Abdominal Examination – Clinical Examination



abdominal examination abdominal examination begins with inspection abnormalities such as distension scars stretch marks hematomas and engorged veins can provide the first evidence for conditions involving the abdomen the abdomen can be separated into individual regions to more precisely depict anatomical location a classical distribution consists of four quadrants that are separated right from left by a single vertical plane and superior from inferior by a horizontal plane another common scheme divides the anterior abdominal wall into nine anatomical regions as part of this distribution the upper middle and lower abdomen are separated into thirds these regions enable more specific findings during examination in contrast to examining the chest auscultation of the abdomen should occur before palpation otherwise stimulation of the bowels may trigger a false increase in peristalsis bowel sounds are physiologically heard as clicks and gurgles in an irregular pattern hypoactive or absent sounds can indicate a paralytic ileus resulting postoperatively or from a condition like peritonitis hyperactive sounds may indicate gastrointestinal infection or trying to overcome obstruction which could imply a mechanical ileus besides bowel sounds an aortic brut due to an aneurysm or stenosis may be auscultate it at the upper umbilical area listen for possible renal artery Brutes bilaterally from this area assessing percussion sounds is helpful in determining the size position and density of abdominal contents solid organs fluids or tumors lead to dull sounds that may sound similar to percussion sounds of the thigh in contrast the percussion sound of hollow air filled intestines is more drum like in nature and is therefore known as tympanic or tympanic tympanic sounds are even more extreme in conditions involving the accumulation of excess gas within the bowels a scene in abdominal bloating a distended abdomen has various causes including adiposity bloating a tumor or ascites in addition to percussion being able to form a belly fold may help in determining the cause physiologically the examiner should be able to form a small belly fold in contrast in patients with massive ascites it would be difficult or not possible to do so the most reliable clinical sign to detect ascites is checking for shifting dullness if a patient with ascites is lying supine fluid accumulates in the flank regions leading to dullness on percussion at the same time the air-filled bowel loops are forced upwards by the free fluid due to buoyancy resulting in tympanic percussion to locate specifically where dullness shifts to timpani or the air fluid level percussion should be performed from the sides towards the middle to confirm that the dullness is caused by ascites ask the patient to switch to a lateral decubitus position if ascites is present the air-filled bowel loops will shift accordingly and remain at the surface of the fluid as a result the air fluid level will shift as well this is known as shifting dullness palpation should be conducted last it can be uncomfortable for some patients causing them to tense up to help relax the abdominal muscles you can try distracting patients with the conversation or asking them to breathe deeply to prevent the patient from tightening the abdominal muscles otherwise known as guarding it is important to begin palpating at a point far from any painful areas and to avoid using cold hands begin by shallowly palpating the surface doing so may already elicit involuntary guarding that could indicate peritonitis pay attention to the patient's expressions such as flinching as they may help in interpreting pain now continue by systematically palpating deeper to assess the abdominal organs take note of any pressure pain rebound tenderness or abdominal masses palpating a normal-sized liver is sometimes difficult it usually extends beyond the ribcage in the area of the right midclavicular line and traverses the epigastric region even in this region the liver can only be felt through deep palpation start the examination by asking the patient to exhale afterwards as the patient is inhaling slowly slide your fingers towards the right ribcage so they are near the livers edge when the lower liver edge is felt its surface structure consistency and size can be evaluated since a severely enlarged liver can extend as far as the lower abdomen palpation should start further down in the right lower quadrant if necessary by manual palpation can help locate the liver in patients with the larger abdominal diameter another possibility to determine the size of the liver is the scratch test although its reliability and precision remain controversial one method is to place the stethoscope on the chest just below the xiphoid process lightly scratch the abdominal skin in the right lower quadrant with a fingernail parallel to the expected liver border the air-filled bowel loops under the fingertip poorly transmitted the sound waves to the stethoscope proceed with the scratch test by gradually moving cranially towards the ribcage the transition from bowel to liver tissue through which sound waves can travel more intensely is notable for a sudden increase in loudness of the scratching and marks the lower liver border continue the scratch test further upwards until a sudden drop in loudness is observed marking the transition from liver to lung this is where the upper liver border is located in this patient percussion palpation and scratch tests reveal a physiological liver size the cranial caudal length of the right liver lobe in the midclavicular line is around 10 centimeters these examination techniques can help in examining a suspected hepatomegaly but do not replace the standard clinical practice of abdominal ultrasound which helps assess the liver more precisely assess the gallbladder next which should only be palpable in a pathological State for example if hydrops is present palpation takes place somewhat medial to the midclavicular line below the right ribcage evaluating for tenderness on palpation is important since it may indicate cholecystitis cholecystitis can also be evaluated by testing for a positive Murphy's sign to test this sign first ask the patient to exhale while palpating the gallbladder area medial to the midclavicular line now instruct the patient to take a deep breath so the gallbladder is pushed down and against the examiners fingertips as the lungs expand if cholecystitis is present the patient will experience a sharp and sudden pain causing an abrupt halt to inhalation this reaction is known as a positive Murphy sign the spleen is generally not palpable in healthy adults a pathologically enlarged spleen is palpated under the left costal margin during inspiration as the inferior edge descends to the examiners fingertips if an enlarged spleen is already suspected palpation should begin further down the examination may be facilitated by gently lifting the left flank of the patient ventrally percussion of the kidneys located in the retroperitoneum can also be done on abdominal examination keep in mind that the upper pole of the left kidney can be found at the level of the twelfth thoracic vertebra because of the liver the right kidney lies around three centimeters lower than the left careful percussion of the flanks in the lower ribcage area should not elicit pain in a healthy patient pain on percussion however should raise suspicion for a pathological process such as pyelonephritis or euro lathy osis you

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