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Common client complaints ?Appetite ?Presence of dysphagia ?Food intolerance ?Abdominal pain ?Nausea ?Vomiting ?Bowel habits (any diarrhea or constipation) ?Past history of abdominal diseases

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1.General appearance 2.Inspection 3.Auscultation 4.Percussion 5.Palpation Components and techniques of abdominal assessment
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Think Anatomically: ?Abdominal Quadrant Approach: Examine the abdomen using a four-quadrant system (RUQ, RLQ, LUQ, LLQ).This suggests irritation of the peritoneum (the lining of the abdominal cavity).Abdomen- Palpation 16 Normal Findings oPalpate for rebound tenderness oNormally pain is not felt by the patient (performed at the end of the examination) Abnormal Observations oPain on release of pressure conforms rebound tenderness which indicates peritoneal inflammation that usually accompanies appendicitis.Exam of the Abdomen

Quadrants of the Abdomen

8 Topical Anatomy of the Abdomen

oRestlessness and constant turning with colicky pain (sharp, localized gastrointestinal or urinary pain that can arise abruptly, and tends to come and go in spasm like waves) oAbsolute stillness.oDecreased skin turgor

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Abnormalities on Inspection

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Obese abdomen

Hepatomegaly

Ascites

Markedly enlarged gall bladder

Umbilical Hernia

2.Abdomen- Inspection 10 Normal Findings oPeristaltic waves oAortic pulsation Abnormal Observations oMarked pulsation of aorta occurs with widened pulse pressure (hypertension, aortic aneurysm).Percussing The Kidneys

25 Normal Versus Abnormal Abdominal Percussion findings:

oLiver: Usually mostly covered by ribs; occasionally a small edge protrudes below the costal margin.Abdomen- Auscultation (Bowel sounds) 11 Normal Findings oDiaphragm of the stethoscope- Begin at the RLQ oBowel sounds are high pitched, gurgling, cascading sounds, occurring irregularly from 5 to 30 times per minute.Abnormal Observations oA systolic bruit is a pulsatile blowing sound and occurs with stenosis, partial occlusion or aneurysm of an artery.oTympany should predominate oShifting dullness Abnormal Observations oDullness- distended bladder, adipose tissue, fluid or mass oHyperresonance is present with gaseous distension.?Anatomical Awareness: Visualize the organs located within each quadrant during inspection, auscultation, palpation, and percussion.oHyperperistalsis due to hyperactive bowel sound (borborygmus) Abnormal Observations oHyperactive sounds- loud, high pitched, rushing, tinkling sounds that signal increased motility.Abdomen- Auscultation(Vascular sounds) 12 Normal Findings oNo vascular sounds or bruits over the aorta, renal arteries, ileac and femoral arteries.oNo surgical scars oNormal Skin turgor oRespiratory movements Abnormal Observations oRedness indicates localized inflammation.Abdomen- Percussion 13 Normal Findings oMove clockwise, all 4 quadrants -determine the existing tympany & dullness..Place your hands gently on the right lower quadrant at McBurney's point (located about midway between the umbilicus and the anterior superior iliac spine).Abdomen- Inspection 8 Normal Findings oUmbilicus is midline, inverted, without discolouration, inflammation or hernia.oAbout 4-20% of healthy people may have a normal bruit originating from the celiac artery, which is systolic, medium to low in pitch, heard between xiphoid process and the umbilicus.oHepatomegaly- liver palpated more than 1- 2 cm below the right costal margin oPain during inspiration- inflamed gall bladder.To minimize the risk of rupturing an inflamed appendix, don't repeat the maneuver for assessing rebound tenderness.If the individual feels sudden pain in the right lower quadrant of the abdomen, it is indicative of a positive Rovsing's sign

Rebound Tenderness:

Pain felt when pressure on the abdomen is released, not when it's applied.oKnees flexed up, facial grimacing, and rapid, uneven respirations also indicate pain.General appearance 6 Abnormal Observations

oScaphoid abdomen caves in. oProtuberant abdomen indicates abdominal distension.oMarked visible peristalsis together with a distended abdomen indicates intestinal obstruction.Abnormal Observations oLiver is displaced downwards from hyper inflated lung.?Differential Diagnosis: Knowing organ location aids in identifying normal findings and potential pathologies.TYMPANY--a clear, hollow sound similar to a drum beating--occurs when you percuss over hollow organs such as an empty stomach or bowel.Abdomen-Percussion Normal Findings oTo assess the Kidney -place one hand over the 12th rib at the costovertebral angle on the back.Don't percuss if the patient has an abdominal aortic aneurysm or a transplanted abdominal organ.Abdomen- Palpation

15 Normal Findings oPalpate for the kidneys oOccasionally, the lower pole of the Rt. kidney is felt as a round, smooth mass that slides between the fingers.oLook for symmetry

Abnormal Observations

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Common client complaints
●Appetite
●Presence of dysphagia
●Food intolerance
●Abdominal pain
●Nausea
●Vomiting
●Bowel habits (any diarrhea or constipation)
●Past history of abdominal diseases

4

1.General appearance
2.Inspection
3.Auscultation
4.Percussion
5.Palpation
Components and techniques of abdominal assessment

5

7

Think Anatomically:
●Abdominal Quadrant Approach: Examine the abdomen using a four-quadrant system (RUQ, RLQ, LUQ, LLQ).
●Anatomical Awareness: Visualize the organs located within each quadrant during inspection, auscultation, palpation, and percussion.
●Differential Diagnosis: Knowing organ location aids in identifying normal findings and potential pathologies.
Exam of the Abdomen

Quadrants of the Abdomen

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Topical Anatomy of the Abdomen

•Restlessness and constant turning with colicky pain (sharp, localized gastrointestinal or urinary pain that can arise abruptly, and tends to come and go in spasm like waves)
•Absolute stillness.
•Knees flexed up, facial grimacing, and rapid, uneven respirations also indicate pain.

1. General appearance
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   Abnormal Observations

•Scaphoid abdomen caves in.
•Protuberant abdomen indicates abdominal distension.
•Hernia- protrusion of abdominal viscera through abnormal opening in the muscle wall.
•Bulging
•Visible mass
•Asymmetric shape.
2. Abdomen- Inspection
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Normal Findings
•Normal contour/ shape is rounded or flat.
•Look for symmetry

Abnormal Observations

يجري التحميل…

2. Abdomen- Inspection
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   Normal Findings
   •Umbilicus is midline, inverted, without discolouration, inflammation or hernia.
   •Umbilicus becomes everted and pushed upward with pregnancy.

Abnormal Observations
•Everted with ascites or underlying mass.
•Deeply sunken with obesity
•Enlarged, everted with umbilical hernia.
•Bluish periumbilical colour occurs with intraperitoneal bleeding (Cullen Sign).

2. Abdomen- Inspection
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   Normal Findings
   •Smooth and even skin surface.
   •No surgical scars
   •Normal Skin turgor
   •Respiratory movements
   Abnormal Observations
   •Redness indicates localized inflammation.
   •Striae, glistening & taut skin- ascites.
   •Surgical scar -possible adhesions, & excess fibrous tissue.
   •Spider angiomas -liver disease.
   •Decreased skin turgor

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Abnormalities on Inspection

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Obese abdomen

Hepatomegaly

Ascites

Markedly enlarged gall bladder

Umbilical Hernia

2. Abdomen- Inspection
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   Normal Findings
   •Peristaltic waves
   •Aortic pulsation
   Abnormal Observations
   •Marked pulsation of aorta occurs with widened pulse pressure (hypertension, aortic aneurysm).

•Marked visible peristalsis together with a distended abdomen indicates intestinal obstruction.

3. Abdomen- Auscultation (Bowel sounds)
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   Normal Findings
   •Diaphragm of the stethoscope- Begin at the RLQ
   •Bowel sounds are high pitched, gurgling, cascading sounds, occurring irregularly from 5 to 30 times per minute.
   •Hyperperistalsis due to hyperactive bowel sound (borborygmus)
   Abnormal Observations
   •Hyperactive sounds- loud, high pitched, rushing, tinkling sounds that signal increased motility.
   •Hypoactive or absent sounds- after abdominal surgery or with peritonitis.

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Auscultate the abdomen for vascular sounds with the bell of the stethoscope. Using firm pressure, listen over the aorta, as shown, as well as over the renal, iliac, and femoral arteries.

3. Abdomen- Auscultation(Vascular sounds)
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   Normal Findings
   •No vascular sounds or bruits over the aorta, renal arteries, ileac and femoral arteries.
   •About 4-20% of healthy people may have a normal bruit originating from the celiac artery, which is systolic, medium to low in pitch, heard between xiphoid process and the umbilicus.
   Abnormal Observations
   •A systolic bruit is a pulsatile blowing sound and occurs with stenosis, partial occlusion or aneurysm of an artery.

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4. Abdomen- Percussion
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   Normal Findings
   •Move clockwise, all 4 quadrants -determine the existing tympany & dullness..
   •Tympany should predominate
   •Shifting dullness
   Abnormal Observations
   •Dullness- distended bladder, adipose tissue, fluid or mass
   •Hyperresonance is present with gaseous distension.
   •Ascites -heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, cancer.
   •Test for a fluid wave
   •The blow will generate a fluid wave through the abdomen if ascites is present.
   •A distinct tap will also be felt in the left hand (examiner).

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Drum and Humdrum!

Normally, two sounds can be heard during percussion of the abdomen: TYMPANY AND DULLNESS.

TYMPANY—a clear, hollow sound similar to a drum beating—occurs when you percuss over hollow organs such as an empty stomach or bowel. The degree of tympany depends on the amount of air present and gastric dilation.

When you percuss over solid organs, such as the liver, kidney, or feces-filled intestines, the sound changes to DULLNESS.

Abdominal Percussion

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5. Abdomen-Percussion
Normal Findings
•To assess the Kidney -place one hand over the 12th rib at the costovertebral angle on the back. Thump that hand with the ulnar edge of the other fist. The person normally does not feel pain, but feels a thud.
Abnormal Observations
•Costovertebral angle tenderness
•Sharp pain -inflammation of the kidney or paranephric area.

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STOP!
Don’t percuss if the patient has an abdominal aortic aneurysm or a transplanted abdominal organ. Doing so can precipitate a RUPTURE OR ORGAN REJECTION.

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■ Have the patient sit up.
■ Place the ball of your nondominant hand on the patient’s back at the
Costovertebral angle of the 12th rib.
■ Strike the ball of that hand with the ulnar surface of your other hand. Use just enough force to cause a painless but perceptible thud.
Percussing The Kidneys

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Normal Versus Abnormal Abdominal Percussion findings:

•Liver: Usually mostly covered by ribs; occasionally a small edge protrudes below the costal margin. Percussion reveals a dull sound.
•Spleen: Usually, resonance but dull only with splenomegaly (enlarged spleen).
•Intestines: Tympanic (drum-like) sounds due to gas; dullness possible if fluid-filled.
•Stomach: Tympanic sound in the left upper quadrant, near the sternum.
•Overall: Percussion helps determine the cause of abdominal distention.

5. Abdomen- Palpation
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   Normal Findings
   •Palpate for liver in the RUQ. its normal to feel the edge of the liver with the fingertips. It feels like a firm, regular ridge.
   •Spleen- normally not palpable.

Abnormal Observations
•Liver is displaced downwards from hyper inflated lung.
•Hepatomegaly- liver palpated more than 1- 2 cm below the right costal margin
•Pain during inspiration- inflamed gall bladder.
•Note for McBurney point tenderness.
•Enlarged spleen bumps the finger tips. Stop palpating if enlarged spleen is felt, because over palpation can lead to rupture.
•Muscle guarding, rigidity, large masses or tenderness.

Palpate for spleen
Palpate for liver

5. Abdomen- Palpation

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Normal Findings
•Palpate for the kidneys
•Occasionally, the lower pole of the Rt. kidney is felt as a round, smooth mass that slides between the fingers.
•The left kidney sits 1 cm higher than the right and is not palpable normally.

Abnormal Observations
•Enlarged kidneys and kidney masses

5. Abdomen- Palpation
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   Normal Findings
   •Palpate for rebound tenderness
   •Normally pain is not felt by the patient (performed at the end of the examination)
   Abnormal Observations
   •Pain on release of pressure conforms rebound tenderness which indicates peritoneal inflammation that usually accompanies appendicitis.
   •Rovsing's sign- pain in the RLQ when pressure is applied in the LLQ

يجري التحميل…

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Rebound Tenderness (Blumberg's sign)
● Help the patient into a supine position with his knees flexed to relax the abdominal muscles.
● Place your hands gently on the right lower quadrant at McBurney’s point (located about midway between the umbilicus and the anterior superior iliac spine).
● Slowly and deeply dip your fingers into the area; then release the pressure in a quick, smooth motion.
●Pain on release—rebound tenderness—is a positive sign. The pain may radiate to the umbilicus.

To minimize the risk of rupturing an inflamed appendix, don’t repeat the maneuver for assessing rebound tenderness.

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Rovsing’s sign
Rovsing’s sign is performed on an individual lying flat on their back, usually on an examination table. A clinician will press slowly and gently into the left lower quadrant of the individual’s abdomen, and then gradually release pressure. If the individual feels sudden pain in the right lower quadrant of the abdomen, it is indicative of a positive Rovsing’s sign

Rebound Tenderness:

Pain felt when pressure on the abdomen is released, not when it's applied. This suggests irritation of the peritoneum (the lining of the abdominal cavity). It's a general indicator of peritonitis, which can stem from various causes, including appendicitis.

Rovsing’s Sign:
Pressure is applied to the left lower quadrant of the abdomen. If this causes pain in the right lower quadrant (where the appendix is located), it's a positive Rovsing's sign. This is thought to happen because pressure on the left side pushes gas across to the right, causing distention and pain in the already inflamed appendix region.
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Is Rovsing’s sign the same as Rebound Tenderness?