Abdomen

Symptoms & Local

Exam
Symptoms of Digestive System:

 1- Dysphagia: difficulty in
swallowing
• Where does the food stick?
· Oral dysphagia: dry mouth, painful
condition, paresis of the tongue
· Esophageal: the food is felt to stick
in the throat or behind the sternum
• Is it worse with liquids or solids?
• Is swallowing painful ‘odynophagia’?
Symptoms of Digestive System:
 2- Pain
• Site
• Radiation
• Character
• Severity
• Duration
• Frequency & periodicity
• Aggravating factors
• Relieving factors
• Associated phenomena
Symptoms of Digestive System:

 3- Heartburn: is a burning
sensation experienced behind
the sternum. In most cases it is
due to reflux of acid into the
esophagus.
 4- Regurgitation: is rarely
preceded by nausea and is often
effortless
Symptoms of Digestive System:
 5- Vomiting
• Frequency
• Its relation to pain
• Does it relieve pain or not?
• Character of vomited matter?
· Amount
· Color: yellow color indicates bile
· Smell: foul smelling; ulcerated cancer
stomach, pyloric obst, fecal matter in
intestinal obstruction.
 Symptoms of Digestive System:

· Does it contain blood?

· Does it look like “Coffee ground”?
· Does it contain residue of food taken
the day before?
 6-Nausea: Sensation of
sickness without actual
vomiting, frequently
accompanied with salivation,
sweating, and feeling of
faintness
 Symptoms of Digestive System:

 7- Hematemesis: Vomiting of
blood
• May be bright red or coffee ground
• Ask about recent intake of aspirin,
NSAID, alcohol, hist of peptic ulcer or
chronic liver disease.
 8- Melena: passage of black,
soft, tarry stool.
Symptoms of Digestive System:

 9- Disturbance of Appetite:
• Loss of appetite (Anorexia): must be
distinguished from fear of eating
because of painful condition in the
mouth or gut.
• Excessive:
· anxiety states
· Thyrotoxicosis
· DM
Symptoms of Digestive System:
 10- Water brash: Filling of the
mouth with composed of saliva.
• It is not necessarily a symptom of
organic disease.
• May be due to reflex stimulation of
saliva from GIT lesion.
 11- Eructation “Belching”:
usually indicates air swallowing of
psychogenic origin. May occur in
organic diseases.
Symptoms of Digestive System:

 12- Dyspepsia/ Indigestion:

It is a term that usually describe a
collection of symptoms.
• Defined as pain or discomfort
centered in the upper abdomen
that may be associated with
upper abdominal fullness, early
satiety, bloating, belching, or
nausea.
Symptoms of Digestive System:

 13- Constipation
• Normal stool frequency varies
between 3 times daily to 3 times
weekly.
• What is the normal patient habit?
• Has there any recent change in
habit?
• If so, can this be explained by a
change in diet, medicine….?
Symptoms of Digestive System:
Constipation (cont’)

• Does constipation alternate with

diarrhea?
• If so, can this be explained by taking
purgatives?
• Has he any colicky pain?
• Has he had any vomiting?
• Has he passed blood?
• Has he any weight loss?
Symptoms of Digestive System:

 14- Diarrhea:
• Number
• Time of occurrence of motion
during the day.
• Their relation to meals or special
kind of food.
• Color of the motion
• Consistency: formed, watery, frothy
 Symptoms of Digestive System:
• Do they float in the lavatory or difficult to flush
away? Note: pale, bulky, soft, frothy and smelly
stool is characteristic of “Steatorrhea”
• Has he ever passed any blood?
• Does the patient use purgatives?
 15- Tenesmus: often accompanies
diarrhea and consists in straining with a
desire to empty the lower bowel without
complete evacuation taking place.
Symptoms of Digestive System:

 16-Flatulence: the patient

may complain of winds or
abdominal distension.
 17-Bleeding per rectum:
Symptoms of Digestive System:

 18- Jaundice: Yellowish

discoloration of the skin and
mucus membranes caused by the
presence in the blood of an
excess of bile pigments.
• Color of urine and stool
• Itching
• History of Contact with jaundiced
person.
Symptoms of Digestive System:
Jaundice (cont’)
• Injection ,dental procedure, tattooing, operation,
blood transfusion.
• Drug history, Alcohol intake.
• Previous dyspepsia or biliary colic
• Hist of weight loss.
• Fever and rigors: cholangitis (stone,malign). Usually
in viral hepatitis, the fever subsides with appearance of
jaundice.
 Kidney and Urinary Tract

 I- Disturbance in the Act of

Micturition.
1- Frequency (without increase in
the amount of urine): results from
irritation of the bladder or
reduction in its capacity or may
be due to polyuria.
2- Nocturia: The need to pass urine
during sleeping hours.
 Kidney and Urinary Tract
(Cont’)
3- Retention.
4- Incontinence.
5- Dysuria: pain or discomfort during the
act of micturition.
6- Urgency: sensation of constantly
needing to urinate
 II- Alteration in the Amount of
urine:
1- Polyuria
2- Oliguria and Anuria.
 Kidney and Urinary Tract
(Cont’)
 III- Alteration in the Appearance of
urine:
1- Red (Hematuria)
2- Cloudy in infection
3- Frothy
4- Dark orange in obstructive
jaundice
5- Pneumatoria: vesico-colic fistula.
 Kidney and Urinary Tract
(Cont’)
 IV- Alteration in the Force of
micturition.
• Poor stream in prostatic hypertrophy
 V- Pain
 VI- General Symptoms
1- Renal edema
2- Fever
3- Symptoms of renal failure
 Local
Examination
 Local Examination
 Inspection
 Palpation
 Percussion
 Auscultation: If you want to exam for
intestinal sound, auscultation should be done
after inspection
 Pelvic, genital, and rectal
examination are part of abdominal
evaluation.
Anatomical Consideration

 Think anatomically: imagine

what organs live in the area
you are examining.
 The abdomen is roughly
divided into 4 quadrants.
 Think Anatomically

 Another way is to divide the

abdomen into 9 areas by:
• 2 vertical lines (MCL),
• 2 horizontal lines:
· The upper at the level of 10th
costal cartilage,
· The lower at the level of the
ant. Sup. Iliac spines
 RHQ LHQ
Epigastric

R Lumbar L Lumbar
Umbilical

Hypogastric L Iliac
R Iliac
Exposure of the Abdomen
 Uncover the abdomen
from just below the
breast, to the pelvic
brim.
 Abd muscles should be
relaxed. You can ask
the pat to flex their
knees to relax abd
muscles.
 I- Inspection
 1- Shape (contour)
• Normal
• Sunken (Scaphoid): as in
starvation, malignancy.
• Distension
· Generalized: fat, fluid, flatus,
feces, fetus
· Localized: gross enlargement of
an organ, or mass.
Normal Shape of the Abdomen
Obesity
Ascites
Ascites
Localized Enlargement
 Inspection
 2- Umbilicus:
i. Shape: normally slightly
retracted and inverted.
· Everted: as in umbilical hernia
· Deeper than normal: obesity
i. Site
ii. Nodules: malignancy
iii. Pigmentation
Normal Umbilicus
 Umbilicus is
deeper than
normal

Obesity
Inspection (cont’)
 3- Movement of the Abd.
Wall
i. Movement with respiration:
absent of diminished with generalized
peritonitis.
ii. Visible pulsations
iii. Visible peristalsis:
• pyloric obst,
• intestinal obstruction .
• May be normal in elderly with thin abd
wall (no history of pain)
 Inspection (cont’)
 4- Skin:
i. Smooth and shiny in marked
distension.
ii. Striae:
· white or pink linear marks.
· Produced by gross stretching of the skin
with rupture of elastic fibers.
· Indicates recent change in the size of the
abdomen: preg, ascites, wasting diseases
· Wide purple striae are characteristic of
cushing and excessive steroid therapy
i. Scars
Striae
Scar
Inspection
4- skin (cont’)
iv. Abnormal veins: dilated, tortuous.
Check direction of flow:
• Portal hypertension: veins are centrally
placed
• IVC obstruction: on the sides of the abd.
iv. Hair distribution.
v. Pigmentation and rash.
Feminine Hair Distribution
Inspection

 5- Divarication of Recti
 6- Hernial orifices:
• Better while the patient is
standing
• Ask him to cough
• Look for expansile impulse
Divarication of Recti
Umbilical Hernia
More prominent with cough
Strangulated Umbilical Hernia
Inguinal Hernia
 II- Palpation
 1- Superficial palpation:
• Pain & Tenderness.
• Rigidity
• Superficial swelling.
 2- Deep Palpation
• Liver, Spleen, Kidney, GB
• Aorta and para-aortic glands
• The urinary bladder
• Rt & Lt lower quadrants.
• If a swelling is palpable, illicit its features
• Dipping method
 Liver
 Palpate both Rt & Lt lobes
 Lt lobe is palpated in the middle line.
 Rt lobe is palpated in the Rt MCL lateral to
the rectus muscle.
• Different methods for palpation
· Both hands side by side with fingers pointing to the ribs
· Rt hand parallel to the costal margin
· Hooking method
 Comment on:
• Size: normal, enlarged, shrunken
• Edge: sharp, rounded
• Surface: smooth, nodular
• Consistency: soft, firm, hard.
• Tenderness.
Palpation of the Liver
Palpation of the Liver
Hooking Method
 Spleen
 Start from the Rt lower quadrant moving
toward Lt costal margin while asking the pat
to take deep breath.
 Lt hand is placed over the lowermost rib
cage posterolaterally.
 If not palpable; repeat while the pat is in the
Rt lateral position.
 Try to feel the notch on the medial border.
 In contrast to kidney swelling, you can’t get
above the upper pole of the swelling.
 Comment on the size, edge (sharp),
tenderness, consistency.
Palpation of the Spleen
 Kidney
 Felt bimanually
 Lt hand is placed in the renal angle
 Rt hand is placed anteriorly in the
lumbar region.
 Ask the pat to take deep breath in,
press Lt hand forwards and Rt hand
backwards.
 The kidney is felt as a rounded firm
swelling between both hands (i.e.
bimanually palpable) and can be
pushed from one hand to the other.
Palpation of the Left Kidney
Palpation of the Right Kidney
 Urinary Bladder
 Normally not palpable.
 If there is retention of urine:
• It is felt as smooth, firm, regular, oval-shaped
swelling in the suprapubic region.
• Its upper border may reach the umbilicus.
• Its lower border can’t be felt (pelvi-abdominal
mass)
 In women, it has to be differentiated from
gravid uterus, fibroid, ovarian cyst (usually
eccentrically placed to Lt or Rt side)
 The Aorta
 May be palpated a little above
the umbilicus.
Palpation of the Aorta
 Dipping
 When there is large amount of ascites,
palpation of enlarged viscera may be
difficult.
 This method of palpation is performed
by a quick pressure of the tips of the
fingers over the region where the edge
of the organ is expected.
 Abdominal Mass
 1- make sure that it is not a
normal structure:
• pelvic colon particularly when
loaded with stool, the caecum
• The caecum: soft, rounded swelling
• Lower pole of the Rt kidney
 2-Next consider whether it could
be due to enlargement of intra-
abd organs e.g liver, spleen,
kidney, GB..
 Abdominal Mass
Comment on the following
 Site: extra or intra-abd., abd or pelvi-
abd
 Size
 Shape
 Surface, edge, consistency
 Mobility and attachment
 Is it bimanually palpable? Renal
 Is it pulsatile? Transmitted or
expansile
 III- Percussion
 1- To define the boundaries of
abd organs e.g upper and lower
border of the liver, spleen,
urinary bladder.
 2- Detection of ascites”
• Shifting dullness.
• Knee-elbow position
• Fluid thrill.
Percussion of Lower Border of the Liver
Percussion of the Upper Border of the Liver
Percussion of Urinary Bladder
Percussion of Ascites
Percussion of Ascites
 Resonant

As the pat turns to the Rt, the fluid moves down,

and the Lt loin well be resonant on percussion.
Fluid Thrill
 IV- Auscultation
 Minor role.
 Done before palpation and
percussion as touching the
abdomen may alter the abd
sounds.
 Use the warm diaphragm, and
listen for 15-20 sec.
 Examine for bowel sounds:
• Are bowel sounds present or absent?
• If present, are they frequent of sparse? Normal
frequency is variable: every 5-10 sec
• What is the quality of the sounds? Exaggerated in
intest obst.

 Succussion splash in pyloric obst

 Vascular sounds:
• Venous hum: in portal hypertension
• Systolic murmur: suggest narrowing of an
artery
 Friction Rub: peri-hepatitis, peri-splenitis.
Succussion Splash
Auscultation for Renal Artery Stenosis
Auscultation for Hepatic Rub
Auscultation for Splenic Rub
Auscultation of Intestinal Sounds