the abdomen system

The Abdomen system

General
• Good light - a relaxed patient – full exam of abdomen from xiphoid process to symphysis pubis.
• Pt should not a full bladder.
• Have worm hand and stethoscope, and short fingernails....
• Inspection  Auscultation  Percussion  Palpation.
Inspection
• Skin:
- Scars  describe and location.
- Striae  old silver striae (after pregnancy or pt in the past is obese put now is thin).
• Dilated vein: a few and small is normally (large dilation veins  hepatic cirrhosis or inferior vena cava obstruction).
• Peristalsis: normal in thin pt and some women (increase peristalsis wave  intestinal obstruction).
• Pulsation: normal in children's (increase pulsation  HTN or aortic aneurysm).
• Rashes and lesions.
• The umbilicus: (hernia)  describe contour, location and any sign of inflammation.
• The contour and asymmetry (masses or enlarged organ).
Auscultation
• Bowel sound:
- Right lower quadrant is good area.
- Exam for 3 - 5 min for more sure.
- Normal 5 - 34 \ min.
- Increase  diarrhea or intestinal obstruction.
- Decrease  constipation.
• Pulse:
- Pulsation: 7 places (aorta, 2 renal artery, 2 iliac artery, 2 femoral artery).
- Bruits sound: like murmurs (HTN or aortic aneurysm) It found in epigatium, upper quadrant and posterior in the costovertebral angles when the pt set up.
• Fracture rubs: inflammatory of the peritoneal surface.
Percussion
• Most area it tympanic sound.
• Liver: (right side)
1. Ask the pt to take deep inspiration and stop.
2. Percuss from up to down, when the sound change from resonance (lung) to dullness (liver) sign it, then percuss from down to up, when the sound change from tympanic (gastric) to dullness sign it.
3. Make it on the midsternal (normal 4-8 cm) and on the midclavicular (normal 6-12 cm).
- Generally greater man than women.
- Gas in colon may produce tympanic in the right upper quadrant.

• Spleen: (left side)
- May be percussing posterior.
- Anterior tympanic sound, if it dullness it is abnormal (splenomegaly).
• If the sound is dullness it is abnormal (fluid or masses).
Palpation
1. Light palpation:
- Masses - enlarged organ - tender.
- Involuntary muscle spasm (peritoneal inflammation).
2. deep palpation:
- Identify any masses (location, size, shape, tenderness, pulsation and mobility).
- Tenderness (peritoneal inflammation, appendicitis, cholecystitis...)
• Pulse:
- 7 places for pulsation.
• Liver
- With left hand support from posterior and with right hand palpate anterior on the 4 cm in midclvicular line and ask the pt to take deep breath (palpate a lower border).
- Hooking technique: place both hands, side by side, on the right abdomen below the border of liver, and ask the pt to take deep breath (palpation of lower border of liver in fat pt).
• Spleen
- With left hand support from posterior and with right hand palpate anterior on below left costal margin and ask the pt to take deep breathing (feel a tip or edge of spleen).
- Note tender and contour.
• Kidney
- Kidneys usually not palpable.
- With left hand support from posterior on 12th rib and with right hand palpate anterior on below left costal margin and ask the pt to take deep breathing (to capture the kidney between both hands).
- For palpate right kidney keep pt on supine position put for left kidney move the pt to the left side.
- If the kidney palpate describe its size, contour, and tenderness.
- Note kidney tenderness: ask the pt to stand up, and put hand on costovertebral angle, and then with other hand strike it (if the pt feels tender mean complaining of kidney infection).
• Special technique
a. Ascites
- It means accumulation of fluid in the abdomen cavity.
- Dullness place of tympanic sound with percussion.
- To differential between dullness cause by fluid or fat make following technique:
1. test for shifting dullness:
a. Put the pt on the right or left side.
b. Percussion above and below the midline
- If the above tympanic and the below dullness  fluid.
- If the above and the below dullness  fat.
2. test for fluid wave:
- 2 nurses: one put both hands with midline and other nurse put hand on lateral side, and with second hand strike lateral side.
- If the nurse feel of waves  fluid
- If the nurse not feel of waves  fat
* put both hand with a midline help to stop transmission of waves by fat.
b. Appendicitis
1. Rebound tenderness: deep palpate on right lower quadrant, and then remove hand quickly.
2. Rovsing's sign: deep palpate on left lower quadrant, and then remove hand quickly.
3. Psoas sign: place hand above right pt's knee and ask the pt to flex his thigh.
4. Obturator sign: flex the pt's right thigh and rotate the leg internally.
5. Cutaneous hyperesthesia: fold of abdomen skin without pinching.
 Appendicitis pt in all last technique feels painful in the side of inflammation.