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PHYSICAL SIGNS OF THE ABDOMEN

PHYSICAL SIGNS OF THE ABDOMEN. Lidia Ionescu Cl.III chirurgie. Abdomen. Region of the trunk, between the diaphragm and the inlet of the pelvis. Abdomen. Diaphragm=primary muscle of respiration, dome-shaped: right dome-upper border 5 th rib, left dome-lower border 5 th rib.

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PHYSICAL SIGNS OF THE ABDOMEN

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  1. PHYSICAL SIGNS OF THE ABDOMEN Lidia Ionescu Cl.III chirurgie

  2. Abdomen • Region of the trunk, between the diaphragm and the inlet of the pelvis.

  3. Abdomen • Diaphragm=primary muscle of respiration, dome-shaped: right dome-upper border 5th rib, left dome-lower border 5th rib. • Openings: • aorta opening, • esophageal opening, • caval opening • Pelvic inlet: sacral promontory, ileopectineal lines and symphysis pubis.

  4. xiphoid process X • costal cartilages (ribs 7-10) • tips of ribs 11 and 12 • vertebrae L1-L5 • iliac crests IC • tubercle of the crest TC • anterior superior iliac spine ASIS • anterior inferior iliac spine AIIS • inguinal ligament IL • pubic tubercle PT • pubic crest PC • pubic symphysis PS • the separation of the abdomen from the pelvis, the pelvic brim PB

  5. Rectus sheath • Is a covering envelope over the rectus abdominis m.(RA) created by the aponeurosis of the other three musc. Above arcuate line – ant.- RA has aponeurosis of EO, and ant half of IO aponeurosis . - behind it, is the post half of IO aponeurosis, TA. aponeurosis  and TF. Below  arcuate line - all musc aponeurosis run in front of RA m., leaving only transversalis fascia behind it. • The idea is that - to keep the tension of the ant wall of abdomen. • Where the hell is the Arcuate line?  About 1/3 of the way between the umbilicus and the pubic crest. 

  6. Surface landmarks • Xiphoid process • Costal margin • Iliac crest • Symphysis pubis • Inguinal ligament • Superficial inguinal ring • Linea alba • Umbilicus • Rectus abdominis • Linea semilunaris

  7. NORMAL ABDOMEN

  8. NORMAL ABDOMEN

  9. Use your knowledge to project the anatomy onto the surface of the abdomen. • You will want to be able to visualize the relative positions of abdominal organs as they lie within the abdomen. • By subdividing the surface into regions, one person can tell another person exactly where to look for possible problems

  10. Layers of the abdominal wall - skin - superficial fascia - deep fascia - muscle - subserous fascia - peritoneum

  11. These regions are formed by two vertical planes and two horizontal planes. • The two vertical planes are the lateral lines LLL and RLL. These lines are dropped from a point half way between the jugular notch and the acromion process. • The two horizontal planes are the transpyloric plane TPP and the transtubercular plane TTP. The tubercles are the tubercles of the iliac crests.

  12. As you examine the abdomen in thin subjects, you may be able to see the superficial veins that drain the abdominal wall. These veins drain into one of two major veins: subclavian and femoral (F) and also into a minor, but important vein, the paraumbilical vein PU. • The paraumbilical vein drains into the portal vein and then through the liver. This is an important clinical connection. • The lower abdominal wall is drained by way of the superficial epigastric SE and superficial circumflex iliac SCI veins into the femoral vein. • The upper abdominal wall is drained by way of the thoracoepigastric TE and lateral thoracic LT veins into the subclavian.

  13. The most superficial layer of anterolateral muscles are the: external abdominal obliques EAO • The cutaneous nerves to the abdomen are mainly continuations of the lower intercostal nerves (T7 - T12). • The lowermost part of the abdominal wall is supplied by a branch of L1, the iliohypogastric IH nerve. Its other branch is the ilioinguinal II nerve. • Linea alba LA. is where the aponeuroses of the external abdominal oblique, internal abdominal oblique, and transverse abdominis muscles converge at the midsagittal part of the abdominal wall.

  14. In the image, the left external abdominal oblique has been cut away at the white dotted line and removed in order to show the internal abdominal oblique IAO. • You can also see lower cut edge of the external abdominal oblique at the inguinal ligament IL • The anterior wall of the rectus sheath RS has also been removed on the right side in order to see the underlying right rectus abdominis RA muscle. • Note that the rectus abdominis muscle is subdivided into small sections by so called tendinous inscriptions TI. • You may also see a small muscle overlying the inferior end of the rectus abdominis muscle, the pyramidalis muscle PY. This small muscles tenses the lower part of the linea alba.

  15. The rectus abdominis muscle, internal abdominal oblique and anterior rectus sheath have been removed. You can identify the posterior rectus sheath and its lower free margin, the arcuate line AL. • What you see below this line is the transversalis fascia and running in the fascia is the inferior epigastric artery IEA, a branch of the external iliac artery. This artery enters the rectus sheath posterior to the rectus abdominis muscle and supplies the anterior abdominal wall. Extending from the top, is a branch of the internal thoracic (or mammary) artery, the superior epigastric artery. • Also note that the cutaneous nerves are found to lie between the internal abdominal oblique and the transversus abdominis muscles.

  16. Good abdominal examination • Good light • Relaxed patient • Full exposure of the abdo. from xiphoid process to the SP. • The groin should be visible although the genitalia should be kept draped

  17. Inspection • Note the shape of the abdomen • Look for scars, sinuses, fistulae • Look for distended veins • Look for visible peristalsis- Bowel obstruction

  18. Inspection • Inspection is always an important first step in any physical examination. Look at the abdominal contour and note any asymmetry. Record the location of scars, rashes, or other lesions.

  19. ABDOMEN DRAPING

  20. ASCITES

  21. CAPUT MEDUSA

  22. HEPATOMEGALY

  23. OBESITY

  24. ASSYMETRIC ABDOMEN

  25. UMBILICAL HERNIA

  26. Auscultation • Unlike other regions of the body, auscultation comes before percussion and palpation (the sounds may change after manipulation). Record bowel sounds as being present, increased, decreased, or absent.

  27. Auscultation • Bowel sounds- gurgling noises if it contains a mixture of fluid and gas • Normal bowel sounds- low-pitched gurgles • No bowel sounds- silent abdomen • High-pitched bowel sounds- “tinkling sounds”-mechanical bowel obstruction • Systolic bruits over the aorta and iliac arteries

  28. ABDOMINAL ASCULTATION

  29. Bruits • In addition to bowel sounds, abdominal bruits are sometimes heard. Listen over the aorta, renal, and iliac arteries. Bruits confined to systole do not necessarily indicate disease. Don't be fooled by a heart murmur transmitted to the abdomen.

  30. Palpation • Begin by feeling the area that you might otherwise forget: • Feel the supraclavicular fossa for lymph nodes • Feel the hernial orifices at rest and when the patient coughs. • Feel the femoral pulses • Examine the external genitalia

  31. PALPATION

  32. Light palpation • Begin with light palpation. At this point you are mostly looking for areas of tenderness. The most sensitive indicator of tenderness is the patient's facial expression.

  33. Deep palpation • Proceed to deep palpation after surveying the abdomen lightly. • Try to identify abdominal masses or areas of deep tenderness.

  34. Palpation of the liver • To palpate the liver edge, place your fingers just below the costal margin and press firmly. • Ask the patient to take a deep breath. You may feel the edge of the liver press against or slide under your hand. A normal liver is not tender.

  35. Alternate method for liver palpation • An alternate method for palpating the liver uses hands "hooked" around the costal margin from above. • The patient should be instructed to breath deeply to force the liver down toward your fingers.

  36. Palpation of the aorta • The aorta is easily palpable on most individuals. • You should feel it pulsating with deep palpation of the central abdomen. • An enlarged aorta may be a sign of an aortic aneurysm.

  37. Palpation of the spleen • Press down just below the left costal margin with your right hand while asking the patient to take a deep breath. • It may help to use your left hand to lift the lower rib cage and flank. The spleen is not normally palpable on most individuals.

  38. Palpation Tenderness Guarding Rigidity

  39. Palpate for masses • Site • Shape • Size • Surface • Edge • Consistence • Mobility • Tenderness

  40. Percussion • Shifting dullness- ascitis • Tympanism- hyperresonance- bowel distension • Measure the height of the liver dullness

  41. Percussion • Tympany is normally present over most of the abdomen in the supine position. • Unusual dullness may be a clue to an underlying abdominal mass.

  42. Liver span • Measure the liver span by percussing hepatic dullness from above (lung) and below (bowel). • A normal liver span is 6 to 12 cm in the midclavicular line.

  43. Splenic enlargement • To detect an enlarged spleen, percuss the lowest interspace in the left anterior axillary line. • Ask the patient to take a deep breath and repeat. A change from tympany to dullness suggests splenic enlargement

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