The liver could be resected (partial hepatectomy).
2- Liver cirrhosis, that causes liver's shrinkage.
3- Pneumothorax (air in the pleural cavity), that pushes the liver
downward; in this case, the liver's size is the same, but the span or
the dullness will decrease.
4- Emphysema (permanent enlargement of air spaces), and its
effect resembles the pneumothorax effect.
5- Perforated viscus in the abdomen, which is themostimportantcause
from a surgical point of view, because if you have a perforated colon
or stomach or so on, the air inside these organs will go out to the
surface of the liver, and will make it more tympanic; although the
liver's size is normal, its span is less!!
>> So whenever you have a decreased liver span, usually the cause is
serious!!

Auscultation phase :

This phase is a very sensitive phase, and the doctor likes to bring it in the
OSCE exam.

We use the stethoscope in this phase , which has 3 parts ; the earpieces
,the tube and the chestpiece that also has 2 parts ; the diaphragm (for
hearing the high-pitched sounds; high sounds) and the bell (for hearing
the low-pitched sounds; low sounds).

1-

Wehave7thingstobeexaminedbyauscultation :
Thebowels'sounds:

(CLICK HERE)

We use the diaphragm to hear them, as you can put it anywhere on

the abdomen and hear the bowels' sounds, the best area to hear
them is theareajustbelowandtothe rightoftheumbilicus, and you
should listen completely for 1min.
You will hear a sound like "trrrrrr - trrrrrr", normally you can hear 3-15
sound/min.

Note : you cant listen for 15 sec and mul7ply the number by 4!! , you
must keep listening for 1 min!!
You should describe their frequency (how many bowels' sounds/min)
and the pitch (the
sound's amplitude; low-pitched sound, normal-pitched sound, highpitched sound) and you will decide if the sound's pitch is normal or
abnormal by experience!!

n the case of the intestinal obstruction , the bowels' sounds will be highpitched; because the intestinal contractions will be stronger to overcome
the obstruction.
f you kept hearing for the bowels' sounds for 1 min and you did not hear
anything, keep your stethoscope on the abdomen for another 3 mins, if
you did not hear any bowels' sound also during the 3 mins; bring the pulp
of your nger and draw a trapezium on the paIent's abdomen (as this
movement will stimulate the bowels' sounds by stimulating the
peristalsis), then put your stethoscope for another 1 min!! ;
>> If you didnt hear anything during that min, you diagnose the patient
with having "paralytic ilius" , which means that the intestine is not
moving!!
Themostcommoncause for paralytic ileus is operative ; any patient
who undergoes a bowels' surgery (for ex. appendiciIs) , his intesIne
will shut down for 24hs.
nd
The 2 most common cause of paralytic ileus is hypokalemia , which
usually occurs in
patients who are put on IV fluids; although our need for K is 1 milliequivalent per 1 body Kg; when patients are given IV fluids for many
days, they wont get this amount, so they will develop hypokalemia
that will lead to paralytic ileus, so when doctors put patients on
drips, they add KCl to provide the patient with the needed amount of
potassium.

2-

Therenalarterybruit:

(CLICK HERE)

The renal artery surface anatomy is like this :

o 2 inches above the umbilicus ("star") , then 2 inches

lateral to the umbilicus; you then will get a right angel (90
o); go with an angle of 45 o for 2 inches, and you will be
in the site of the renal artery ("circle").

 nother way to determine the anatomical site of the renal artery , is by

taking the whole distance between the xiphisternum and the umbilicus,
and then divide it into an upper 2/3 and a lower 1/3; at the juncIon
between the upper 2/3 and the lower 1/3 go 2 inches laterally, and you
will find the renal artery.
Put the diaphragm of the stethoscope on the site of the renal artery,
and listen if there is a bruit or not.

hebruit is a sound like the wind's or whistling sound; "hooo - - hooo",

and it is defined as a high-pitchedsystolicsound (systolic means that we
hear a sound with the systole then a pause with diastole , sound then a
pause, ).
>> The bruit is caused by a narrowing inside an artery; during systole,
the blood will contract a lot, as it attempts to move through a narrow
area, that causes a turbulence in it's flow inside the artery, so you hear a
bruit, while during diastole, the amount of the blood that is going to be
pumped to the artery is less than that in the systole; so the blood will go
through the narrow area without a turbulence in its flow, so you wont
hear a bruit.
The bruit is always high-pitched, it is arterial due to stenosis and it
is always in the
systole.
need to hear through your stethoscope ONLYfor1sec; because the bruit is
either there or not!! ; if there is a renal artery stenosis, you expect to
hear 70 bruits/min!!!
very important point to pay aKenIon to; is to examine the 2 sides for
bruit!!
>> renal artery stenosis is one cause for surgical hypertension (can be
corrected by surgery), so the doctor should examine both sides for
stenosis, if he does not, this can be fatal!!

Never, ever examine for the renal artery bruit in one

side only!!!
3- Theaorta :
Put the stethoscope just aboveandlateraltotheumbilicus, and hear
through it for 1 sec; if there is an aortic stenosis , you will hear a bruit.
4- Theiliacarteries :

5- Thecommonfemoralartery :

- Where is the femoral artery??

ut your finger on the anterior superior iliac spine (ASIS) , lower down,
there is another tubercle (the pubic tubercle (PT)) , and these two
elevations are connected by the inguinal ligament, 1 cm below the PT
towards the midline; we have the symphysis pubis (SP).
ut your finger on the point that is half the distance between ASIS and PT,
that is called : the midpointoftheinguinalligament, then go up for 0.5 inch
(1.25 cm); this is the deepinguinal ring.
ut your finger on the point that is half the distance between ASIS and SP,
this point is called : themidinguinalpoint, then go down for 1 cm, you will
nd the femoralartery .
ut the stethoscope on the mid inguinal point (the surface anatomy for the
femoral artery) and hear for any bruits.
6TheVenoushum : (CLICK HERE)
- Inside the artery, the pressure in the systole is about 120 mmHg, that
decreases to 80 mmHg in the diastole, and inside the vein, the pressure is
always around 15-20 mmHg during both systole and diastole ;
>> If we make a connection between the two ; during systole, the blood will go
from the artery to the vein, in diastole also, the blood will go from the artery to
the vein, if there is any connection between an artery and a vein we call it
"arterio-venous malformation" or "arterio-venous stula" and the blood will
keep flowing from the artery to the vein through both systole and diastole.
The arterio-venous malformation is systolic and diastolic (pan-systolic),
it is low-pitched (because the vein is a capacitance vessel).
- The blood supply to the liver is 70% from the portal vein and 30% from the
hepaIc artery, if a patient has a liver tumor, it will produce a vascularendothelial growth factor, that will lead to a process called "angiogenesis" ,
which is a process of new blood vessels formation, produced by the tumor cells,
so these are abnormal vessels with abnormal connections between arteries and
veins!!
Inside the tumor, there will be multi-arterio-venous malformations!!
Put the bell of the stethoscope on the liver, and hear; if you hear this
sound "tshhh-tshhh- tshhh" ; (which is a low-pitchedpan-systolicsound that
is called "venous hum") this indicates hepatoma until proven otherwise!!

7-

Thefrictionsounds :

(CLICK HERE)

Put the diaphragm over the liver, and ask the patient to take a deep breath.
If you hear a rubbing sound (that is called "friction rub" ) at the end of
inspiration, this indicates that the patient has perihepatitis or perisplenitis!!

>> You can hear this sound in the chest in the case of pleurisy; which is the
inflammation of the pleura.
- AJer nishing these 7 auscultaIons, go and examine the genetalia (scrotum
and penis or vagina) in details, then put your gloves on your hands and do
PR(PerRectal)examination.

Never, ever forget to do PR examination after you finish

auscultation!!!
>> If you did not put your finger in the rectum, you will miss the diagnosis of
the prostatic cancer, or a metastatic tumor from the stomach to the pouch of
douglas, and other many diseases.

** Never, ever do these 4 fatal

mistakes : 1Finishinspectionwithoutinspectingforhernia
s!!!
2- Finish palpation without palpating for hernias!!!
3- Examine for the renal artery bruit in one side only!!!
4- Forget to do PR examination after you nish auscultation!!!

Examining for Hernias :

>> If the examiner in the exam wants you to examine for inguinal hernia, he
will ask you to examine the groin rather than the abdomen!!
- When you examine thegroin, keep in your mind these 3 points:
1. You can examine for hernias.
2. You can examine the femoralartery ; for ex. for aneurism.
3. You can examine for lymphnodes.
>> The most difficult thing in teaching, is the
examination for hernias, so pay attention!!

- To examine a hernia in the groin, answer the following (5) questions :

1- Is this swelling a herniaornot??

f the patient told you that it bulges when he coughs or strains, and
disappears when he sleeps
It is a Hernia.

2- Is this hernia inguinalorfemoral??

he femoral hernia goes lateralandbelowthepubictubercle (always below
PT), it is commoner in females and bakers, and it usually kills the
patient; because it has a narrow neck, so if a bowel's loop enters it, it
would be very susceptible for strangulation; so it needs an emergent
manipulation.
he inguinal hernia goes upandmedialtothepubictubercle (always above
PT).

3- If this hernia is inguinal; is it directorindirect??

sk the patient to reduce the hernia, then bring 2 ngers of yours and
put them over the deep inguinal ring (1.25 cm above the mid point of
the inguinal ligament), then ask the patient to cough.
f the hernia comesoutandhityourfingermedially; this is a direct hernia,
that comes
through the posterior abdominal wall.
f the hernia doesntcomeout; this is an indirect hernia, that couldnt
come out because you are controlling "the door; the deep inguinal ring"
, as the indirect hernia comes out through the peritoneal cavity, the
deep inguinal ring , the superficial inguinal ring then out to the scrotum.
==> This test is called : "Obliteration test".

4- Is this hernia reducibleornot??

sk the patient to reduce it, if he could it is reducible, if he couldnt it is
irreducible.

5- What is the content of this hernia??

ry with your hand to return the hernia back to the peritoneal cavity ;
>> If you feel as if you are holding mud or dough ( ) , we call this
"doughy", which indicates that the content is omentum.
>> If you feel water or fluid sounds and vibrations, we call this
"gurgling", which indicates that the content is intestine.

THE END

PS. At the end of the lecture, the doctor presented 10 MCQs, that are very important, and some
of them may come in the exam, and those Qs will be included in an upcoming lecture en sha
allah.

Done by : Rawan Y. Tahboub

www.shifa2006.com