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9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 2
Abdominal regions
Conventionally the abdomen
is divided into 9 regions
There are 4 dividing lines:
midclavicular (2) -
vertical
subcostal - upper
horizontal
Trans-tubicular - lower
horizontal
Alternatively they can be
divided into 4 quadrants
Anteriorsuperioriliac spine
Subcostalline
Midclavicularline
LumbarUmbilical
Epigastic
Suprapubic
Hypochondrial
IliacTrans-tubercular
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 3
Remember to always do a general
Inspection This can be undertaken with the patient upright
General appearance
Demeanour, Pallor, Jaundice, Cachexia, etc.
Hands and nails
Ask the patient to dorsiflex at the wrist (cock their hands
back) to observe for a liver flap (a flapping of the hands
back and forth associated with metabolic disorders)
Vital signs (BP, Pulse, RR, Temp)
Mouth, teeth, tongue and breath
Palpation of lymph nodes
They may enlarge for a number of reasons,
including infection, malignancy and systemic
disease.
Certain groups are assessed as part of
limited local examinations:-
Cervical and Supraclavicular in abdominal
examination.
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 4
9/19/2011 Clinical Skills Resource Centre, University of Liverpool, UK 5
Lymph nodes for abdominal examination
Deep cervical
Superficial
cervical
Supraclavicular
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 6
Abdominal examination
The patient should be relaxed in a warm environment
Lying flat on their back, with hands by their sides and a single pillow under the head
Hips and knees may be flexed to relax abdominal muscles
The abdomen should be exposed (from xiphisternum to the suprapubic area - inguinal and genital areas are covered until they are to be examined)
Examiner should have warm hands
Should position him/herself to be on level with the abdominal surface
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 7
Inspection of the torso
Should be done with the patient supine
Look for spider nivae (only on the chest)
Gynaecomastia in males
Scars
Skin
Distension
Swellings
Dilated veins
Visible peristalsis
Abdominal wall movement
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 8
Causes of abdominal distension
Flatus (gas)
Faeces
Fluid (ascites)
Fat
Foetus
F****ing big tumours
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 9
Superfical Palpation
Always start palpation
away from any site of pain.
Palpate systematically all
abdominal regions. Always
observe patients face for
signs of discomfort.
Superficial palpation
Using light pressure
assess for tone,
tenderness and any
obvious abnormalities
Use the flat of the palmar
surface of fingers to palpate
through the abdominal wall
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 10
Assessing muscle tone with superficial
palpation
Gentle pressure applied to the abdominal wall should allow the
examiner to depress the anterior wall of the abdomen as the
muscles relax
Contraction of the muscles underlying the hand as pressure is
applied is called “guarding” and may indicate some underlying
inflammation
A rigid abdominal wall, resisting any attempt to push back the
abdominal wall and usually not moving with respiration, indicates
underlying peritoneal inflammation and is called “rigidity”
A marked, acute exacerbation of pain on sudden release of pressure
applied to the abdominal wall is called “rebound”
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 11
Deep palpation
Deep Using firm pressure to
assess for deep swellings/abnormalities
Deep palpation must be done with the palmar aspect of the fingers (get on the same level as the abdomen)
Can be done using 1 or 2
hands. Making sure not to push
down on fingertips
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 12
Organ Palpation
Organ palpation Liver
Gall bladder
Spleen
Kidneys
Aorta
Use the radial margin of the index finger to move from the furthest direction enlargement can occur towards the position the organ normally lies to detect enlargement
Costal
margin
Use the edge of the index finger
to detect organ edges
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 13
Palpation
When palpating organs or masses feel for the edges
The edges provide a better contrast between
surrounding organs/tissues and the mass/organ
Palpation of masses or organs may be assisted by
assessment of mobility in relation to respiration
liver descends towards right iliac fossa on
inspiration
spleen descend inferio-medially on inspiration
towards the right iliac fossa
the kidneys descend on inspiration
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 14
Palpation of the liver
The liver lies predominantly
under the ribs on the right side,
although it does cross the mid-
line
The lowermost edge of the liver
lies approximately parallel with
the costal margin (the lower
edge of the rib cage)
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 15
How liver moves on insperation
The liver moves
inferiorly on
inspiration
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 16
How liver enlarges
Enlargement of the
liver also occurs in
an inferior direction
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 17
How liver is palpated
In view of the direction of enlargement,
palpation for the liver should
commence well away from the costal
margin in the right iliac area
The thumb is extended to expose the
lateral margin of the index finger
The hand is positioned so that the
lateral margin of the index finger is
parallel with the costal margin
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 18
How liver is palpated 2
The patient is asked to take a
deep breath in and pressure
applied to the abdominal wall by
the examining hand
If the liver is not palpated, the
examining hand is moved closer to
the costal margin by about 1 cm
The patient is asked to repeat
deep inspiration and the process is
repeated
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 19
How liver is palpated 3
The process is repeated until the
liver edge is palpated or the
costal margin reached
A normal liver may be palpated
close to the liver costal margin
An enlarged liver may be
palpated distal to the costal
margin
The distance is measured in cms
from the costal margin
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 20
Feeling the liver edge 1
The hand is placed on the
abdominal wall at the right iliac fosa
distance below the right costal
margin. The border of the index
finger is exposed by extending the
thumb.
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 21
Feeling the liver edge 2
Pressure is applied to the
abdominal wall so that the hand
presses slightly depresses the
superficial surface
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 22
Feeling the liver edge 3
The patient is asked to
breath in deeply through
their mouth. This flattens the
diaphragm and the liver
moves inferiorly.
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 23
Feeling the liver edge 4
An enlarged liver will
move towards the lateral
border of the index finger
as inspiration reaches
maximum
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 24
Feeling the liver edge 5
As the enlarged liver continues
to move downwards it lifts the
the finger and the edge can be
appreciated. The point at which
the edge is palpated at
maximum inspiration can be
measured from the right costal
margin
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 25
Palpation of the spleen
The spleen lies entirely under the ribs on the left side
The normal spleen is approximately fist sized
The long axis of the spleen lies along the the line of the 10th rib
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 26
Position of spleen in health
The spleen moves inferio-medially on inspiration
Even on deep inspiration the normal spleen cannot be felt on palpation
To be palpable the spleen must enlarge to at least twice normal size
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 27
Position of an enlarged spleen
Enlargement of the spleen also
occurs in an inferio-medial
direction
Indeed, a massive spleen may
extend into the right lower
abdomen
When very large you may be able
to palpate the distinctive splenic
notch
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 28
Palpation of the spleen 1
In view of the direction of
enlargement, palpation for the
spleen should commence well
away from the costal margin in
the right iliac area
The thumb is extended to expose
the lateral margin of the index
finger
The hand is positioned so that the
lateral margin of the index finger
is parallel with the left costal
margin
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 29
Palpation of the spleen 2
The patient is asked to take a deep breath in and pressure applied by the examiners hand to the abdominal wall
If the spleen is not palpated, the examining hand is moved closer to the costal margin by about 1-2 cm
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 30
Palpation of the spleen 2
If the spleen is not
palpated
The patient is asked to
repeat deep inspiration
and the process is
repeated
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 31
Palpation of the spleen 3
The process is repeated until
the spleen is palpated or the
costal margin reached
A normal spleen will not be
palpated
An enlarged spleen may be
palpated distal to the costal
margin
The distance is measured in
cms from the costal margin
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 32
If palpation is difficult
Palpation for the spleen can be facilitated by placing the left hand under and behind the lower left rib and applying traction in the direction shown
This may encourage an enlarged spleen, otherwise not palpable, to appear beyond the costal margin on inspiration
Some clinicians prefer the patient to roll onto their right side to achieve the same effect
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 33
Palpation of the kidneys
Extend from the twelfth thoracic vertebrae to the third lumbar vertebrae.
Not normally palpable unless the patient is thin
The right kidney is lower than the left due to the position of the liver
They have a firm consistency and smooth surface
They move downwards towards the end of inspiration
Posterior view
L R
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 34
Renal angle
They are retroperitoneal organs and deep bimanual palpation is required.
To examine position the patient close to the edge of the bed
Tuck the palmar surfaces of one hand into the patients flank
Nestle the finger tips in the renal angle
Posterior View
L R
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 35
Bimanual examination of the kidneys 1
One hand under the patients
flank, fingers in the renal angle
(between posterior costal
margin and spine
The other hand with fingers flat
placed below the costal margin,
lateral to the rectus muscle
Hands should be opposite one another
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 36
Bimanual examination of the kidneys 2
Palpate the lower pole of the kidney between the fingers of both hands
Asks the patient to breathe in deeply and press the fingers of both hands firmly together
The rounded lower pole of the kidney may be felt passing between the opposing fingers as the patient breaths in and out
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 37
Percussion
Assess the need to perform percussion depending on your clinical findings.
It is important to distinguish kidney enlargement from splenomegaly on the left and hepatomegaly on the right
Percussion of an enlarged liver or spleen will be dull whereas over the kidney it should be resonant due to the overlying bowel
The kidneys can be “balloted” this a technique where by a structure that is not fixed can be patted between the examining hands
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 38
Percussion technique
Take note of the technique
Use the tip of the finger
The blow is delivered by a
sharp wrist movement
Strike the middle phalanx
firmly. Two – three taps
only.
Remove striking finger
immediately
PRACTISE!
Please see basics of examination
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 39
Percussion
General abdomen - should be resonant
Organs
Liver - dull
Spleen - dull
Kidneys - resonant
Bladder - dull
Ascites
Shifting dullness
Dullness peripheral
Ovary
Dullness central
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 40
Detecting shifting dullness
Determines cause of abdominal distension, distinguishes
between fluid and gas.
There has to be a lot of fluid (ascites) present which can flow
freely for the method to work
With the patient lying on their back the highest point of fluid is
detected by percussion and marked
The patient rolls to an angle and is allowed to rest in this
position for a short time to allow the free fluid to flow and
establish a new upper level
Percussion is repeated and fluid confirmed by detecting
dullness “above” the previous level
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 41
Auscultation
Bowel sounds – Listen in
one area, bowel sounds
should be heard within 2-3
minutes.
Bruits
Liver
NB A full abdominal
examination should
normally include
examination of the groins,
external genitalia and
rectum
Renal
Aortic
Iliac
Femoral
Sites of abdominal bruits
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 42
Recording your findings
Don’t forget when recording your findings
Patient identifier, date (and time), signature and name
When documenting the size, position and shape of
a swelling, a diagram may often be useful. Where
possible remember to comment on the consistency,
surface and mobility of the swelling also.
Remember examination techniques will vary
depending on the patient and clinician