Transcript The Physical examination of abdomen

The Physical Examination of
Abdomen
2nd Affiliated Hospital
China Medical University
内科
郑长青
.
Abdominal landmarks
xiphoid process
lower margin of costal
arch
iliac antero-superior
spina
umbilicus
symphysis pubis
abdominal middle line
Abdominal regions
four quadrants system
nine regions system
seven regions system
four quadrants system
one line
extending
vertically from
the xiphoid to the
symphysis pubis,
the other line
extending
horizontally
at the level of
the umbilicus
Right upper quadrant
liver
gallbladder
pylorus
duodenum
pancreas(head)
right kidney
hepatic flexure of colon
Right lower quadrant
cecum
appendix
ascending colon
small intestine
right ovary and
tube
Left upper quadrant
liver (left lobe )
spleen
stomach
pancreas
(body tail)
left kidney
splenic flexure of colon
Left lower quadrant
sigmoid colon
descending colon
small intestine
left ovary and tube
Nine regions system
the abdomen is divided into nine
regions by four intersecting lines,
two horizontal lines—costal arch
line and iliac spina line,
two vertical lines extending
vertically across the middle point
from iliac antero-superior spina to
abdominal middle line.
Regions
right & left
hypochondrial
right & left lumber
right & left iliac
epigastric
umbilical
hypogastric
Right hypochondrial
liver gallbladder
right kidney
hepatic flexure of colon
right lumber
ascending colon jejunum
right kidney
right iliac
cecum appendix
right ovary and tube
Epigastric
liver (left lobe) pylorus
duodenum omentum
transverse colon
the head and body of pancreas
umbilical
duodenum jejunum ileum
mesentery abdominal aorta
lymph node omentum
hypogastric
bladder womb ureter
Left hypochondrial
spleen stomach
splenic flexure of colon
pancreas (tail part )
left kidney
left lumber
descending colon
jejunum ileum
left iliac
sigmoid colon
left ovary and tube
Seven quadrants system
Inspection
the contents of inspection
1. abdominal contour
2. respiratory movement
3. abdominal veins
4. peristalsis
5. abdominal skin
1. Abdominal contour
in healthy person abdomen is
usually flat from xiphoid to
symphysis pubis , we call
abdominal flat or even abdomen.
the umbilicus is located in the
abdominal center. depending on
the nutritional status, the
abdominal contour may be lightly
protuberant or scaphoid.
Abdominal bulge
generalized abdominal bulge is
usually caused by ascites
some causes for ascites:
heart failure
cirrhosis of liver
nephrotic syndrome
TB peritonitis
When the patient is in supine
position, the flanks of patient is
bulging, the shape of abdomen
is like frog we call frog
abdomen. how to measure
abdominal circumference? with
a belt ruler go around abdomen
through umbilicus to see how
long it is (cm)
the other causes of
abdominal bulge:
include the distention of the bowel
with trapped gas, such as
intestinal obstruction, massive
tumor, such as ovariogenic
cystoma, factitious abdominal
fullness with air,
pregnancy obesity
both the patients with massive
ascites and obesity have
abdominal distention, how do
we distinguish from each other,
you can observe the
appearance of the umbilicus,
umbilicus is usually deeply
inverted in obesity and everted
in long—standing ascites
located abdominal fullness
upper abdominal fullness may
result from a mass in the upper
abdominal structures, such as liver
pancreas, stomach or transverse
colon. similarly fullness in the
lower abdomen may result from
bladder distention, pregnancy or
masses from the ovaries, uterus or
colon
the mass or tumor may be on the
abdominal wall or in the
abdominal cavity, how to
differentiate, you can ask patient
to make abdominal muscles
contract, if the tumor is more
distinct the tumor is on the
abdominal wall, if the tumor is not
distinct the tumor is in the
abdomen
Abdominal retraction
anterior abdominal wall is much lower
than the level from xiphoid to
symphysis pubis,
generalized abdominal retraction
we called scaphoid abdomen, mainly
seen in sever malnutritional status,
marasmus, cachexia, acute diffusive
peritonitis due to muscle rigidity.
located retraction: mainly seen in
scar after operation.
2. Respiratory movement
the manner of breathing: in men
and children, manner of breathing
is abdominal respiration. But in
women the manner of breathing is
thoracic respiration. In some
diseases such as perforation
because acute peritonitis., the
respiratory movement is limited or
disappear.
3. Abdominal veins
in healthy person abdominal
vein can not be seen or or can
be seen a little in thin person,
but not dilated, in patient with
obstruction of the portal
venous system or in the vena
cava,You may find distended
vains.
when you find distended veins on
the abdomen you should ascertain
the direction of flow. the normal
direction of flow is away from the
umbilicus , that is the upper
abdominal veins carry blood up
ward to the superior vena cava.
And the lower abdominal veins
flow downward to the inferior
vena cava.
how to ascertain the
direction of blood flow
you can choice a segment
of vein, then the vein is
emptied between two
fingers to a distance
of a few centimeters,
then allows blood to
refill the vein from
one direction by removing
one compressing finger
4. Gastric or intestinal pattern
and peristalsis
in healthy person peristalsis is not
visible, but in patient with pyloric or
intestinal obstruction you can see
peristalsis, in pyloric obstruction on
epigastrium the peristalsis is from left
costal margin to right, in intestinal
obstruction you can see peristalsis
around umbilicus the direction of
peristalsis is irregular.
5. The skin of abdomen
(1) skin eruption
in some diseases especially
infectious disease such as
typhoid fever you can find
roseolas on the skin of
abdomen,
(2) Pigment
in normal condition, the pigment
of abdomen is more decreased
than exposed part of skin, in
patient with chronic
adrenocortical hypofunction also
called addison’ s disease,
hyperpigmentation can be found
at the belt line.
There are two special sings of
discoloration on the abdominal
skin, One is Cullen’s sign: a bluish
discoloration around the umbilicus,
another is Turner’s sign: a bluish
discoloration of the flanks. these
two signs may occur as the result
of hemoperitoneum such as
hemorrhagic pancreatitis
broken of ectopic pregnancy.
(3) Striae
silver striae distribute on the
lower quadrants of abdomen or
iliac regions, it is seen after a large
gain of weight or after pregnancy.
bluish striae (purple) distribute
on lower quadrants of abdomen
upper legs or hips this is found in
hypercortisolism.
(4) Scar
when you find a operation scar
on the patient abdomen, you
should ask some question about
the scar, when and why the
patient got the scar, the history
of operation may be helpful to
diagnosis of the disease
(5). Hernia
umbilical hernia may be seen in
belly or patient with a massive
ascites
incisional hernia operation scar
femoral hernia mainly seen in
female
inquinal hernia mainly seen in
male
(6) Hair distribution
in female the pubic hair is roughly
triangular with the base above the
symphysis. where as in male it is in
the shape of a diamond often with
hair continuing to the umbilicus,
the distribution and quantity of
hair maybe changed by chronic
liver disease and endocrine
abnormalities
(7). Epigastric pulsation
may be seen in the following
condition:
(1). thin person
(2). Right ventricular
hypertrophy COPD
(3). Abdominal aneurysm