Thus, in cases of prior surgery or infection with resultant adhesion formation, this may not be a very useful technique. Palpation can also be used to check for ascites see below. First warm your hands by rubbing them together before placing them on the patient.
The pads and tips the most sensitive areas of the index, middle, and ring fingers are the examining surfaces used to locate the edges of the liver and spleen as well as the deeper structures. You may use either your right hand alone or both hands, with the left resting on top of the right. Examine each quadrant separately, imagining what structures lie beneath your hands and what you might expect to feel.
What can you expect to feel? In general, don't be discouraged if you are unable to identify anything. Remember that the body is designed to protect critically important organs e. It is, for the most part, during pathologic states that these organs become identifiable to the careful examiner. However, you will not be able to recognize abnormal until you become comfortable identifying variants of normal, a theme common to the examination of any part of the body.
It is therefore important to practice all of these maneuvers on every patient that you examine. Ask the patient or an observer to place their hand so that it is oriented longitudinally over the center of the abdomen.
They should press firmly so that the subcutaneous tissue and fat do not jiggle. Place your right hand on the left side of the abdomen and your left hand opposite, so that both are equidistant from the umbillicus. Now, firmly tap on the abdomen with your right hand while your left remains against the abdominal wall. If there is a lot of ascites present, you may be able to feel a fluid wave generated in the ascites by the tapping maneuver strike against the abdominal wall under your left hand.
This test is quite subjective and it can be difficult to say with assurance whether you have truly felt a wave-like impulse. The abdominal examination, like all other aspects of the physical, is not done randomly. Every maneuver has a purpose. Think about what you're expecting to see, hear, or feel. Use information that you've gathered during earlier parts of the exam and apply it in a rational fashion to the rest of your evaluation.
If, for example, a certain area of the abdomen was tympanitic during percussion, feel the same region and assure yourself that there is nothing solid in this location.
Go back and repeat maneuvers to either confirm or refute your suspicions. In the event that a patient presents complaining of pain in any region of the abdomen, have them first localize the affected area, if possible with a single finger, pointing you towards the cause of the problem. Then, examine each of the other abdominal quadrants first before turning your attention to the area in question. This should help to keep the patient as relaxed as possible and limit voluntary and involuntary guarding i.
Make sure you glance at the patient's face while examining a suspected tender area. This can be particularly revealing when evaluating otherwise stoic individuals i. The goal, of course, is to obtain relevant information while generating a minimal amount of discomfort.
Chronic liver disease usually results from years of inflamation, which ultimately leads to fibrosis and decline in function. Histologically, this is referred to as Cirrhosis. This can be driven by a number of different processes, most commonly chronic alcohol use, viral hepatitis B or C or hemachromatosis the complete list is much longer. It's important to realize that a cirrhotic liver can be markedly enlarged in which case it may be palpable or shrunken and fibrotic non-palpable.
After many years generally greater then 20 of chronic insult, the liver may become unable to perform some or all of its normal functions. There are several clinical manifestations of this dysfunction. While none are pathonomonic for liver disease, in the right historical context they are very suggestive of underlying pathology. Quadrants of the Abdomen. Topical Anatomy of the Abdomen. Draping the Abdomen.
Various Causes of Abdominal Distension. Obese abdomen. Irritation of serosal surfaces may produce a sound rub as an organ moves against the serosal surface. Atherosclerosis may alter arterial blood flow so that a bruit is produced. Palpation is the examination of the abdomen for crepitus of the abdominal wall, for any abdominal tenderness, or for abdominal masses.
Expand all sections Register Log in. Trusted medical expertise in seconds. Find answers fast with the high-powered search feature and clinical tools. Try free for 5 days Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer. Abdominal examination. Summary A fundamental part of physical examination is examination of the abdomen, which consists of inspection, auscultation , percussion, and palpation.
Suggested sequence Positioning Instruct the patient to lie down and expose the patient's abdomen. If your hands are cold, warn the patient prior to palpating the abdomen. Inspection of the abdomen Note any scars, striae , vascular changes e.
Purpose: to assess bowel sounds Auscultate over all four quadrants. Listen for bruits. Normal findings : : gurgling bowel sounds every 5—10 sec Percussion of the abdomen Purpose: to determine the size and location of intra-abdominal organs Percuss over all four quadrants. If so, begin palpation in the non-painful area. Observe the patient's face during abdominal palpation , as it is the main indicator of the intensity and location of pain.
Procedure: Superficial palpation : to assess for superficial or abdominal wall processes Deep palpation in all four quadrants : to assess intraabdominal organs potential signs of peritonitis Rebound tenderness : abrupt increase in pain when an examiner suddenly releases compression of the abdominal wall. Caused by irritation of the receptors in parietal peritoneum Abdominal guarding : patient contraction of the abdominal wall muscles during palpation Involuntary guarding also referred to as " rigidity " : involuntary tightening of the muscles due to peritoneal inflammation and is often localized to a specific abdominal quadrant.
Voluntary guarding: voluntary contraction in order to avoid pain during the examination and is often generalized over the entire abdomen. Palpation of the liver Place the pads of your fingers over the right upper quadrant , approx. Palpate as you move towards the right upper quadrant and attempt to feel for the edge of the liver.
Continue until you feel the liver or reach the costal margin. Asking the patient to take a deep breath may facilitate palpation of the liver , as the movement of the diaphragm will move the liver toward your hand.
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