|Written by Dr.Md.Redwanul Huq (Masum)|
|Sunday, 23 December 2012 14:19|
shiny nail due to pruritis,
Examination of mouth, throat & esophagus:
Lips, teeth, gums, tongue, buccal mucosa & opening of salivary glands, hard & soft palates, fauces, tonsils, pharynxand salivary glands.
Examination of Abdomen:
A: Appearance: Shape, skin condition (e.g. Scar, superficial veins, lesion, lump)
V: Visible pulsation & visible peristalsis
D: Distension (including flank).
U: Umbilicus (Position, inverted or everted, vertical or transverse, retracted or protracted)
M: Movement of abdomen with respiration
E: External genitalia & hernial orifices
A) Superficial palpation ( light palpation):-
Placing the hand over abdomen in left iliac fossa & maintaining continuous contact with patient’s abdominal wall (if there is no pain in left iliac fossa).
B) Deep palpation:-
Abdomen is palpated deeply from left iliac fossa (if there is no pain in left iliac fossa).
C) Organ palpation:
i) Palpation of Liver: For palpation of liver right hand is placed flat on the abdomen in left iliac fossa vertically or parallel to right costal margin pressing hand firmly inwards & upwards, giving pressure during inspiration and tracing edge, surface & consistency of liver.
ii) Gall bladder:Placing fingers of right hand over gall bladder area.
iii) Spleen: Palpation begins from right iliac fossa through umbilicus to left costal margin, giving left hand in back of left side of the chest. If not palpable then moving fingertips under left costal margin (Insinuation test). If still not palpable, patient is asked to turn on right side & flexing the left knee & then the same maneuver is done.
iv) Left kidney: Right hand is placed on anterior abdominal wall & left hand below posterior wall on the left side.Then pressing by right hand and thursting by left hand to palpate lower pole of left kidney.
v) Right kidney: Right hand is placed on anterior abdominal wall & left hand below posterior wall on the right side.Then pressing by right hand and thursting by left hand to palpate lower pole of right kidney.
vi) Urinary bladder: Usually not palpable, but if it is full due to retention of urine it is palpable in suprapubic region.
vii) The aorta & common femoral vessels:
1) Aorta: Palpable by deep palpation a little above & to the left of the umbilicus.
2) Common femoral vessels: below mid-inguinal point.
viii) Palpation of external genitalia & hernial orifices.
Usually the percussion note is resonant (tympanic) throughout the abdomen except over the liver, where the note is dull. Percussion is done for followings-
a) Hepatomegaly: Liver is palpable. Then upper border of liver is assessed by percussion from 3rd or 4th right inter costal space. Then the size of the liver is measured by measuring tape in cm.
b) Splenomegaly (Enlarged spleen): Spleen is percussed both below & then above the left costal margin.
c) Urinary bladder: In case of retention of urine palpable urinary bladder is reassured by percussion which is dull.
d) To identify the causes of abdominal distension either it is due to gas (e.g. intestinal obstruction) or ascites or cystic (e.g. large ovarian cyst) or solid tumors-
i) In gross ascites:
Dull in flanks
Shifting dullness positive
Fluid thrill positive
ii) In large ovarian cyst:
Resonant in flank
iii) In intestinal obstruction
Resonant throughout the abdomen.
e) Shifting dullness to detect ascites:
Patient is in supine position. Percussion is done from epigastrium to umbilicus, then from umbilicus to left side in to the flank until a dull note is obtained. The level is marked & the finger is kept in that place as the patient rolls on to the right side. Pause for at least 10 seconds. Patient is asked to roll away to left side slowly. Ascites is suggested when the note becomes resonant & confirmed by obtaining a dull note while percussing back towards the umbilicus i.e. shifting dullness is present. The process is repeated on the right side of abdomen.
f) Fluid thrill to detect free fluid in abdomen:
Patient is in supine position. One hand (detecting hand) is placed flat on the patients flank, the patient is asked to place the side of his/her hand firmly in the mid line of abdomen. Then flicking or tapping of opposite flank is done.A fluid thrill or wave is felt as a definite impulse by detection hand. Patient’s hand is placed in mid line of abdomen to dampen any possible thrill transmitted via the abdominal wall.
4) Auscultation of abdomen:
In examination of abdomen following auscultations are done-
a) Auscultation of bowel sound: In this case the stethoscope should be placed in one side of the abdominal wall (just to the right of the umbilicus is best). Auscultation of bowel sounds must be auscultated for at least 3 minutes before deciding that they are absent.
b) Auscultation of aortic bruit: In this case the stethoscope is placed lightly on the abdominal wall over the aorta, above & to the left of the umbilicus
c)Auscultation of renal bruit
d) Auscultation of hepatic bruit
e) Auscultation of hepatic/ splenic rub
f) Auscultation of uterine suffle
g) Auscultation of fetal heart sound
h) Auscultation of iliac artery in corresponding iliac fossa
i) Auscultation of common femoral arteries in each groin.
Normally palpable organs in abdomen:
1) Liver: In line & thin persons,
2) Kidney- lower pole,
3) Abdominal aorta,
5) Urinary bladder.
Abnormal characters of umbilicus:
1) Everted & transverse- in ascites,
2) Everted & vertical – in ovarian cyst.
Points to be considered during palpation of liver:
5) If liver is palpable, percussion to detect upper border of liver dullness.
6) Measurement of enlarged liver by tap from tip of right 9th costal cartilage in mid clavicular line. If enlargement in mid line or just right to the mid line it should be mentioned.
Enlarged spleen differs from enlarged left kidney by the following points:
a) Direction of the swelling
b) Getting above the swelling
c) Presence of splenic notches over enlarged spleen
d) Insinuation test
e) Percussion – (Spleen is dull on percussion)
f) Kidney- Bimanually palpable
[Spleen- ballotable- when hugely enlarged,
Kidney- dull on percussion when hugely enlarged].
Palpable gall bladder differs from enlarged right kidney by following points:-
a)Gall bladder is not bi manually palpable
b)Borders of gall bladder are rounded
c)Gall bladder moves more with respiration than kidneys
d)Gall bladder lies just beneath the anterior abdominal wall.
Palpable urinary bladder differs from gravid uterus or fibroid uterus or a ovarian cyst by following points:
a) Swelling of urinary bladder is symmetrical in suprapubic region below the umbilicus
b) It is dull on percussion
c) Pressure on it gives the patient a desire to micturate.
Firmer, moves side to side.
Usually eccentrically placed to left or right side.
Verbal description of findings of Liver:
Liver is not palpable/palpable/enlarged 1/2/3/4/5 cm from Right costal margin in Right mid-clavicular line
Upper border of liver dullness is in Right 5th inter costal space
Surface is smooth/irregular/nodular
Margin is sharp/rounded
Consistency is soft/cystic/firm/firm to head/ hard
Hepatic bruit/ rub- present/absent
Liver is pulsatile / non-pulsatile.
Examination of Hepatobiliary system (HBS):
1) Test for flapping tremor
2) Plantar reflex
3) Examination of liver & and gall bladder – Described above.