ABDOMINAL

EXAMINATION
INGUINOSCROTAL
EXAMINATION

DR. HAZEM ZAKARIA

Contribution to Diagnosis

HISTORY
EXAMINATION
INVESTIGATION
Appendix
Caecum
Right Ovary
Small bowel
Bladder
Uterus
Small bowel
Sigmoid colon
Left ovary
Small bowel
Descending
colon
Small bowel
Aorta
Spleen
Colon
Stomach
Duodenum
Tr colon
Aorta
Pancreas
Liver
Gallbladder
Duodenum
Ascending
colon
Aorta
Small bowel
ABDOMINAL EXAMINATION
COMPLAINT
• Abdominal swelling
• Abdominal pain
• Vomiting, Heart burn
• Dyspepsia
• Haematemsis
• Bleeding per rectum
• Bowel habbit changes
• Abdominal distension
• Loss of weight,Anorexia
• Easy fatigability
• Urinary complaint
• Gynacological symptoms
Purpose of examination

• To elicit physical signs

• To aid formulation of a diagnoses

• To comfort the patient

ABDOMINAL
EXAMINATION/GENERAL

• General exam begins on first sight of

the patient

• Examine the whole patient

Abdominal
Examination/GENERAL
• General observation
– Comfort
– Position
– Colour
– Respiration
ABDOMINAL
EXAMINATION/GENERAL

• General examination:
Mental state: drowsiness,loss of conc.
Posture:Leaning forward..Pancreatic
lesion
Facies: toxic,earthy in uraemia,liver
failure
Body built: Underweight,
Cachexia,well
Vital signs,Head, eyes, Mouth,
Abdominal
Examination/GENERAL
• Head and Neck
– Eyes
• Colour of sclera
• Pallor of eyelids
– Tongue
• Hydration

– Cervical and supra-clavicular lymph

nodes
•Examine from the
patients right side
ABDOMINAL EXAMINATION
Equipment Needed
A Stethoscope

General Considerations
. The patient should have anempty bladder
The patient should be lying supine on the
.exam table and appropriately draped
The examination roommust be quiet to
perform adequate auscultation and
.percussion
ABDOMINAL EXAMINATION
.Starting the examination
All examinations start in the same way.
Firstly, the examinee introduces him or
herself to the patient, and checks that the
patient is comfortable and happy with the
procedure. The patient is thenpositioned
andexposed. The examiner should make
sure that there is the best light available
that is possible and that both the patient 
.and the examiner are comfortable
ABDOMINAL EXAMINATION
Watch the patient's face for signs of discomfort
.during the examination
Use the appropriate terminology to locate your
:findings
vertical lines,2 transverse 2
lines(subcostal,intertubercular
plane
(Right Upper Quadrant (RUQ
(Right Lower Quadrant (RLQ
(Left Upper Quadrant (LUQ
(Left Lower Quadrant (LLQ
:Midline
Epigastric
Periumbilical
INSPECTION
• Expose abdomen from nipple to knee
• Stand back: Symmetery
Abdominal movement with
respiration
• Contour: from the foot of the patient
• Subcostal angle: 90-110
widened.. Inc. Intra abdominal pressure
Rising test: Contraction of Ant. Abd.wall
muscle
INSPECTION
• Umbilicus: site, shape, impulse on cough,
discharge,sinus
Dilated veins: Caput Medusae,IVC,SVC
Pubic hair distribution
Impulse at hernial orifices
Scars of previous operation
Back : scoliosis,Kyphosis,swelling
Scrotum: mass, skin changes
Swelling : site, Intra- or Extra- abdominal
(test),size,
shape,surface,skin
overlying,pulsation,impulse
Abdominal
Examination/Palpation
Clean hands & nails
Warm hands
Kneel down
Inform patient of your plans -Ask
about pain
Begin with light palpation
Examine the quadrants in an anti-
clockwise manner starting so that a
painful quadrant is last
Use one hand for palpation & one for
positioning
Abdominal Examination/Palpation

:Avoid guarding of abdominal Muscles

Warm hand
Ask patient to flex his knees
Ask the patient to open his mouth and
breath
deeply in &out
:Technique
Start from region opposite to patient
complaint
affected region should be the last &
Abdominal Examination/Palpation
Move hand gently and steadily from one
quadrant to the next
Look at the patients face as you are
examining

Deep palpation – follow the same course as

for light palpation but with a little firmer
pressure
If a mass is palpated try to delineate it and
note its consistency surface, movements
and relations to surrounding structures
Abdominal Examination/Palpation

Examine the liver

Begin with the hand low in the
(.abdomen ( level of Rt I F
Deeply palpate with the edge of the
examining hand as the patient
inspires move towards the costal
margin with successive inspirations
Four steps should be enough
Percuss the liver to delineate the size
Abdominal Examination/Palpation

• Alternate Method
• This method is useful when the patient is
obese or when the examiner is small
compared to the patient.
• Stand by the patient's chest.
• "Hook" your fingers just below the costal
margin and press firmly.
• Ask the patient to take a deep breath.
• You may feel the edge of the liver press
against your fingers.
Other methods for liver
palpation
1-Bimanaual method:
liver edge can be more prominent
by
putting Lf. Hand under lower ribs
2-Dipping method : in tense ascites
Abdominal Examination/Palpation

Liver Span
Percussdownward from the chest in theright
midclavicular line until you detect the top edge
.of liver dullness ,(tidal percussion).. fifth space

Percussupward from the abdomen in the same

line until you detect the bottom edge of liver
.dullness
Measure the liver span between these two points.
This measurement should be 6-12 cm in a normal
.adult
Abdominal Examination/Palpation

• Palpation of the Aorta

• Press down deeply in the midline
above the umbilicus.
• The aortic pulsation is easily felt on
most individuals.
• A well defined, pulsatile mass,
greater than 3 cm across, suggests
an aortic aneurysm.
AORTIC ANEURYSM
Abdominal Examination/Palpation

Examine for the spleen

Normal: spleen not palpable (infant,2% in
adults.. Could palpate with deep
(inspiration
Spleen must enlarge 1.5 time to be palpable
Begin palpation for spleen in the RIF, move
toward the LUQ stepwise with inspiration
Six steps should be enough
Recognize the notch
Don’t be surprised if you can’t find it
Abdominal Examination/Palpation

Splenic Dullness
Percuss the lowest costal interspace in the
left anterior axillary line. This area is
.normally tympanitic
Ask the patient to take a deep breath and
percuss this area again. Dullness in this
.area is a sign of splenic enlargement
Other methods: Bimanual examination
Hooking method
Examination of the Kidneys
Normal kidney is not palpable
In suspecting renal mass.. Look for renal
angle fullness
Ballottement .. Bimanual examination
Place left hand on back below costal margin
and palpate with right hand
Murphy’s kidney punch.. Tender renal angle
with thumb
Again don’t be surprised if you can’t palpate
the kidney
Examination of abdominal
mass
• Site, Intra- or Extra- abdominal
• Temperature, tenderness
• Size, shape, surface, skin, edge
• Consistency, signs of inflammation
• Pulsation, mobility in 2 directions
Percussion
Percuss in all four quadrants using
.proper technique
A- Use the wrist
B- Use middle finger of Rt hand
opposite middle phalynx of oppsite
middle finger

Categorize what you hear as

tympanitic or dull. Tympany is
normally present over most of the
abdomen in the supine position.
Unusual dullness may be a clue to an
 PERCUSSION

• Percuss liver,spleen,kidney (renal

angle normally resonant)
• Ascites :
• Moderete(1500-3000) : shifting
dullness
• Minimal( 500-1500) : Percuss
umbilicus in knee elbow position
• Massive : Fluid thrill
Traube’s area
• Area of tympanic note in lower Lf. Part of
the front of the chest(gas of stomach).
• Boundaries:
LF. :ant. margin of spleen
RT.: inf. Border of liver
Superior: lower border of Lf. Lung
Inf. : Lf. Costal margin
Dull in : splenomegaly,hepatomegaly,pleural
effusion,huge gastric mass
 Auscultation
• Place the diaphragm of your
stethoscope lightly on the abdomen.
• Listen for bowel sounds. Are they
normal, increased, decreased, or
absent?
• Listen for bruits over the renal
arteries, iliac arteries, and aorta.
• Venous hum: below xyphoid cartilage
in portal hypertension…
engorgement of splenic vein
Abdominal sounds

• Absent bowel sounds, ileus, is a condition in

which the examiner is unable to hear any bowel
sounds after listening to each area of the
abdomen .

• Reduced bowel sounds (hypoactive) include a

reduction in the loudness, tone, or regularity of
the bowel sounds. Hypoactive bowel sounds are
normal during sleep, and also occur normally for
a short time after the use of certain medications
and after abdominal surgery.
Abdominal sounds
• Increased bowel sounds (hyperactive sounds) are
sometimes heard even without a stethoscope.
They occur at a higher pitch and greater
frequency than normal bowel sounds.
Hyperactive bowel sounds reflect an increase in
intestinal activity.

• The sudden stopping of bowel sounds, or absent

bowel sounds after a period of hyperactive bowel
sounds, are significant findings that can indicate
a potentially life-threatening crisis such as
rupture of the intestines or strangulation of the
bowel
Abdominal sounds
• Common Causes: Hyperactive, hypoactive, or
absent bowel sounds:
• mechanical bowel obstruction (caused by hernia,
tumor, adhesions, or similar conditions that can
physically block the intestines)
• paralytic ileus, a problem with the nerves to the
intestines (reduced nerve activity can result from
infection, overdistended bowel, trauma, bowel
obstruction, vascular obstruction, and chemical
imbalances such as hypokalemia)
 Abdominal sounds
• Hyperactive bowel sounds (other
causes):
• diarrhea (any cause including
emotional stress)
• Crohn’s disease
• GI bleeding
• ulcerative colitis
• food allergy
• infectious enteritis
Special Tests

• Rebound Tenderness
This is a test for peritoneal irritation.
Warn the patient what you are about to
do.
Press deeply on the abdomen with your
hand.
After a moment, quickly release pressure.
If it hurts more when you release, the
patient
 Special Tests
• Costovertebral Tenderness
CVA tenderness is often associated
with renal disease.
Warn the patient what you are
about to do.
Have the patient sit up on the exam
table.
Use the heel of your closed fist to
strike the patient firmly over the
costovertebral angles.
Compare the left and right sides.
Special Tests

• Psoas Sign
• This is a test for appendicitis.
• Place your hand above the patient's
right knee.
• Ask the patient to flex the right hip
against resistance.
• Increased abdominal pain indicates a
positive psoas sign.
 Special Tests

• Obturator Sign
• This is a test for appendicitis.
• Raise the patient's right leg with the
knee flexed.
• Rotate the leg internally at the hip.
• Increased abdominal pain indicates a
positive obturator sign.
RECTAL EXAMINATION
• THE RECTAL EXAMINATION
– Position on left side with knees drawn
right up into chest
– KY on glove
– Inspection first
– Index inserted to full length
– Comment on tenderness, prostate,
mass, blood, mucous, faeces
 HERNIA
• Swelling : increase on cough & decrease in lying down.
Usually painless
• Complication: irreducibility,obstruction,strangulation
• Exam: standing up,inspection:
Inguinal hernia, femoral hernia D.D: Pubic tubercle test
site, size, surface,shape, expansile impulase on cough, scrotum,
other swelling
Palpation: Temp., tenderness, consistency, gurgling,edge
D.D scrotal from inguinoscrotal swelling, D.D between direct
&indirect inguinal hernia (Int. ring test, Ext.ring test)
Auscultation: Intestinal sounds if content is intestine
Transillumination : a hydrocele is translucent while hernia is
not
The scrotum
• C/O : Pain, swelling, infertility, discharge
urinary troubles
Inspection: Symmetry, size of testis, absent
testis, swelling , skin (ulcers, sinuses), penis
Palpation : a. Spermatic cord
matted :filariasis, nodules : T.B, cyst: encysted
hydrocele .varicocele (bag of warm)
b. Testis : loss of testicular sensation
(malignancy,Gumma), mass
c. Transillumination