Internal Medicine (Physical Examination) Examination of the Abdomen MUDr. Yvona Pospíšilová, IHOK FN Brno a LF MU MUDr. Andrea Křivanová,Ph.D. IHOK, FN Brno Examination of the Abdomen ⚫ The lowest points of both costal margins and both anterior superior iliac spines, + midclavicular lines EPIGASTRIUM RIGHT HYPOCHONDIRUM LEFT HYPOCHONDIRUM RIGHT MESOGASTRIUM UMBILICAL AREA LEFT MESOGASTRIUM RIGHT HYPOGASTRIUM LEFT HYPOGASTRIUM SUPRAPUBIC AREA 9 areas Examination of the Abdomen ⚫ Line between the xiphoid process and the pubic symphisis + line across umbilicus LEFT UPPERRIGHT UPPER 4 QUADRANTS RIGHT LOWER LEFT LOWER Examination of the Abdomen LEFT UPPERRIGHT UPPER 4 QUADRANTS RIGHT LOWER LEFT LOWER Examination of the Abdomen - Inspection  Kachexia Examination of the Abdomen - Inspection  Icterus Examination of the Abdomen - Inspection  „Spider naevus“ (hepatic failure) Examination of the Abdomen - Inspection  Gynecomasty – failure of the liver Examination of the Abdomen - Inspection  Icterus (jaundice), foetor ex ore, dehydratation…(hepatic failure) Examination of the Abdomen - Inspection  Movements of of the abdominal wall during breathing, protrusion in some parts of abdomen, collateral venous circulation in obstruction portal system (caput medusae) etc…. Examination of the Abdomen - Inspection  Tumor of gallbladder Examination of the Abdomen - Inspection  Enlargement of the spleen Examination of the Abdomen - Inspection  Aortic artery Examination of the Abdomen - Inspection  Collateral venous circulation (hepatic failure) Examination of the Abdomen - Inspection  SCARS – scar following upper–mid- laparotomy Examination of the Abdomen - Inspection  Scars – scar following gallbladder surgery and appendectomy Examination of the Abdomen - Inspection  Fibroma – benign skin tumors Examination of the Abdomen Inspection - Percussion Examination of the Abdomen Inspection - Percussion  Examination of the Abdomen - Percussion  Pain  „Plenis´sign“ ⚫ Peritonitis (peritoneal irritation) – diffuse rigidity of the abdominal muscles Examination of the Abdomen Inspection - Percussion  Examination of the Abdomen - Percussion ⚫ Physiologically: TYMPANY ⚫ the pitch and timbre of the percussion sound change according to the presence and amount of gas, fluid or other material in the peritoneal cavity: ⚫ „DIFFERENTIAL TYMPANITIC percussion“ Examination of the Abdomen - Percussion  Vyšetření břicha poklepem ⚫ Obsah břišní dutiny  Diferencovaně bubínkový poklep – norma  Bubínkový poklep – zvýšený obsah plynu ⚫ V trávicí trubici – ileus ⚫ V dutině břišní – pneumoperitoneum (perforace trávicí trubice)  Zkrácený – přítomnost tekutiny nebo nevzdušné tkáně ⚫ Ascites – proměnlivá hranice dle polohy pac. ⚫ Velké cystycké útvary (cysta ovaria) ⚫ Tumorozní masy ⚫ Močový měchýř ASCITES URINARY BLADDER and OVARIAL CYST Examination of the Abdomen - Auscultation  Examination of the Abdomen – Auscultation  normal gut peristalsis  functional disturbances of bowel motility  silence in paralytic ileus  pulse of aorta (systolic murmur in aneurysm of the abdominal aorta) Examination of the Abdomen Inspection - Palpation  Examination of the Abdomen - Palpation  (to bend the knees slightly and relax the abdominal wall as much as possible to relieve the tension of the abdominal muscles…)  Size  Edge  Texture  Surface  Tenderness (pain) on palpation  Guarding (peritoneal irritation – diffuse rigidity of the abdominal muscles Examination of the Abdomen ⚫ LIVER ⚫ GALLBLADDER ⚫ SPLEEN ⚫ KIDNEYS LIVER Inspection Percussion Palpation (auscultation) LIVER  Enlargement of the liver - hepatomegaly LIVER  Enlargement of the liver - hepatomegaly LIVER  Percussion 6.th interspace right costal margin Resonant Tympany Dull or flatMCL NORMAL 8-12 cm LIVER  Palpation MCL Normal size of the liver LIVER  Palpation MCL hepatomegally LIVER  Palpation - enlargement 10 cm in MCL LIVER  Palpation ⚫ Edge of the liver  sharp – normal  rounded – right heart failure, hepatitis (inflammation of the liver) LIVER  Palpation ⚫ Edge of the liver  hard and bumpy – metastasis, carcinoma of the liver LIVER  Palpation ⚫ Texture  I. – soft, smooth  – normal liver tissue  II. – firmer, but still elastic  – heart failure  III. – hard, non-elastic  – liver cirrhosis  IV. - very hard, stone–hard  - cancer LIVER  Palpation ⚫ Tenderness (pain)  Non-painfull ⚫ Cirhosis of the liver ⚫ Carcinoma of the liver, metastasis to the liver  Painfull ⚫ Congestion of the liver ⚫ Inflammation - hepatitis LIVER  Palpation ⚫ Hepatojugular reflux  right heart failure GALLBLADDER MKLČ Cross-section between MCL and the right costal margin – slightly medially  Inspection ⚫ Non - visible – normal finding ⚫ Visible – hydrops  Palpation ⚫ Murphy´s sign – inflammation of the gallbladder  Palpation in the gallbladder position  Strong pain in inspirium GALLBLADDER SPLEEN ⚫ Inspection ⚫ Palpation ⚫ (auscultation) ⚫ (percussion) NORM SPLEEN  Inspection ⚫ Non-visible – normal finding ⚫ Visible - splenomegaly SPLEEN  Inspection SPLEEN  Palpation  in the supine position  in the right oblique position 15 cm in MCL KIDNEY ⚫ Palpation – Israeli ś palpation  Non- palpable – normal finding  Palpable – ptosis of the kidney, tumor, cyst, hydronephrosis ⚫ Percusssion – TAPOTTEMENT  Negative – normal finding  Positive – inflammation or hydronephrosis of the kidney ASCITES ⚫ FLUID in the cavity of abdomen ⚫ Physically can be find: 1-2 litr ASCITES ⚫ Inspection ASCITES ⚫ Inspection ASCITES ⚫ Inspection ASCITES -percussion tympany flat tympany flat tympany flat ASCITES ⚫ Percussion – we can touch the undulation (fluid wave) or transmitted shaking of the abdominal wall