PE Abdomen

©SPCABELLERA, UPCM Class 2021 INTRODUCTION Good morning/afternoon, Dr. ____. ____. I am ___, an LU3 student of UPCM and I am here for the Abdominal PE. May May I proceed?

INSPECTION I will now begin inspection of the patient. . Note: Contour  Flat, rounded, protuberant, scaphoid (markedly concave or hollowed)? Symmetry  Asymmetric or symmetric? Relation to inspiration  Any sign of respiratory distress? Presence of abdominal movements/pulsations  Peristalsis? Aortic pulsations? *Common in thin people Presence/absence of engorged veins, scars, skin lesions, discolorations, masses  The patient s abdomen appears to be (contour) and (symmetry). There are no signs of respiratory distress. There is (presence of abdominal movements/pulsations) as well as (presence/absence of engorged veins, skin lesions, masses). ASUCULTATION I will now begin auscultating the patient s abdomen. Auscultate each quadrant thoroughly. Note: Bowel sounds  Clicks/gurgles with frequency of 5-34/minute is normal Borborygmi (prolonged gurgles of hyperperistalsis; stomach growling) Bruits  Vascular sounds resembling heart murmurs; may indicate vascular occlusive disease Auscultate: R and L renal arteries, aorta, R and L iliac arteries

Magandang umaga/hapon po! Ako po si ___, ___, isang mag-aaral ng UP Kolehiyo ng Medisina. Andito po ako para suriin ang inyong tiyan.  Andito po si Dr. ___ para gabayin ang ating eksaminasyon. Gusto ko lang ipaalam na lahat ng gagawin natin ay sa atin lang po. Kung maari lang po ay tanggalin niyo po ang pantaas na damit at humiga po kayo ng nakatihaya. May bahagi po ba sa tiyan niyo na masakit ngayon? Maari niyo pong ituro sa akin?

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Friction rubs Auscultate: liver, spleen Succusion splash  Sloshing sound heard with patient ’s sudden movement; suggests presence of gas or fluid in an obstructed organ Rock patient back and forth ( side to side if supine) while auscultating all quadrants There is presence of bowel sounds at (frequency). There appears to be (presence/absence of bruits, friction rubs, succusion splash). 

Papakinggan ko na po ang inyong tiyan. Sabihin niyo po sa akin kung may masakit.

©SPCABELLERA, UPCM Class 2021 PERCUSSION I will now begin percussing the patient s abdomen. Note: Liver span (6-12cm in R MCL, 4-8cm in MSL)  Percuss below nipple line, MCL (should be resonant  lungs), percuss downwards (becomes dull  liver) mark area between resonance and dullness, then percuss downwards (becomes tympany  colon), mark area between dullness and tympany, measure with ruler ’ 

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Spleen Percuss Traube ’s space (left lower anterior chest from border of cardiac dullness at 6 th rib to AAL, then from costal margin to AAL) Prominent tympany = no splenomegaly Splenic percussion sign: percuss lowest interspace in L AAL  patient breathes deeply; percuss again  change to dullness indicates splenomegaly, (+) splenic percussion sign

Fluid wave Patient places ulnar side of hand on middle abdomen (stop s transmission of wave through fat)  tap one flank sharply with fingertips, feel on opposite flank for transmitted fluid impulse  repeat on other side (+) fluid impulse suggests ascites

Shifting dullness Patient turns to one side  percuss and mark borders, note chan ges

Tatapikin ko na po ang inyong tiyan. Sabihin niyo po sa akin kung may masakit. (If patient is female, gently displace breast to access thoracic area)

©SPCABELLERA, UPCM Class 2021 

Costovertebral angle tenderness (CVAT) Patient sits up; place fingertips onto lower border of 12 th rib and transverse processes of adjacent lumbar vertebrae on L side  tap fist once or twice onto fingertips  if pain is elicited, there is (+) CVAT of kidney  repeat on other side

The patient s liver span appears to be (measurement in cm). The patient  s spleen also appears to be (describe size, (+/-) splenic  percussion sign). The patient tested (+/-) on shifting dullness, indicating (presence/absence of as cites). The patient tested (+/-) on costovertebral angle tenderness, indicating (presence/absence of tenderness of the kidney). PALPATION I will now begin palpating the patient  s abdomen. Note: Tenderness  Direct and rebound tenderness Organs  Liver: Place L hand behind patient, II to and supporting 11 th-12th ribs and adjacent soft structures  press L hand upwards, palpate for inferior edge of liver using R hand below lower border of liver with fingers poin ting superiorly  patient breathes deeply  palpate for liver, lighten pressure, note tenderness, liver edge [soft, sharp, regular, smooth surface] ’ 

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Liver (hooking technique):  Place B hands side to side below inferior border of liver, press in with fingers and up toward costal margin  patient breathes deeply  palpate

Hahawakan ko na po ang inyong tiyan. Sabihin niyo po sa akin kung may masakit.

©SPCABELLERA, UPCM Class 2021 -

Spleen: Reach over with L hand around patient ’s lower left rib cage, press hand forward  R hand palpates below L costal margin, AAL  patient breathes deeply  palpate edge of spleen, note tenderness, contour, distance from lowest point to left costal margin  repeat with patient lying on R side with hips and knees flexed

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Retroperitoneal structures: L Kidney: Place R hand behind patient below and II t o 12 th rib at CVA  lift, displace kidney anteriorly  place L hand over LUQ  patient breathes deeply  at inspiration, press L hand firmly and deeply into LUQ below costal margin  patient breathes out, stops br eathing briefly  slowly release pressure, note size, contour, tenderness; repeat on other side with switch of hand positions for R kidney

Presence of masses and hernias Retroperitoneal structures Murphy’s sign  RUQ pain and tenderness suggest acute colecytitis Hook L thumb or fingers of R hand under costal margin at point where lateral border of rectus intersects costal margin  ask patient to breathe deeply  note breathing and degree of tenderness Rovsing’s sign  Referred rebound tenderness for acute appendicitis Press deeply and evenly in LLQ  quickly withdraw fingers Psoas sign  Suggests acute appendicitis Place hand on patient ’s R knee  patient flexes hip against resistance Alternative: patient lies on left side, passively extend R hip Obturator sign  Suggests irritated obturator internus by acute appendicitis Flex patient ’s R hip with knee flexed, then rotate hip internally The patient presents with (presence/absence of tenderness of liver). The liver appears (soft, sharp, regular, and smooth) upon  palpation. The patient also presents with (presence/abs ence of tenderness of liver). The spleen appears (contour, distance). There is ((+/-) CVAT over L/R kidney. L/R kidney appears (size, contour). There appears to be (presence/absence of masses/hernias). Patient tested (+/-) for (___sign), suggesting (presence or presence of condition). CLOSING Those are all my findings, Dr. ___. Is there anything e lse you would like me to do? Thank you, Dr. ___.  

Tapos na po ang eksaminasyon. Maraming salamat po!