Abdominal Flow 2010.Ppt_0

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ABDOMINAL FLOWABDOMINAL FLOW

Theodore A Makoske MD Theodore A Makoske MD



Anterior AnatomyAnterior Anatomy



Deep Anterior AnatomyDeep Anterior Anatomy



Pain ComplaintsPain Complaints



Posterior AnatomyPosterior Anatomy



Pain ComplaintsPain Complaints



Entering the RoomEntering the Room

INTRODUCES SELF and explains roleINTRODUCES SELF and explains role Hi. I’m Student Doctor _____. I’ll beHi. I’m Student Doctor _____. I’ll be

talking with you first today, and then Dr.talking with you first today, and then Dr. _____ will be in to see you. _____ will be in to see you.

Wash your hands, drop the paperWash your hands, drop the paper

towel in the trash, shake thetowel in the trash, shake thepatient’s hand.patient’s hand.

Ask permission to start theAsk permission to start the

examination.examination.



InspectionInspection

Properly expose the abdomenProperly expose the abdomen Stand on the right side of the supineStand on the right side of the supine

patientpatient Notice theNotice the

sheet – if sheet – if the patientthe patient

is supineis supinethey get athey get a

sheetsheet Notice theNotice the

distancedistance

below thebelow the

umbilicusumbilicus



General ContourGeneral Contour Flat, scaphoid, distended, protuberantFlat, scaphoid, distended, protuberant



Asymmetry and MassesAsymmetry and Masses



Lesions and ScarsLesions and Scars



What is your differentialWhat is your differential

diagnosis?diagnosis?

Significant weightSignificant weightlossloss

Past pregnancyPast pregnancy

Cushing'sCushing's



What is your diagnosis?What is your diagnosis?

Cholecystectomy, possibleCholecystectomy, possiblea endectoma endectom



ABDOMINAL WALL HERNIASABDOMINAL WALL HERNIAS



UmbilicusUmbilicus



Umbilical HerniasUmbilical Hernias



PiercingPiercing



Venous Pattern – caputVenous Pattern – caput

medusamedusa

•Hepatic cirrhosis

•Inferior vena cava obstruction



Rectus DiathesisRectus DiathesisHave patient flex or raise head off tableHave patient flex or raise head off table

A weakness inA weakness in

the abdominalthe abdominal

fasciafascia



Pulsations and PeristalsisPulsations and Peristalsis

AneurysmsAneurysms

Bowel ObstructionBowel Obstruction



AUSCULATIONAUSCULATION

PRIOR TOPRIOR TO

PALPATION orPALPATION or

PercussionPercussion All four quadrantsAll four quadrants Quiet in RUQ –Quiet in RUQ –

why?why?



Identify bowel soundsIdentify bowel sounds

““Normal” bowel soundsNormal” bowel sounds Clicks and gurglesClicks and gurgles Borborygmus: Rumbling of the large bowelBorborygmus: Rumbling of the large bowel

FrequencyFrequency Hypoactive: ileus, peritonitis (must auscultate for 2 minutes)Hypoactive: ileus, peritonitis (must auscultate for 2 minutes) Normoactive: 5 to 34 per minuteNormoactive: 5 to 34 per minute Hyperactive: diarrhea, early obstructionHyperactive: diarrhea, early obstruction

PathologyPathology BorborygmiBorborygmi

Absence with ileusAbsence with ileus Increase with obstructionIncrease with obstruction

High-pitched tinklingHigh-pitched tinkling Intestinal air and fluid under high pressure in a dilated bowelIntestinal air and fluid under high pressure in a dilated bowel

Rushes of high-pitched sounds concurrently with cramping:Rushes of high-pitched sounds concurrently with cramping:obstructionobstruction



Vascular AuscultationVascular Auscultation



Venous HumVenous Hum

RareRare Systolic andSystolic and

diastolicdiastolic Indicates increasedIndicates increased

collateralcollateral

circulation betweencirculation between

portal and systemicportal and systemicvenous systemsvenous systems

Hepatic cirrhosisHepatic cirrhosis



Friction RubsFriction Rubs

RareRare Grating whichGrating which

occurs withoccurs withrespirationsrespirations IndicateIndicate

inflammation of inflammation of

peritoneal surfacesperitoneal surfaces Tumors, infection, Tumors, infection,

abscess, splenicabscess, splenicinfarctinfarct



PERCUSSIONPERCUSSION

Assess resonanceAssess resonance Dullness: increasedDullness: increased

with mass,with mass,

organomegalyorganomegaly Tympanic: Tympanic:

predominates,predominates,gastric bubblegastric bubble

Hyperresonant:Hyperresonant:obstructionobstruction

Liver spanLiver span Bladder heightBladder height



PALPATIONPALPATION

Use distractionUse distraction Watch facial expression forWatch facial expression for

grimacegrimace

Flex hips and knees if Flex hips and knees if abdomen is tenseabdomen is tense

Light palpation (think skinLight palpation (think skinand sub Q tissues)and sub Q tissues) One hand using fingerOne hand using finger

padspads Tenderness, masses Tenderness, masses

Deep palpation (thinkDeep palpation (thinkabdominal organs)abdominal organs) Two hands, one on top Two hands, one on top

the otherthe other



Deep PalpationDeep Palpation

Tenderness Tenderness MassesMasses Hepatomegaly/massesHepatomegaly/masses

Begin in the RLQ and workBegin in the RLQ and workcephalad to the rightcephalad to the rightcostal margincostal margin

Use rolling hand techniqueUse rolling hand technique KidneyKidney

Uterine height – only inUterine height – only inpregnant patientspregnant patients Bladder distensionBladder distension Size of the aortaSize of the aorta



Uterine HeightUterine Height

Normally onlyNormally onlypalpable onpalpable onabdominal exam inabdominal exam inpregnant womenpregnant women

Distance above theDistance above thepubic symphasis ispubic symphasis isrelated torelated togestational agegestational age

This will be This will becovered in depth incovered in depth inOb/GynOb/Gyn



SplenomegalySplenomegaly

Begin at theBegin at theumbilicus and workumbilicus and workdiagonally to thediagonally to theleft costal marginleft costal margin

May use posteriorMay use posteriorliftlift

Normal spleen isNormal spleen isnot palpable innot palpable inmost patientsmost patients



Kidney PalpationKidney PalpationHave patient take deep breathHave patient take deep breath

Attempt to “catch” the kidneyAttempt to “catch” the kidney



Palpation of thePalpation of the

AortaAorta



Clinical ScenariosClinical Scenarios

Acute abdomenAcute abdomen GuardingGuarding

RigidityRigidity ReboundRebound

Ask patient which hurts moreAsk patient which hurts more

Pushing in: push in slowly but deeply ORPushing in: push in slowly but deeply OR

Letting go: suddenly lift hand from depressedLetting go: suddenly lift hand from depressedpositionposition

Should be a significant differenceShould be a significant difference



AsciticsAscitics

Fluid WaveFluid Wave Patient is supinePatient is supine

Place lateral handsPlace lateral handsdown the abdomendown the abdomencentrally (inhibitscentrally (inhibitstransmissiontransmissionthrough adipose)through adipose)

Tap one side and Tap one side andfeel forfeel for

transmission intransmission inopposite handopposite hand



Shifting Dullness toShifting Dullness to

PercussionPercussion

Seen with ascitesSeen with ascites Not present withNot present with

obesity orobesity or

pregnancypregnancy



CholecystitisCholecystitis

Murphy SignMurphy Sign Push up under the rightPush up under the right

costal margin until youcostal margin until you

just elicit pain just elicit pain Have patient take in aHave patient take in a

deep breath – liverdeep breath – livermoves downmoves down

Positive sign = patientPositive sign = patient

suddenly halting thesuddenly halting thedeep breath as thedeep breath as theinflamed gallbladderinflamed gallbladderpresses against thepresses against thefingersfingers



AppendicitisAppendicitis

Rovsing’s signRovsing’s sign Press/push sharply on the left lower quadrantPress/push sharply on the left lower quadrant Assess for pain in the right lower quadrantAssess for pain in the right lower quadrant

Psoas SignPsoas Sign Have patient push up right leg againstHave patient push up right leg against

resistance -resistance - oror Turn patient on left side, Extend right leg at Turn patient on left side, Extend right leg at

the hipthe hip Obturator signObturator sign

With patient supine, flex right leg at the hipWith patient supine, flex right leg at the hipwith knee bentwith knee bent

Rotate leg internally at the hipRotate leg internally at the hip



Nephrolithiasis,Nephrolithiasis,

hydronephrosis, pyelonephritishydronephrosis, pyelonephritis CVA tendernessCVA tenderness

(Lloyd’s Punch)(Lloyd’s Punch) Palpate the area firstPalpate the area first

May elicit tendernessMay elicit tenderness Place hand over thePlace hand over the

costovertebral anglecostovertebral angle

Strike your hand, notStrike your hand, notthe patientthe patient

Pain suggestsPain suggestsinflammationinflammation

The abdominal exam The abdominal exam

is not complete untilis not complete until

you thump theyou thump the



Digital Rectal ExaminationDigital Rectal Examination

NOT done on Standardized PatientsNOT done on Standardized Patients

or fellow studentsor fellow students

Will be covered in SPECWill be covered in SPEC You should ALWAYS think of this as You should ALWAYS think of this as

part of a complete physicalpart of a complete physical

examinationexamination



When you areWhen you are

finished:finished:1.1. Ask if there are anyAsk if there are any

questionsquestions2.2. THANK THE PATIENT! THANK THE PATIENT!

Abdominal Flow 2010.Ppt_0

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