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REGIONS OF ABDOMEN
• ARBITRARILY DIVIDED INTO 9 REGIONS BY
• 2 IMAGINARY VERTICAL LINES
• Mid pt of clavicle on either side
• 2 IMAGINARY HORIZONTAL LINES
• At level of L1 vertebrae (i.e. Transpyloric plane)
• At level of tubercles of iliac crest
SYSTEMIC EXAMINATION OF ABDOMEN
• INSPECTION
• SHAPE
• UMBILICUS
• MOVEMENTS
• VISIBLE PULSATIONS
• VISIBLE GASTRIC/INTESTINAL PERISTALSIS (VGP/VIP)
• SKIN/SURF OF ABDOMEN
POSITIONING FOR ABDOMINAL EXAMINATION
INSPECTION
• UMBILICUS
• SHAPE
• SKIN/SURF OF ABDOMEN
• MOVEMENTS
• VISIBLE PULSATIONS
• VISIBLE GASTRIC/INTESTINAL PERISTALSIS (VGP/VIP)
PROC TO INSPECT
• UMBILICUS & SHAPE
• Look
• Tangentially across abdomen &
• From foot of bed
UMBILICUS
• NORMAL : Slightly Inverted & Retracted
• ABNORM
• EVERTED = Ascites, Umbilical hernia
• SLIT
• VERTICAL = Pelvic/Ovarian tumor
• HORIZONTAL = Cirrhosis of liver + Ascites
• SUNKEN = Obesity
SHAPE
• NORM
• Flat/Slightly scaphoid
• Symmetrical
• ABNORM
• GENERALISED FULLNESS/DISTENSION = 5 F’s
• Fat, Fluid, Flatus, Faeces, Foetus
• LOCALISED DISTENSION
• SYMMETRICAL & CENTERED ARD UMBILICUS = Small bowel obstruction
• ASYMMETRICAL = Liver, Spleen, Ovary
• Congenital anomalies
• Compression by
• Massive ascites
• Tumors
• Hypercoagulable states (i.e. Nephrotic syndrome)
• Idiopathic retroperitoneal fibrosis
• OC
• Trauma
• 2° to Inf
CLINICAL FEATURES
• OBSTRUCTION CAUDAL TO RENAL V
• Oedema of both lower limbs
• Dil of superficial v of legs & abdomen
• OBSTRUCTION AT LEVEL OF RENAL V
• Lumbar pain
• Renal enlargement
• Haematuria, Proteinuria
• OBSTRUCTION ABOVE RENAL V
• Budd Chiari syndrome
ANASTOMOSIS
• BETWEEN
• BELOW : Superficial epigastric & Superficial circumflex iliac v
• ABOVE : Lat thoracic v
• CONVEYING BLOOD FROM : Long saphenous v Axillary v
• VEINS SEEN IN
• Paraspinal region
• Lat wall of abdomen
CLINICAL EXAMINATION
• PROC
• Pt made to stand
• Select long segment of v w/o tributaries below umbilicus
• To detect flow
• INTERPRETATION
• Flow towards umbilicus, Cephalic direction = IVC OBSTRUCTION
• Flow away from umbilicus, Downward direction = PORTAL HT
MOVEMENTS
• NORM
• Gentle rise on inspiration
• Fall during expiration
• ABNORM
• SILENT/STILL = Peritonitis
VISIBLE PULSATIONS
• ABDOMINAL AORTIC PULSATIONS
• Thin pt
• Aortic aneurysm
VGP/VIP
• PHYSIOLOGICAL
• Thin pt
• Elderly pt w lax abdominal wall
• PATHOLOGICAL
• VGP
• Wave of gastric peristalsis
• Lt hypochondrium Epigastric region Rt lumbar region
• IN : Gastric outlet obstruction
• VIP
• Hypermotile small intestine Step ladder peristatltic wave in Umbilical region
• IN : Distal small bowel obstruction
KIDNEYS
• INDICATED BY : Morris quadrilateral on either side
• Draw 2 parallel horizontal lines
• On back
• At levels of 11th dorsal & 3rd lumbar spine
• Draw 2 vertical lines
• 3.75 cm & 8.75 cm from midline respectively
GALLBLADDER
• At junc of
• 9th costal cartilage &
• Outer border of rt rectus abdominis
• GREY-TURNER’S METHOD
• Draw line from lt ASIS through umbilicus
• Gallbladder at junc of this line & costal margin
• NOTE
• Gallbladder better seen than felt when enlarged
PALPATION OF LIVER
• PROC 1
• Place hand flat on abdomen
• Finger pointing upwards
• Position sensing fingers (i.e. index & middle) lat to rectus muscle
• Press hand firmly inwards & upwards
• Keep steady while pt takes deep breath through mouth
• Wait 1 full phase of respiration
• Continue up
• PROC 2
• Keep rt hand below & parallel to rt subcostal margin
• RESULT
• Liver edge felt against radial border of index finger
• Confirm w percussion
• PRECAUTION
• Avoid placing hand over rectus abdominis
• Do NOT begin palpation too close to costal margin
CHARACTERISTIC OF LIVER COND/DISEASE
FIRM Chronic congestive cardiac failure (i.e. Nutmeg liver
REGULAR Cirrhosis of liver
Obstructive jaundice
NODULAR LIVER Advanced 2° carcinoma
Hepatoma
PULSATILE LIVER Systolic pulsations – TR
Diastolic pulsations – TS
SOFT Acute viral hepatitis
TENDER
• j
PALPATION OF SPLEEN
• PROC 1
• Palpate from Rt Iliac fossa to Lt Hypochondrium
• Wait 1 full phase of respiration
• Release P on examining hand at height of INSPIRATION
• Finger tips slip over lower pole of spleen
• Confirm Presence & Surf characteristics