Abdomen (PDCI CSL lab):

-when a patient comes with a GIT problem, the main complaint would be
abdominal pain.

-the upper part of the GIT is from the mouth to the ligamentem teres

-you can only see the mouth and pharynx

-first start with inspecting the upper GIT

-examine the cheeks for ulcers, there are two types of ulcers:

-painless ulcers: in malignancy

-painful ulcers

-check the oral cavity for white patches, which can be caused fungal infections
especially in immune-compromised patients

-white patches called leukoplakia which is a pre-cancerous condition

-check the teeth for any decayed ones

-check the gum for any hypertrophy which can be a side effect from some drug

-check the tongue, any white patches, if it’s thin and smooth, any ulcers

-use a tongue depressor to see the tonsils, to check for tonsillitis

-does the patient have hallotosis? (means bad oral smell)

Abdomen examination:

-when examining the abdomen expose it till the inguinal region

Inspection:

-stand at the foot-end of the patient

-inspect the shape: if it’s flat, scaphoid or distended

-any fluid would accumulate in the flanks first

-check if the abdomen is uniformly distended from the xiphoid till the
pubic symphysis

-normally the distance from the xiphoid till the umbilicus is equal to the
distance from the umbilicus to the pubic symphysis
 -inspect the umbilicus shape, location, and hernia; it is normally centre
and inverted

-ask the patient to breathe to check the movement of the abdomen with
respiration, the whole abdomen should move uniformly

-check for any visible intestine movements (a.k.a peristalsis :p), this would
indicate an intestinal obstruction or pyloric stenosis

-check for prominent dilate veins:

-dilated veins in the flanks indicate IVC obstruction

-dilated veins in the umbilicus (a.k.a Caput medusae) indicate portal

hypertension

-stretch marks: can be white or dark, white in obesity, dark during

pregnancy

-if the abdomen is distended with empty flanks then it maybe fat or just a
full stomach

-to check for hernias, ask the patient to turn to the opposite side and
cough

-check for scars; from injuries or surgeries, if you’re going to describe a

scar tell in which region it is.

-a midline scar may indicate a laparotomy if it’s above the umbilicus or a

C-section if it’s below the umbilicus

-How to tell if a mass is above or below the rectus?

Ask the patient to flex his head or lift his legs in order to tighten the
muscle, now with the muscle tightened, if the mass is more
prominent then it’s above the rectus abdominis, but if it becomes
less prominent it is underneath the muscle

Auscultation:

-Normal gut sounds are absent in paralytic ilea and after an intestinal
surgery

-auscultate bruites over vascular tumour, and you hear it after a

degeneration of cirrhotic nodules and hemiangioma

-friction rubs are heard over the liver and spleen in inflammation as they
rub with their capsule
Palpation:

-two parts: superficial and deep

-First ask the patient if he/she has any pain, if it’s in the epigastrium then
it can be gastritis

-How to distinguish a gastric ulcer from a duodenal?

-gastric ulcer: feels pain when eating so he/she loses weight by not
eating much

-duodenal ulcer: the pain is relieved when the patient eats so he

gains weight

1) Superficial palpations:

Check for: 1) any superficial masses; hernia, lipoma or

neurofibroma

2) abdomen consistency: normally soft but when

inflamed the muscles would be tight to protect the underlying
structures

3) tenderness can be generalized as in peritonitis or

localized as in appendicitis, there is also rebound tenderness; It
refers to pain upon removal of pressure rather than application of
pressure to the abdomen

-In peritonitis, the patient doesn’t control the rigidity of his abdomen so it
won’t abolish like in guarding

2) Deep palpations:

-ask the patient to turn his head to the opposite side and take deep
breaths

a) Liver:

-start from the right iliac fossa to the right hypochondrium

-usually not palpable

-palpate the liver with the radial border of the index finger by
placing it parallel to the costal margin

-start from the right iliac fossa, ask the patient to take a deep
breath so you can tough the edge of the liver

-normally it is not palpable but sometimes in normal people it can

be palpable with deep breath
 -measure the enlargement of the liver at the mid-clavicular line,
starting from the costal margin till the edge of the liver.

-An enlarged liver is found in lymphoma & congestive cardiac failure

(CCF)

b) Spleen:

-normally it’s behind the 9th, 10th, and 11th ribs

-is palpated by using 2 techniques

-to palpate start from the right iliac fossa, because if the spleen
enlarges it’ll enlarge in an oblique direction

-palpate with the tip of the two fingers (index & middle)

-another technique is “hooking”; stand at the left side of the patient

and only if the spleen wasn’t palpable using the first technique then
use the “hooking technique”, use for palpating small spleens, it’s
easier to palpate by applying pressure with one hand posteriorly,
and the other palpating the spleen.

-the spleen is more superficial than the liver.

-when palpating an enlarged spleen, palpate the spleen notch for

confirmation

-An enlarged spleen is found in lymphoma, CML: chronic myeloid

leukemia, malaria , and kala azar (where kala is indian for black,
and that is a disease where the patient becomes hyperpigmented)

Kidneys:

-use a bimanual palpation technique (one hand placed)

-one hand is placed posterior (at the lumbar region) and the other is
placed anteriorly (below the umbilicus)

- normally not palpable

-An enlarged kidney is seen in polycystic kidney and hydronephrosis

Uterus:

- is enlarged in pregnancy
 -won’t be able to put your hand beneath it (use the hooking
technique)

1) Talk about measurement

2) The edge can be sharp as in the liver, or round as in the spleen, or even
more round as in the kidney

3) Surface of the mass can be smooth as in hepatitis, or congestive heart

failure or lymphoma, or it can be irregular as in cancer, or nodular as in
liver cirrhosis

4) Consistency: it can be soft as in congestive heart failure, or firm as in

cirrhosis, or hard as in malignancy

5) Movement with respiration: the kidney would move less compared to the
liver and spleen, while the uterus and bladder don’t move at all, and the
spleen would be the one that moves the most.

6) Tender or not tender

7) Any pulsations as in aortic aneurysm, or hemangioma (when there is a

connection b/w the arteries and veins)

Percussion:

-for percussing fluid there is shifting dullness, fluid thrill and puddle sign

-shifting dullness is positive if the fluid is 1000 cc

-fluid thrill is positive if greater than 2 Litres

-If the fluid is 4 Litres then the whole abdomen would be dull, so use three
hands; It is performed by having the patient push their hands down on the
midline of the abdomen. The examiner then taps one flank, while feeling
on the other flank for the tap. Fluid allows the tap to be felt on the other
side. A positive fluid wave test indicates that there is a free fluid(ascites)
in the abdomen. When one side of the abdomen is pressed, the other side
will also be painful due to the transfer of the fluid in it.

-How to detect fluid if it’s less than 1 L, like 120 ml?? use puddle sign: tell
the patient to stand on his knees to make the fluid dependent, then
percuss to see if the abdomen is dull

-puddle sign can detect fluid till 120 ml

-Percussion of organs:

-Liver and spleen are usually tested for percussion

-the liver is the most important organ to percuss

-to percuss the spleen start from the mid-axillary line to the right
iliac

-the spleen usually can’t be percussed because the colon can go up

and when percussed it’s resonant.