Dr. K. Shaarawy Abdomen Assessment Dr. K. Shaarawy Dr. K. Shaarawy

Anatomy of the Abdomen 4 Quadrants 4 Quadrants: The word "abdomen" has a curious story behind it. It comes from the Latin "abdodere", to hide. The idea was that whatever was eaten was hidden in the abdomen. 4 Quadrants: RUQ: Rt Upper Quadrant. RLQ: Rt Lower Quadrant. LUQ: Lt Upper Quadrant. LLQ: Lt Lower Quadrant. 4 Quadrants Dr.Karim Shaarawy,MD

9 Regions Dr. K. Shaarawy Dr.Karim Shaarawy,MD

Dr.Karim Shaarawy,MD

Location RUQ Liver (Rt Lobe) Gall Bladder Duodenum Pancreas (Head) Rt Kidney Adrenal Galnd Dr.Karim Shaarawy,MD

Location RLQ Cecum Appendix Rt Ovary Rt Fallopian Tube Ascending Colon Dr.Karim Shaarawy,MD

Location LLQ Sigmoid Colon Lt. ovary Lt Fallopian Tube LUQ Stomach Spleen Pancreas (Body,Tail) Lt Kidney Lt Adrenal Gland Dr.Karim Shaarawy,MD

GI Variations Due to Age Aging- should not affect GI function unless associated with a disease process Decreased: salivation, sense of taste, gastric acid secretion, esophageal emptying, liver size, bacterial flora Increased: constipation!امساك Dr.Karim Shaarawy,MD

GI Variations with pregnancy Decrease in gastric motility High incidence of GERD (pregnancy hormones cause “heartburn” or acid reflux) Bowel sounds diminished because enlarged uterus displacing intestines Linea Nigra- increased pigmentation of abd midline Striae Gravidarum (stretch marks) Dr.Karim Shaarawy,MD

Health History - Abdomen Ask about: Appetite Weight gain or loss Dysphagiaصعوبة فى البلع Intolerance to certain foods Any Abdominal Pain, Nausea and Vomiting Bowel movements Any past abdominal problems Dr.Karim Shaarawy,MD

Health History Infants and Children – Ask: bottle or breast fed, any table foods, how often & how well & how much the baby eat, any problems with constipation, c/o of any abdominal pain Older Adults Ask: Do you have any trouble swallowing? How often do your bowels move? How often do you take anything for constipation? What medications do you take? Dr.Karim Shaarawy,MD

Focused Health History Nutrition Allergies Medications Cigarette/tobacco Alcohol intake Drug use Stool characteristics Urine characteristics Exposure to infectious diseases. Recent stressful life events Possibility of Pregnancy Dr.Karim Shaarawy,MD

Physical Assessment Auscultation Percussion Palpation (always last) General Observation Inspection Auscultation Percussion Palpation (always last) Dr.Karim Shaarawy,MD

Examination Techniques Provide privacy Good lighting/appropriate temp in room Expose the abdomen Empty bladder Position pt supine, arms by side & head on pillow with knees slightly bent or on a pillow Warm stethoscope & hands Painful areas last Distraction techniques Dr.Karim Shaarawy,MD

Inspection Overall observation Abdominal contour- flat, scaphoid, round, protuberant Abdominal symmetry and skin color – Note any masses, striae, scars, veins, pigmentation Pulsations Dr.Karim Shaarawy,MD

Abnormal Abdominal Appearance Dilated veins: hepatic cirrhosis or inferior vena cava obstruction Umbilical bulge: hernia Asymmetric abdomen: mass or enlarged organ Protuberant abdomen: fat, tumors, gas, ascites, or pregnancy Convex abdominal contour: pregnancy, obesity, ascites, urinary retention, gas (presenting with acute distention from bloating) Visible Peristalsis: Obstruction Dr.Karim Shaarawy,MD

Auscultation Always done before percussion & palpation as they may disrupt the noises produced by the bowel sounds. Use diaphragm of stethoscope Listen lightly Start with RLQ (follow route of Large intestine) Listen to each quadrant for 15 seconds each. Dr.Karim Shaarawy,MD

Auscultation Should be approximately 5-35/min clicks and gurgles in each quadrant. Note character & frequency of bowel sounds. Listen for 5 minutes before documenting absent bowel sounds Hyper- gastroenteritis, obstruction, hunger Hypo- pregnancy, peritonitis Absent - Ileus Dr.Karim Shaarawy,MD

Abnormal Auscultation Hyperactive bowel sounds- “borborygmi” Listen for bruits- aortic, renal, iliac, femoral Peritoneal Friction Rub- rough, grating heard over liver & spleen- inflammation of peritoneal surface from tumor, infection, etc. Dr.Karim Shaarawy,MD

Percussion Gently tapping on the skin to create a vibration Detect fluid, gaseous distention and masses Tympany- gas (dominant sound because of air in small intestine) Dullness- solid masses, distended bladder Percuss liver, spleen ,kidneys Dr.Karim Shaarawy,MD

Percussion Abnormal Findings Enlarged organs, Palpable masses, Distention, Ascites Marked tenderness Dr.Karim Shaarawy,MD

Palpation of Abdomen Light palpation- depress about 1 cm. Assess skin pulsations. Always done first- clockwise Deep palpation- depress skin about 5-8 cm. Always assess tender areas last. Watch patients expression during palpation Dr.Karim Shaarawy,MD

Palpation Abnormal Findings Tenderness- rebound- done away from painful area- done at end of exam Masses- document location, size, shape, mobile, pulsating, smooth, nodular, firm Firmness or muscle guarding/rigidity- intraabdominal bleeding- DO NOT CONTINUE TO PALPATE!!!!!! Dr.Karim Shaarawy,MD

Special Procedures Fluid Wave - need 3 hands- feel for impulse of the wave of fluid across the abdomen= ascites Rebound Tenderness - Blumberg’s Sign Iliopsoas Muscle Test - thigh muscle lift R leg and push down on R thigh= appendicitis Obturator Test - lift R leg and rotate at 90 degrees= muscle is irritated by appendicitis Murphy’s Sign - “inspiratory arrest” palpate the liver should be painless= cholecystitis Dr.Karim Shaarawy,MD

Special Procedures McBurney’s Point - RLQ midclavicular= appendicitis Referred pain - location of pain is not where the involved organ is! May be felt where the organ was located in fetal development ex: spleen= L shoulder pain/ kidney= groin pain Cullen’s Sign- bluish discoloration around the umbilicus(Pancreatitis) Kehr’s Sign- abd pain radiating to Lt shoulder= spleen or pancreatitis Dr.Karim Shaarawy,MD

Sample Documentation Normal Exam- Abdomen soft, rounded and symmetric without distention; no lesions or scars, or visible peristalsis. Aorta midline without bruit or visible pulsation; umbilicus inverted and midline without herniation; bowel sounds present in all 4 quadrants. Liver, kidney and spleen non-palpable; no tenderness on palpation. Reports good appetite; no constipation, nausea or diarrhea. Voiding well and denies laxative use. Dr.Karim Shaarawy,MD