1. بسم الله الرحمن الرحيم

2. Abdominal Examination by Dr. Sally Abed Lecturer Tropical Medicine

3. ABDOMINAL EXAMINATION
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION

4. Anatomy
Regions (Anatomical)
Quadrants (Clinical)

5. ABDOMEN: Inspection ABDOMEN: Inspection
There should be adequate exposure of the abdomen for proper inspection. The patient should be exposed from the inferior chest to the anterior iliac spines bilaterally.

6. INSPECTION Mid line inspection Inspection of sides 1-Subcostal angle
2-Epigastric pulsation
3-Divercation of recti
4-Umblicus
5-Suprapubic hair distribution
6-Hernial orifices
1-Contour of abdomen
2- Dilated veins
3- Skin
4-Scars
5- Movement with resp
6-Visible peristalisis

7. - Site - Dilated veins MID LINE INSPECTION
1-Subcostal anglecauses of 
2-Epigastric pulsationcauses
3-Divercation of recti??
4-Umblicus
- Site Dilated veins
- shape Skin
- Hernia Discharge
5-Suprapubic hair distribution
6-Hernial orifices

11. 2- Collaterals (dilated veins) 3- Skin abdominal wall
INSPECTION OF SIDES
1-Contour of abdomen
2- Collaterals (dilated veins)
3- Skin abdominal wall
-Striae, scratch marks, sinus& fistula
-Pigmentation, purpura
4-Scars
Type, site, pigmentation, impulse on cough
5- Movement with respiration
6-Visible peristalsis

14. Causes of abdominal enlargement ?
Generalized:
Fluid (ascites)
Fat (obesity)
Flatus and faeces
Fluid in cyst (ovarian cyst)
Fetus (pregnancy)
Full bladder
2)Localized:
Hernias → size ↑ with cough
Masses in abdominal wall ( abscess & tumors)
Enlargement of intra-abdominal organs

15. 1)Portal vein obstruction
Collaterals (dilated veins)
1)Portal vein obstruction
2)IVC obstruction
1-Site
-Central around the umbilicus (caput medusa)
-Lateral in flanks and back
2-Direction of filling
-Away from umbilicus.
From below upwards
3-Oral glucose test
Blood glucose in abd. wall veins = cubital vein
Blood glucose in abd. wall veins > cubital vein

17. IVC obstruction

18. PALPATION

19. Ensure that your hands are warm Stand on the patient’s right side
Help to position the patient
Ask whether the patient feels any pain before you start
Begin with superficial examination
Move in a systematic manner through the abdominal quadrants
Repeat palpation deeply.
Leave the painful area for last. Move in a systematic manner through the nine regions of the abdomen in the direction of the painful area.
Make sure you use the pads of your fingers and not the finger tips as this might hurt the patient.

20. PALPATION Superficial Deep 1- Liver Tenderness 2- Spleen Regidity
Masses
1- Liver
2- Spleen
3- Kidneys
4- Gall bladder
5- Colon

21. Normally Palpable Structures

22. PALPATION OF THE LIVER
Technique of palpation:
1- Upper border
2- Lower border
3- Liver span
Comment on:
1- Size Consistency
2- Surface Tenderness
3- Edge Pulsation

23. Liver Span

24. Causes of hepatomegaly?
1)Infection:
-Viral: Viral hepatitis ,IMN, CMV
-Bacterial: Brucellosis ,T.B
-Parasitic: Bilharziasis, Malaria ,Fasciola
2)Congestion:
-Rt side ht failure
-Tricusbed valve disease
-Constrictive pericarditis
-Budd chiari syndrome
-Veno-occlusive disease

25. 3)Infiltration 6)Neoplastic: 7)Miscellaneous: - Amyloidosis - Leukemia
- Lymphoma
6)Neoplastic:
- HCC
- Metastasis
7)Miscellaneous:
-Collagen disease
-Congenital cysts

26. Causes of tender liver : 1- Infection 2- Congestion 3- Cholestasis 4- Infiltration 5- Malignancy

27. PALPATION OF THE SPLEEN
Technique of palpation
- Usual method
- Bimanual examination
- Two handed method
- Hooking method
- Dipping method

28. : Palpation: Spleen
Palpation: Spleen (correctly - position, breaths, palpating deepest full inspiration, 1 hand under L side, 1 feeling)
Palpation: Spleen (if not palpable, R lateral decubitus)
: Palpation: Spleen
Palpation: Spleen (attempts to do)
Palpation: Spleen (correctly - position, breaths, palpating deepest full inspiration, 1 hand under L side, 1 feeling)
Palpation: Spleen (if not palpable, R lateral decubitus)

29. Right lateral decubitus
PALPATION OF SPLEEN
Palpation of Spleen:
Right lateral decubitus.
Right lateral decubitus

30. Causes of spenomegaly ? 1)Infection: 1-Viral: IMN, CMV
2-Bacterial: Septecemia ,Typhoid fever ,Brucellosis T.B ,Syphilis
3-Parasitic: Bilharziasis, Malaria, Leishmania
2)Congestion: (portal hypertension)
3)Infiltration
-Amyloidosis Sarcoidosis
-Lipid storage disease -Leukemia-
-Gaucher disease Lymphoma

31. 4)Blood disease: -Anemia 2-Polycythemia -Myeloproliferative disease 5)Neoplastic: -Hemangioma -Sarcoma -Metastasis 6)Miscellaneous: -Collagen disease -SLE -Rh. artheritis

32. Grades of splenomegaly ?
- Mild:
Spleen just palpable under costal margin
- Moderate:
Spleen is palpable between costal margin and umbilicus
- Huge :
Spleen is palpable below the umbilicus

33. Causes of huge splenomegaly ?
Bilharziasis
Chronic malaria
Kala azar
Chronic myloid leukemia
Hairy cell leukemia
Myelofibrosis, myelosclerosis
B- thalasemia
Amyloidosis
Gaucher, s disease

34. Causes of tender spleen ?
1- Infection:
- Septicemia
- Infective endocardtis
- Typhoid fever
- Brucellosis
- Acute malaria
3- Infarction: (perisplenitis, splenic rub)
4- Sickle cell anaemia
5-Causes of huge splenomealy

35. PALPATION OF THE KIDNEY
Bimanual palpation
Causes of enlargement f the kidney?
1- Hydronephrosis
2- Pyonephrosis
3- Polycystic kidney
4- Tumour

36. R L 135-136: Palpation of Kidneys
Palpation:R kidney (take a deep breath, capture kidney, exhale, slowly release kidney)
Palpation:L kidney (take a deep breath, capture kidney, exhale, slowly release kidney) L
Right kidney (take a deep breath, capture kidney, exhale, slowly release kidney
Left kidney (take a deep breath, capture kidney, exhale, slowly release kidney)

37. Splenic swelling Kidney swelling
1-Notch on anterior border (pathognomoni
-No notch; reniform in shape
2-Hand cannot be insinuated ( ) swelling &costal margin
-Can be insinuated ( ) swelling & costal margin
3-Does not fill renal angle
-Fills the renal angle
4-Dull on percussion & continuous with splenic dullness
-Percussion above swelling → band of colonic resonance anteriorly
5-Moves with respiration
6-No posterior ballotment
-Posterior ballotment

38. Percussion

39. PERCUSSION Ascites Abdominal organs Minimal ascites Liver
Moderate ascites
Tense ascites
Liver
Spleen
Urinary bladder
Any palpable mass

41. Percussion: Liver span
The liver span is estimated by percussion.
Remember that it is easier to hear the change from resonance to dullness – so proceed with percussion from areas of resonance to areas of dullness.
Upper border: In the midclavicular line start percussing in the chest moving down towards the abdomen about ½ to 1 cm at a time. Note where the percussion notes change from resonate to dull.
Lower border: In the midclavicular line begin percussion below the unbillicus and proceed upward until dullness is encounter.
127: Percussion: Liver span
The liver span is estimated by percussion.
Remember that it is easier to hear the change from resonance to dullness – so proceed with percussion from areas of resonance to areas of dullness.
Upper border: In the midclavicular line start percussing in the chest moving down towards the abdomen about ½ to 1 cm at a time. Note where the percussion notes change from resonate to dull.
Lower border: In the midclavicular line begin percussion below the unbillicus and proceed upward until dullness is encounter.
The distance between the two areas where dullness is first encountered is the liver span.
Liver span is normally 6 to 12 cm in the midclavicular line.
The distance between the two areas where dullness is first encountered is the liver span.
Liver span is normally 6 to 12 cm in the midclavicular line.

42. PUDDLE SIGN
JAMA 1992;267:

43. Premature ascites: Dif: Ascites in cirrhotic patients before shrunken liver Causes:
Reversible
Not reversible
1-Hematemsis & melena
2-Severe vomiting & diarrhea
4-Intercurrent infection
5-Old anti-bilharzial
1-Malignant
2-T.B peritonitis
3-B. nephropathy

44. Ascites precox: Dif: Ascites before edema lower limb in cardiac patients Causes: 1-T.R 2-Pericardial effusion 3-Constrictive pericarditis

45. PERCUSSION OF THE SPLEEN 1- Percussion of traube’s area 2- Castell’s method 3- Nixon’s method

46. 1 2
1-Nixon's Method: Place the patient in the right lateral decubitus position. Initiate percussion half-way along the costal margin and percuss cephalad in a line perpendicular to the costal margin. Dullness of >8cm suggests splenomegaly.
2-Castell's Sign (in Traube's Space): in supine percuss in the lowest intercostal space in the left-anterior axillary line in full expiration and inspiration. Splenomegaly is suggested when the percussion is dull or becomes dull on inspiration.

47. Nixon method

48. Traubs area

49. Traub’s area: Area of tympanetic resonance over fundus of the stomach
Causes of dullness in traub’s area:
1-From above: Lt pleural eff., Pericardial eff.
2-From left : Splenomegally
3-From Right : Hepatomegally
4-From below:
-Full stomach Subpherinic abcess
-Gastric tumour Retroperitoneal neoplasm
-Ascites Complete situs inversus
-Pregnancy

50. AUSCULTATION

51. Intestinal sounds
Vascular sound
-Arterial bruit
-Venous hum
Friction rub
-Splenic rub
-Hepatic rub
Succusion splash
Minimal ascites (puddle sign)
Lower border of liver (scratching method)

52. Auscultate Bowel Sounds

53. Auscultate Vascular Sounds