Clinical Examination Dr Osama Mahmoud

I

139

Abdomen

sheet

.,

If the spleen

is not oaipable. position the patient in the right lateral

position with

flexion of left knee and h~:J

..,

Splenic

percussion sign

INe

percuss the last intercostal space anterior axillary

~ne -00"'1'ai

: s :ymoanlitic then, ask the patient to hold inspiration.

if the tympany

__ v.;""iT,

,..~c:,.. ,

= -

::f' ~'I,!en'arged

spleen

•.•p •.••...•

__ ~"""

<:'

",t-.'""

'J

•

II

IA

B

I

IKidney palpation:1

q Bimanual examination:

~ Place the left hand posteriorly

below the lower rib cage in the loin and feel the renal

angle and the right hand over the lumbar region.

,. Push the two hands together

firmly but gently as the patient breathes

out.

i" Feel the lower pole moving down between the hands as the patient

breathes

in deeply.

.

~ Push the kidney back and forwards

between the two hands this is known as

ballotting to differentiate it from the

spleen.

~ Assess the size, surface and consistency

of a palpable kidney.

~ Examine the left kidney from either

side

(see later).

I,

Place

the

examining fingers

over the

gall bladder

area and ask the

patient to

If, take

a deep

breath. Inspiration

may

be sharply arrested

with

tensing

of the

abdominal

, """"'Jisdes because

of a sudden

accentuation

of pain suggesting

acute

cholecystitis.

1)

Shifting dullness for moderate ascites.

2)

Fluid thrill

in tense ascites.

3)

Knee elbow

position in mild ascites.

4)

Puddle sign for minimal ascites.

In

patient with knee elbow position, the

examiner

places

his diaphragm over the

Knee elbow

position

most dependent

part of the abdomen

and

starts flicking

a finger over a flank, then gradually

moves the diaphragm over

the opposite

flank, a positive sign is

a sudden

increase in

intensity of the

sound just as the diaphragm

moves beyond

the edge of the peritoneal fluid.

1)l

Percussion

of spleen: (Splenic percussion

sign) see before.

it~Percussion

of liver: ~

Lower border

Light percussion.

Upper border

Heavy percussion.

Causes of reduced

Fist percussion

Place the ball of one hand in the costovertebral

hepatic dullness:

angle (for kidney tenderness) or in the right lower

Pulmonary

hyperinflation.

intercostal spaces and ribs (for liver tenderness

Shrunken

liver.

e.g amoebic liver abscess) and strike it with the

*

Air under

diaphragm.

ulnar surface of the fist of the other hand.

Percussion

of bladder: with retention

of urine (suprapubic dullness)

'*

Percussion

of any other swelling:

this is according to its site .

"I-Intestinal sounds

or borborygmi:

heard every 5 - 10 seconds)

(Gurgling

sounds

:

"".:-eased in mechanical

intestinal

obstruction, carcinoid syndrome and malabsorption.

:

':'.=~er:~Enoaralvtic

ileus.

Abdomen

sheet

4- Harsh SYstolic murmur

over the flanks in renal artery stenosis.

5- Succussion

splash:

A

splashing

sound

over

the stomach

in case

of PY.lOriC

obstruction,

to elicit a Succusion splash, place

the hands

over

the lower ribs

and

shake the patient quickly and rhythmically

from side to

side.

It is

a souno

iii!<e

shaking

a half filled water

bottle.

6- Hepatic

bruit

over hepatic

carcinoma.

7- Arterial

bruit

8· Peritoneal

friction

rub

exactly as the pleural rub, it may be

palpable,

also friction

rub may

indicate

infarcts

or tumour

of the

liver

and spleen

(heard over

the

right

upper

and left upper quadrants respectively).

9· Foetal

heart

sounds.

10Uterine

souffle.

11Puddle

sign

for

ascites.

Abdomen .hee'

ASCITES

~

R.V.F.

~

Tricuspid valve diseases T.!. T.S.

be)

~

Constrictive pericarditis (Ascites

precox)

He~atic:1

~

Cirrhosis withal! its causes.

~

Veno occlusive disease.

~

I(F) Chylous ascitis:1

1) Abdominal gases~bdomen

is resonant all over.

2) Ovarian cyst:

a- The swelling is central or to one side.

b- Resonant

flanks, no shifting

dullness.

c- Umbilicus pushed upward.

d- Upper border of the dullness

is convex.

e- Blaxland's

ovarian

sign or ruler's test:

After emptying the

bladder

a

ruler is transversely

placed above the

pelvis and

pressed

backwards

with both

hands,

you feel the

transmitted aortic

pulsation in

ovarian

cyst but not in ascites.

1- Urine for Bilharzial

ova and albuminuria.

2- Stool for Bilharzial

ova.

3- X-ray heart, chest, and echocardiography.

4- Liver function tests, kidney function tests.

5- Sa meal for esophageal

varices, pelviabdominal

sonar

6- Examination of ascites

fluid, "remember the differences between exudate and

transudate".

71- Pelvi-abdominal sonar.

8- Laparoscopy + peritoneal biopsy for malignancy

and T. B. peritonitis.

I

146

T:

1

-

-

Cecil Textbook

(Textbook of Medicine).

-

Kumar (Clinical

Medicine).

1 ~

-

Davidson's

-

HenrylThompason

(Clinical Surgery).

1 •••

Cecil

Essentials

of Medicine.

-

The National Medical Series for Independent

Study

1•••

(Medicine).

-

Macleod's

clinical

examination .

-

Hutchison's

clinical

methods.

I ••••

Chamberlain's symptoms and signs in clinical

medicine.

-

Problem - oriented medical diagnosis .

I •••

-

taking .

I ••

I ••

1-

Hepatology.

I

-

2-

Gastroenterology.

3-

Endocrinology.

4-

Rheumatology.

I -

5-

Cardiology.

6-

Nephrology.

I -

7-

Hematology.

8-

Neurology

and psychiatry.

I -

9-

Infectious

genetics, geriatric, toxicology and therapeutics.

10-

Respiratory diseases.

I -

11-

Principles

•

Cardiology

-T:

•

Abdomen

.T.

•

Chest

•

Neurology

•

General