PHYSICAL SIGNS OF THE ABDOMEN

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

7. 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. 

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

13. NORMAL ABDOMEN

14. NORMAL ABDOMEN

15. 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

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

17. 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.

18. 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.

20. 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

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

22. 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.

23. ABDOMEN DRAPING

24. ASCITES

25. CAPUT MEDUSA

26. HEPATOMEGALY

27. OBESITY

28. ASSYMETRIC ABDOMEN

29. UMBILICAL HERNIA

30. 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.

31. 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

32. ABDOMINAL ASCULTATION

33. 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.

34. 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

35. PALPATION

36. 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.

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

38. 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.

39. 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.

40. 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.

41. 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.

42. Palpation Tenderness Guarding Rigidity

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

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

45. 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.

46. 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.

47. 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

48. Rebound tenderness • This is a test for peritoneal irritation. Palpate deeply and then quickly release pressure. • If it hurts more when you release, the patient has rebound tenderness.

49. Costo vertebral angle tenderness • CVA tenderness is often associated with renal disease. • Use the heel of your closed fist to strike the patient firmly over the costovertebral angles.

50. Shifting dullness • If dullness on percussion shifts when the patient is rolled on the side, peritoneal fluid (ascites) may be present.