ABDOMINAL EXAMINATION DR.MRA 1. Introduce urself and greeting (How are u?) 2. screen 3.

. to patient RIGHT and check patient posture (should lying flat without/1 pillow) 4. General Inspection - at the end of the bed a) Exp : He/she is malay 55 years old gentleman/lady. Patient is lying comfortably on the bed with 2 pillow prop up. He/she appear conscious and alert with no respiratory distress. He/she appear slight overweight for people in his/her age..@ He/she appear thin as there is muscle wasting in his/her temporal/deltoid/mastication. There is multiple macula hypopigmentation on his UL and LL. There are chest tube that attach to his/her left chest and iv canular on his/her right dorsum of hand with solution of sodium chloride 0.9%. b) ABDOMEN : Hypo/hyperpigmention / peristaltic wave /body move well with respiratory / masses / swelling / dilated vein / surgical scar / abdomen distended / loss of abdomen hair / visible mass / VISIBLE during inspection

5. General Examination a) Flapping Tremor (after that lt hand put down and continue examination on the right hand) b) Nail - clubbing / colour changes / leukonychia

(hypoalbuminaemia) c) Palm warm@cold / palmar erythema / Dupthryne contracture (2 last finger bend due to the thicken of skin on the palm)/ muscle wasting d) Hand scratch mark (pruritis due to accumulation of bilirubin under the skin) / bruises / hypo@hyperpigmentation / axillary hair (loss if HIGH

estrogen due to liver failure that cannot destroy it) / spider naevi (there are central arteriole and when poke by stick it will blench) e) Eye jaundice / conjunctiva pallor f) Mouth gum bleeding (due to lack of vitamin K and other coagulant factor that secrete by liver) / angular stomatitis (Vit b12 def) /glositis / present of teeth (lack nutrient) / ulcer/ fetor hepaticus (sweet smell) g) Other confusion/ disminished mental state/ LOW/ needle track mark/ tattoo/ body piercing h) Lymph node supraclavicular LN / post triangle LN i) JVP - Position the patient on 45 comfortably and if not see the wave ask the patient to sit down. Rest tha patient head on 2 pillow to get the right angle. Ask patient to look to the left and look across the neck from the right side of patient. Look at the highest point of the JVP at the ant border of sternocleidomastoid. To confirm can do the occlusion as artery will still pulsatate if block. To make sure can use abdomino-jugular reflex. Measure it by putting the 1 rule vertical to the pulse and another ruler horinzontal at the sternal angle (> 4cm is NORM) j) Look at area around the neck if there spider naevi that prominent on shoulder and other visible sign k) Ant chest wall spider naevi / gynaecomastia

(fluctuation around the nipple using 2 fore finger which 1 press and 1 free)

6. Abdominal Examination a) Palpation Superficial : feel for tenderness (S shape from Lt side while looking at the patient)

Deep : feel for masses (ask patient to breath through the mouth) on the 4 region only (LIF, RIF, LHC, RHC)

Liver : start from RIF and continue palpating upward during inspiration. Feel for the edge of the liver by putting palm parallel to the costal margin and to confirm it with percussion. Do the liver span to measure if it is enlarge. Describe the liver if enlarge, EXP : the liver is enlarge which 17 cm with 3 cm below the costal margin. It surface SMOOTH/IRREGULAR , edge SHARP/ROUNDED, consistency SOFT / HARD, TENDERNESS, PULSATILE, audible bruit

Spleen : during the superficial palpation if there is no mass start from umbilicus. Ask patient to breath through mouth again and try feel for the edge during inspiration. Continue diagonally until reach the costal margin. If still not feel, maintain the hand and ask patient to move toward the right. That is the Traube space (between 6th rib + costal margin + ant margin). This is the space which the enlarge spleen will drop. Also can check if there is mild enlargement by percussion on 9,10,11th ICS (should be resonance). During this time, also check for spider naevi on the back and sacral oedema near the vertebra.

Kidney : during inspiration, put the hand deeper on RL @ LL region. When patient inspire, ballote from behind. See whether kidney is ballotable or not.

b) Percussion Shifting Dullness : percuss from the middle to the flank and note the changes for resonance and dullness. Percussion is done with finger horizontal

all the time. Keep finger on the dullness site and ask patient to turn to his opposite site and percuss back. If resonance, positive for shifting dullness and indicate ascites. Fluid Thrill : ask patient to put his/her hand at the centre/ on umbilicus. Flick from other side and feel on the other side. Thrill usually detect on gross ascites. c) Auscultation Only done on the RIF for 30 seconds. Hear for bowel sounds and vascular bruit Hear for renal bruit at between 9th rib tip and umbilicus d) PR Hear also for splenic bruit

7. Pitting oedema start from tibia but if there is no pitting, STOP. If there is, continue upward.

*spider naevi/palmar erythema/gynaecomastia/testicular atrophy d/t ESTROGEN *bruises d/t thrombocytopenia(hypersplenism)/reduced hepatic synthesis of coagulation factors (2,7,IX,X) / multiple falls d/t alcohol intoxication