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 AMC Clinical exam-recalls

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Points : 42144
Join date : 2013-12-26

PostSubject: AMC Clinical exam-recalls   Thu Dec 26, 2013 11:25 pm

You are a resident in a suburban hospital. The surgical registrar asks you to talk to a group of medical students about how to examine the abdominal system in a patient who presents with acute abdominal pains to the emergency department.

YOUR TASK IS TO: explain the principles of the abdominal system examination to a medical student.



Assess and manage Airway, Breathing and Circulation as a priority!!!

First you have to explain to the patient what you are going to do!
The patient should flat and in a comfortable position with a small pillow under the head, hands by their side and with the abdomen exposed from “nipples to knees” (allowing for “privacy”) and the examiner usually stands on the right side of the patient. The examiner should sit or kneel next to the patient.
The examination follows the usual concept of:
It is important to remember what organs live in the area that you are examining. The abdomen is roughly divided into four quadrants: right upper, right lower, left upper and left lower. By thinking in anatomic terms, you will remind yourself of what resides in a particular quadrant and therefore what might be identifiable during both normal and pathologic states. 
Quadrants of the Abdomen
Topical Anatomy of the Abdomen

Other landmarks are the right hypochondrium, the epigastrium, the left hypochondrium, the right lumbar region , the umbilical region, the left lumbar region, the right iliac fossa, the hypogastrium and the left iliac fossa.

• Does the patient look ill, in pain, septic or shocked? (facial expression like pain, discomfort, pallor, dehydration, foetor)
• Are they lying still (think peritonitis), or rolling around in agony (think intestinal, biliary or renal colic)?
• In an emergency department setting: if there are signs that the patient is shocked or acutely unwell, assess quickly but carefully and arrange any early investigations.
• In a community setting: make arrangements for rapid transfer to hospital for further assessment.

Specific points:
1. Respiratory movements
2. Masses (abdominal or pelvic organs)
3. Scars
4. Distension (obesity, fluid/ascites, faeces, flatus/gas, tumour)
5. Hernias
6. Prominent veins
7. Visible pulsations (e.g. AAA)
8. Visible peristalsis ( e.g. pyloric obstruction)
9. Striae
10. Symmetrical movement on in- and expiration

Requires a relaxed patient and warm hands of the examiner! Starting the examination away from the painful or tender area!!!
• LIGHT PALPATION: for tenderness, any lumps or guarding/rigidity (resistance to palpation/involuntary contraction of abdominal muscels) 
• DEEP PALPATION: using the flat hand to detect deeper masses and to define any already identified on superficial palpation! Rebound tenderness
• Identify organs like liver and hepatomegaly, including the nature of the edge of the liver (hard/soft, tender/non tender, regular/irregular, pulsatile/non pulsatile).
• Gallbladder: MURPHY’s sign: on deep breathing the patient experiences a sharp pain, “catches her/his breath” and winces when the examiner presses the hand against the gallbladder. 
• Normally, the spleen can not be felt in the left upper quadrant with the patient rolled towards the examiner on tow-handed examination.
• The kidneys are in the right and left subcostal areas, best examined with bimanual examination (“ballotting”) or with gentle pounding of the costo-vertabral angles!
• Other abdominal masses like AAA, tumours, bladder, ovarian pathology, abscesses, pancreatic cysts etc.
• Inguinal region for lymphgland enlargement and hernias
• Testes and scrotum.
• Testing for ascites and fluid waves.
• Rectal examination

1. Tympanitic (drum-like) sounds produced by percussing over air filled structures. 
2. Dull sounds that occur when a solid structure (e.g. liver/spleen/kidney,bladder) or fluid (e.g. ascites with shifting dullness) lies beneath the region being examined. 
3. Elicits tenderness in patients with peritonitis!

AUSCULTATION: listen in all four quadrants for:
• BOWEL SOUNDS: present/absent, normal (low pitched) or high pitched or “tinkling” (obstruction), frequent or sparse, loud gurgling or ‘borborygmi’.
• BRUITS: usually in pathology over renal arteries or lower abdominal aorta.
• VENOUS HUMS: a continuous low-pitched soft murmur, becoming louder on inspiration around umbilicus and xiphisternum in portal hypertension.

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