Dr.

Suhaemi, SpPD, Finasim

70% of diagnoses can be made based on history alone. 90% of diagnoses can be made based on history and physical exam. Expensive tests often confirm what is found during the history and physical.

Elegant appearance Decent manner Kind attitude Highly responsibility Good medical morals

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7.

The patient should have an empty bladder. The patient should be lying supine on the exam table and appropriately draped. The examination room must be quiet to perform adequate auscultation and percussion. Watch the patient's face for signs of discomfort during the examination. Use the appropriate terminology to locate your findings Disorders in the chest will often manifest with abdominal symptoms. It is always wise to examine the chest when evaluating an abdominal complaint. Consider the inguinal/rectal examination in males. Consider the pelvic/rectal examination in females.

EXAM SECTIONS 1. Inspection 2. Auscultation 3. Percussion 4. Palpation

Have the patient empty their bladder before examination Have the patient lie in a comfortable, flat, supine position Have them keep their arms at their sides or folded on the chest

When looking, listening, feeling and percussing imagine what organs live in the area that you are examining.

Physicians locate findings in the abdomen in one of four quadrants or one of nine regions. The four quadrants are: right upper (RUQ), right lower (RLQ), left upper (LUQ) and left lower (LLQ). THE NINE REGIONS epigastric, umbilical, hypogastric/suprapubic, right hypochondriac, left hypochondriac, right lumbar, left lumbar, right inguinal and left inguinal.

The schematic below is a reminder of what organs are likely to produce findings in each region. For example:
Right hypochondriac (RUQ) : liver and gall

bladder left hypochondriac (LUQ) : the spleen and stomach epigastric : the pancreas, stomach and common bile duct umbilical : the small intestine lumbar : the kidneys iliac regions : the ovaries left iliac/LLQ : the sigmoid colon right iliac or lumbar (RLQ): the cecum and appendix suprapubic : the bladder and uterus

SOME COMMON FINDINGS on ABDOMINAL INSPECTION

Scars : Jaringan parut Striae (stretch marks) : tanda peregangan ibu hamil Colors : - Bluish color at the umbilicus is Cullen's sign a sign
of bleeding in the peritoneum. - Bruises on the flanks are Grey Turner's sign (retroperitoneal bleeding - e.g. from inflamed pancreas)

Jaundice : warna kuning pada kulit Prominent veins : may be due to portal vein obstruction

or inferior vena cava obstruction

Distension of the lower abdomen only can be caused by pregnancy, full bladder, ovarian tumor, or uterine fibroids (common benign growths) Diffuse abdominal distension can be caused by any of the 6 Fs:
Fat (obesity) Fluid (ascites - peritoneal fluid - or obstructed viscera filled

with fluid) Flatus (air) - e.g. from air swallowing or intestinal obstruction Feces (constipation Fetus (pregnancy) Fatal cancer.

GUT SOUNDS

Use the diaphragm of your stethoscope to listen to gut sounds Normal gut sounds are gurgling, 5 to 35 per minute Borborygmi are loud, easily audible sounds. They are normal, too. High pitched , tinkling (raindrops in a barrel) sounds are a sign of early intestinal obstruction Decreased sounds: (none for a minute) are a sign of decreased gut activity. Gut sounds may be markedly decreased after abdominal surgery; abdominal infection (peritonitis) or injury. Absent Sounds : (no sounds for 5 minutes) are a bad sign. They can be caused by longer-lasting intestinal obstruction, intestinal perforation or intestinal (mesenteric) ischemia or infarction

1.Diaphragm of stethoscope used 2.Skin depressed to approximately 1 cm

What it finds: liver size (kind of), spleen, fluid. Percussing the body gives one of three notes: Tympany is found in most of the abdomen, caused by air in the gut. It has a higher pitch than the lung. Resonance is found in normal lung. It is lower pitched and hollow. Dullness is a flat sound, without echoes. The liver and spleen, and fluid in the peritoneum (ascites: ahSY-teez), give a dull note.

Middle finger of striking hand (plexor) should knock the pleximeter firmly, with a strong note

A. Liver Span Percuss downward from the chest in the right midclavicular line until you detect the top edge of liver dullness. Percuss upward from the abdomen in the same line until you detect the bottom edge of liver dullness. Measure the liver span between these two points. This measurement should be 6-12 cm in a normal adult. B. Splenic Dullness Percuss the lowest costal interspace in the left anterior axillary line. This area is normally tympanitic. Ask the patient to take a deep breath and percuss this area again. Dullness in this area is a sign of splenic enlargement.

Shifting Dullness This is a test for peritoneal fluid (ascites). ++ Percuss the patient's abdomen to outline areas of dullness and tympany. Have the patient roll away from you. Percuss and again outline areas of dullness and tympany. If the dullness has shifted to areas of prior tympany, the patient may have excess peritoneal fluid. Psoas Sign This is a test for appendicitis. ++ Place your hand above the patient's right knee. Ask the patient to flex the right hip against resistance. Increased abdominal pain indicates a positive psoas sign. Obturator Sign This is a test for appendicitis. ++ Raise the patient's right leg with the knee flexed. Rotate the leg internally at the hip. Increased abdominal pain indicates a positive obturator sign.

General Palpation 1. Begin with light palpation. At this point you are mostly looking for areas of tenderness. The most sensitive indicator of tenderness is the patient's facial expression (so watch the patient's face, not your hands). Voluntary or involuntary guarding may also be present. 2. Proceed to deep palpation after surveying the abdomen lightly. Try to identify abdominal masses or areas of deep tenderness

Standard Method Place your fingers just below the right costal margin and press firmly. Ask the patient to take a deep breath. You may feel the edge of the liver press against your fingers. Or it may slide under your hand as the patient exhales. A normal liver is not tender. Alternate Method This method is useful when the patient is obese or when the examiner is small compared to the patient. Stand by the patient's chest. "Hook" your fingers just below the costal margin and press firmly. Ask the patient to take a deep breath. You may feel the edge of the liver press against your fingers.

Place left hand posteriorly just below the right 12th rib. Lift upwards. Palpate deeply with right hand on anterior abdominal wall.

Patient take a deep breath. Feel lower pole of kidney and try to capture it between your hands.

Right kidney may be felt to slip between hands during exhalation

Use the heel of your closed fist to strike the patient firmly over the costovertebral angles. Compare the left and right sides.

Warn the patient Patient sit up on the exam table

DIAGNOSIS: SITES OF REFERRED PAIN Site Right subscapular or shoulder Organ(s) Diaphragm, gallbladder, liver Common examples Biliary colic, perforated ulcer, pneumoperitoneum

Left subscapular or shoulder

Back Coccyx Groin or genitalia

Diaphragm, spleen, stomach, tail of pancreas, splenic flexure

Pancreas, duodenum, aorta Uterus, rectum Kidney, ureter, iliac arteries

Splenic rupture, pancreatitis

Pancreatitis, ruptured AAA Uterine colic Ureterolithiasis

AAA, abdominal aortic aneurysm.

PERIUMBILICAL Small intestinal obstruction Appendicitis Pancreatitis Mesenteric ischemia

DIAGNOSIS: TYPICAL SEQUENCE OF SYMPTOMS AND SIGNS OF ACUTE APPENDICITIS Periumbilical painvague, visceral, poorly localized Anorexia, nausea, and/or vomiting Right lower quadrant pain and tenderness localized Fever Leukocytosis

DIANOSIS: SIGNS ON PHYSICAL EXAMINATION SUGGESTIVE OF ACUTE APPENDICITIS Sign What it indicates Description Increased pain with coughing or other movement Lower left quadrant palpation induces right lower quadrant pain Pain on internal rotation of the right hip Dunp Inflammation involving the partial hy peritoneum Rovs ing Obtu rator Localized peritoneal inflammation in the right lower quadrant Pelvic appendicitis

Iliops Retrocecal appendicitis oas

Pain on extension of right hip

Localized tenderness Just below midpoint of line between right anterior iliac crest and umbilicus. Heel strike, riding over bumps in road while driving, coughing, will produce pain.

Patient will experience right lower quadrant pain (in region of McBurneys Point) when left lower quadrant is palpated.

Patient can lay on side and extend leg at the hip or have patient lay on back and try to flex hip against the resistance of examiners hand on thigh. If patient has an inflamed retrocecal appendix, this will produce pain.

Internally rotate right leg at the hip with the knee at 90 degrees of flexion. Will produce pain if inflamed appendix is in pelvis.

Warn the patient what you are about to do. Press deeply on the abdomen with your hand. After a moment, quickly release pressure. If it hurts more when you release, the patient has rebound tenderness. [4]

Examiners hand is at middle inferior border of liver. Patient is asked to take deep inspiration. If positive patient will experience pain and will stop short of full inspiration

Hepatitis, subdiaphragmatic abscess Cholecystitis

Localized enlargement probably distend GB space occupying lesion, hepatomegaly.

Outward flow pattern from umbilicus in all directions ? Portal HTN

Ecchymosis periumbilically. (intraperitoneal hemorrhage ruptured ectopic pregnancy, hemorrhagic pancreatitis..)

 Ecchymosis of

flanks. (retroperitoneal hemorrhage such as hemorrhagic pancreatitis)

Processes which lead to intestinal obstruction initially cause frequent bowel sounds, referred to as "rushes."

Rushes" means as the intestines trying to force their contents through a tight opening.

Epigastric/umbilical area. Soft humming noises in systolic/diastolic component. Indicates collateral between portal and venous systems as in hepatic cirrhosis.

Place left hand posteriorly just below the right 12th rib. Lift upwards. Palpate deeply with right hand on anterior abdominal wall.

Patient rolled slightly toward the examined side; movement of the dull point medially is described as shifting dullness and suggests ascites

Shifting Dullness