Abdominal Examination: A Comprehensive Guide
Abdominal Examination: A Comprehensive Guide
An abdominal examination is a crucial part of diagnosing and treating diseases related to the abdomen. This article will guide you through the steps involved in conducting a scientific and efficient abdominal examination.
1. History Taking:
- Reason for admission:
- History of abdominal pain (after eating, drinking alcohol, heavy labor, weather changes)
- Location of pain
- Duration of pain
- Emergency or non-emergency
- Intensity of pain
- Nature of pain (colicky, dull, radiating)
- Accompanying signs and symptoms:
- Pain from intestinal obstruction, colitis, roundworm migration into the bile duct, ureteral stones often presents with typical colicky pain.
- Pain from pancreatitis, gallstones often radiates to the back.
- Pain from inguinal hernia often radiates to the inner thigh (due to compression of the pudendal nerve).
Matching accompanying signs and symptoms with characteristics of each disease:
- Urinary tract stones: Dysuria, urinary frequency, hematuria.
- Intestinal obstruction, pancreatitis: Vomiting, constipation.
- Biliary tract infection, liver abscess, suppuration: High fever, chills.
- Appendicitis, pelvic inflammatory disease: Nausea, dizziness, fever.
- Appendicitis: Vomiting, constipation.
2. Observation of the patient:
- Complexion: Does the patient appear pale, ashen, cyanotic, flushed…?
- Skin and lips: Are there signs of jaundice, blue, pallor…?
- Breathing pattern: Is the patient breathing fast, gasping, wheezing…?
- Breath: Does the breath have a foul, fetid odor…?
- Speech: Difficulty speaking, slurred speech, stuttering…?
- Posture: Does the patient lie down, sit, stand, curl up…?
- Type of pain: Does the patient grimace, scream, gasp…?
- Demeanor: Is the patient tired, weak…?
3. Emergency management:
- Difficulty breathing: Count the respiratory rate by placing your hand on the epigastric region, watching the clock for at least 15 seconds.
- Abnormalities in pulse, BP, respiratory rate:
- Rapid, weak pulse
- Low BP
- Very fast/slow respiratory rate
- Severe abdominal pain in women, pale, ashen skin, rapid weak pulse, low BP:
- Management: Ruptured ectopic pregnancy, transfer to the operating room for further diagnosis and readiness for intervention.
- Lack of experience: Provide warmth, IV fluids, blood tests (ineffective).
4. Abdominal examination:
- Position: Patient lying on their back, legs raised to the bed to create an angle greater than 45 degrees (relaxed muscles).
- Note:
- If the patient has severe abdominal pain and cannot lie on their back (e.g., perforated peptic ulcer-duodenal perforation): Reassure and communicate with the patient, determine the presence/absence of abdominal rigidity, make a decisive diagnosis.
- Points to observe:
- Moves evenly with breathing
- Concave/distended
- Old surgical scars
- Protrusion on the abdominal wall
- Waste products: vomit, urine, stool
- Analyzing signs:
- Abdomen does not move with breathing: Indicates abdominal rigidity (the rectus abdominis muscles are visibly and constantly tense, like a person straining their abdominal muscles).
- Concave abdomen: Search for Bouveret’s sign (suspected pyloric stenosis).
- In the region above the umbilicus, see the stomach bulging and moving from left to right.
- Not visible, but pressing the palm of the hand on the abdominal wall, you can feel the stomach contracting in waves touching your hand.
- Malgaine’s line: Line connecting the iliac crest-right pubic bone.
- Protrusion on the abdominal wall:
- Above Malgaine’s line: Inguinal hernia.
- Below Malgaine’s line: Femoral hernia.
- Around the umbilicus: Umbilical hernia.
- Below the surgical scar: Incisional hernia.
5. Palpation of the abdomen:
- Procedure: Gently press the entire hand on the patient’s abdomen, press slowly, do not examine with the fingertips, examine from the non-painful to the painful area.
- Analyzing signs:
- Positive abdominal wall reflex: The abdominal muscles are tense, facial expressions of pain, antagonistic movements.
- Abdominal rigidity:
- Localized: Organ rupture but not yet ruptured into the abdomen.
- Generalized: Early signs of perforated hollow viscera.
- Positive peritoneal irritation: Peritoneum is irritated due to inflammatory fluid/blood.
- Gentle palpation of the abdomen also makes the patient uncomfortable.
- Release the hand abruptly after pressing deep, the patient will wince in pain.
6. Abdominal region division:
- Region above the umbilicus (Epigastrium): Stomach, Transverse Colon, Pancreas, Liver Lobe T.
- Region around the umbilicus: Small intestine.
- Region below the umbilicus: Bladder, uterus.
- Right hypochondriac region: Duodenum, gallbladder, liver R, kidney R.
- Right lumbar region: Ascending Colon, right ureter.
- Right iliac fossa: Appendix, cecum, adnexa.
- Left hypochondriac region: Tail of pancreas, spleen, splenic flexure, kidney L.
- Left lumbar region: Descending Colon, left ureter.
- Left iliac fossa: Sigmoid Colon, fallopian tube, ovary L.
7. Specific tender points:
- McBurney’s point: Appendicitis.
- Left parasternal point: Left lobe of the liver abscess.
- Left costovertebral point: Pancreatitis/Acute pancreatitis.
8. Special tests:
- Murphy’s sign: Cholecystitis.
- Liver percussion test: Liver abscess.
- Test to stimulate increased intestinal motility/bowel obstruction: (Borborygmi).
9. Auscultation of bowel sounds:
- Mechanical intestinal obstruction: Present, increased motility.
- Ileus: Absent motility.
10. Hernia:
- Abdominal examination cannot detect an internal hernia: Only external hernia can be detected.
- Normal hernia is not an emergency: Becomes serious when the hernia becomes strangulated causing intestinal obstruction, necrosis.
- Signs of incarcerated hernia: Hernial mass does not spontaneously ascend, patient has pain, vomiting, examination of the neck of the hernia is very painful.
- Contraindication: Absolutely do not try to push the hernial mass back up.
11. Rectal and vaginal examination:
- Required in emergency abdominal examination:
- Assess the peritoneal cavity through examination of the Pouch of Douglas
- Indirectly examine the organs: lateral wall (appendix, adnexa), anterior wall (uterus, vagina)
- Directly diagnose the cause of some diseases: intussusception, ruptured ectopic pregnancy.
- Definitive diagnosis:
- Intussusception in infants: Infant refuses to feed, arches back, cries loudly, rectal examination reveals blood stuck to the glove.
- Ruptured ectopic pregnancy: Sudden fainting, low BP, vaginal bleeding.
- Finger use:
- Rectal examination in adults: Index finger.
- Rectal examination in children: Little finger.
- Vaginal examination: Index and middle fingers.
12. Further examination:
- Auscultation of heart, lungs, examination of the spine, neck: Detect accompanying diseases that may help with diagnosis.
13. Laboratory tests:
- Blood:
- Red blood cells and Hematocrit: Increased: blood is concentrated due to dehydration/shock, Decreased: blood loss.
- White blood cells: Increased: Infection, Ruptured solid organs: liver, spleen.
- Biochemistry:
- High urea: Creatinine, blood potassium.
- High blood sugar: Urinary glucose.
- Vomiting: Electrolyte examination.
- Jaundice: Bilirubin blood test.
- Injection history: HIV, HCV, HBC.
14. Imaging:
- Abdominal ultrasound:
- Presence/absence of peritoneal fluid
- Differential diagnosis of the affected organ: dilated bile duct with/without stones, cholecystitis/gallstones, ruptured solid organs, uterus, ovaries, pancreas, kidneys
- Hollow organs: Small bowel, large bowel
- Mass: diameter of the main tumor, aneurysm of the Aorta/other arteries
- Abdominal X-ray:
- Early, small solid/hollow organs
- Detects gas, blood in the abdominal cavity, even in small quantities
- Determine the extent of the injury
15. Paracentesis:
- In case of suspected peritonitis:
- Difficult to diagnose in comatose patients due to CNS depression, suspected small bowel volvulus, women of childbearing age prone to misdiagnosis of gynecological diseases
Conclusion:
An abdominal examination is an essential skill for diagnosing and treating diseases related to the abdomen. Performing an abdominal examination scientifically and effectively helps to accurately determine the cause of the disease and recommend appropriate treatment. Always remember that examination is an ongoing process that requires a close combination of history taking, observation, clinical examination, and laboratory tests.
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