CLINICAL DIAGNOSIS B PHYSICAL DIAGNOSIS LECTURE – ABDOMEN (INSPECTION)

Far Eastern University – Nicanor Reyes Medical Foundation - umbilicus is inverted/sunken

CD B PD LEC: ABDOMEN - INSPECTION GAS - tympanitic
Dr. Cham, MD - intestinal obstruction & adynamic
(paralytic) ileus
GENERAL APPROACH - marked dilatation in colonic > Small
- Adequate light Intestine obstruction
- Relaxed patient: gentleness and assurance TUMOR - dull on percussion
- Full exposure of abdomen: above xiphoid process to - palpate the attributes
symphysis pubis - air-filled bowel displaced to the
- Must not have full bladder peritoneum
- 1 pillow on head and under the knee - eg. myoma, hydrops, ovarian tumor
- hands on sides or folded across chest PREGNANCY - dull on uterus
- warm hands, stethoscope and short nails. (see picture)
ASCITES - lowest portion of abdomen
2 TOPOGRPAHIC SYSTEM
- 9 quadrants: regions are small
and structures occupy >1
region
- 4 quadrants: preferred by
most

Example of Protuberant Abdomen

Example of Pregnancy 

B. SCARS
STRIAE
- multiple 1-6 cm long
- Run axially under epidermis
- pink or blue  silvery
- chronic stretching skin  rupture of elastic fibers in reticular
layer
- abdomen, thigh, shoulder, breast
- eg: pregnancy, obesity, ascites
SEQUENCE OF EXAMINATION OF ABDOMEN
- Inspection *
- Auscultation
- Percussion
- Palpation *
- Assessment of the liver, spleen & kidneys
- (+/-) rectal exam

PHYSICAL DIAGNOSIS OF THE ABDOMEN Example of Striae Gravidarum (seen in pregnancy)

INSPECTION
A. CONTOUR SURGICAL SCARS
- Flat - red → pink → fade to skin color in 6 mos.
- Rounded - Wound healing by 1st intention
- Scaphoid o produce thin scars
- Protuberant o (-) infection
FAT - most common - Healing by 2nd intention
- Obesity o irritation by drains or infection
- abdominal wall is thick - Keloid
o hyperplastic fibrous Tissue → dense and exuberant

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 CLINICAL DIAGNOSIS B PHYSICAL DIAGNOSIS LECTURE – ABDOMEN (INSPECTION)
o Small Intestine & Large Intestine obstruction
o thin persons

Borborygmi
- intestinal rumbling, stomach growling, prolonged gurgles of
hyperperistalsis
- intestinal rumbling w/o stethoscope + pain → intestinal
obstruction
Example of Keloid Scar - intestinal rumbling w/o stethoscope + without pain → hungry
C. ENGORGED VEINS
- scarcely visible E. PULSATIONS
- if visible may indicate SP >/= 120 mmHg - normal abdominal aorta causes slight pulsation in the
- CLINICAL OCCURENCE epigastric
o above the umbilicus → ↑blood flow - amplification ↑ in widened pulse, tortuous aorta or aneurysm
o below the umbilicus→ ↓blood flow - Clinical Occurrence
o IVC obstruction = flow is ↑ from lower abdomen o Widened pulse pressure  arterial hypertension
o Portal obstruction = upper abdomen has Normal o Aortic aneurysm (especially in elderly > 65 years old)
upward flow o Thyrotoxicosis
o SVC obstruction = ↑ flow in upper abdomen o Tortuous aorta
o Solid mass overlying the aorta
o AR

F. UMBILICUS
- Flat
- Everted: without hernia, a sign of ↑intra-abdominal Pressure
(tumor, ascites, pregnancy)
- Inverted: more deeply inverted in obese
- Clinical Occurrence
Example of Superficial Veins o Umbilical fistula – (+/-) abnormal discharge
▪ urine = patent urachus
▪ pus = urachal cyst or intraabdominal abscess
▪ feces = connection for the colon
o Umbilical calculus
▪ hard mass of dirt
o Nodular umbilicus (Sis Mary Joseph)
▪ abdominal CA especially gastric CA
with metastasis to the navel
Example of Caput Medussae o Bluish umbilicus (Cullen’s sign)
Caput Medussae ▪ bluish discoloration of navel due to
- Dilated subq Veins retroperitoneal hemorrhage
- Severe portal hypertension due to liver cirrhosis
- Massive ascites and umbilicus not seen

Spider Angiomas
- Dilated Arteriole

D. PERISTALSIS
- slow undulations under skin
- light source from feet to head or across the abdomen
- examiner sits at the R side of patient, head slightly higher > Sis Mary Joseph Cullen’s Sign
abdomen
- seen in thin abdominal wall G.ECCHYMOSES
- Clinical occurrence of peristalsis: - Grey Turner’s Sign
o pyloric obstruction o on abdomen and flanks

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 CLINICAL DIAGNOSIS B PHYSICAL DIAGNOSIS LECTURE – ABDOMEN (INSPECTION)
o discoloration due to ecchymosis in lower abdomen and o Palpation and percussion will also possibly alter
flanks observations made in inspection and auscultation
o due to infiltration extra peritoneal T with blood - 6Fs
→ retroperitoneal bleeding o Fats
- Clinical Occurrences: o Fluids
o hemorrhagic pancreatitis o Fetus
o strangulated bowels o Feces
o hemorrhages from abscesses o Flatus
o Myocardial infarction in myxedema o Fatal growths

- Fats:
o Obesity: navel is inverted
- Fluids:
o Ascites (abdominal dropsy): navel is everted
o Bulging flanks: (+) fluid wave
o Shifting dullness: pathognomonic
o Puddle sign: detect 120 ml fluid
Grey Turner’s Sign - Fetus
H. JAUNDICE o Pregnancy: missed period, Breasts engorged, (+) fetus
- staining of body T & fluids by bile pigments - Feces:
- conjugated & unconjugated bilirubin o large amount of feces (megacolon)  distention
- most intense on the face, trunk & sclera
- 1st seen in frenulum
- conjugated bilirubin (B2) is 2-4 mg%
- Intrinsic or Acquired Disease cause
- Causes of Jaundice:
o RBC abnormality  hemolysis
▪ Intrinsic: G6PD deficiency, sickle cell anemia
▪ Extrinsic or acquired: methyldopa, leukemia,
ABO-Rh incompatibility
o Hepatic Disorder Obesity Ascites Pregnancy
▪ Intrinsic: Gilbert’s, Crigler-Najjar syndrome
▪ Extrinsic: viral hepatitis, drugs - Flatus
o Biliary obstruction o Tympanitic (meteorism)
▪ Stones ▪ ↑ gas in stomach & intestine
▪ CA ▪ abdominal distention + tympanitic
▪ Strictures o Mechanical (local) obstruction= high or low
▪ hyperactive Bowel Sounds/ borborygmi
▪ colicky pain
▪ high obstruction
• vomitus is bile stained
• distal to 2nd portion of duo
▪ low obstruction
• fecal vomitus
• colonic obstruction
o Non-mechanical (diffuse) ileus
▪ hypoactive Bowel Sounds or absent Bowel Sounds

Jaundice Clinical Occurrences of Mechanical Obstruction

- Intraluminal: FB, Ca, Gall Bladder stones, bezoars, worms
I. DISTENDED ABDOMEN - Visceral compression: adhesions, stenosis, hernia, volvulus,
- observe first by Inspection intussusception
o palpation and percussion usually brings out the
attributes of each conditions

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 CLINICAL DIAGNOSIS B PHYSICAL DIAGNOSIS LECTURE – ABDOMEN (INSPECTION)
Clinical Occurrences of ileus:
- Surgical or trauma: post-op
- Chemicals: HCl, gastric contents from perforated stomach
or duodenum
- Metabolic: hypokalemia, DKA
- Mechanical: adhesions, tumors, megacolon

J. ABDOMINAL HERNIA
- Protrusion due to weak point in abdominal wall
- Reducible: contents in the sac replaced
- Irreducible/incarcerated: cannot be pushed back
- Strangulated: blood supply interrupted →gangrene
o bowels firm but not tender
o don’t use force →rupture

Post-surgical Hernia Incisional Hernia

Notes from Lecture PPT, MRA trans

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