Abdominal Exam, Histories For Each Disease And Bimanual Palpation Flashcards
Mention the steps of abdominal examination
Establish rapport
Seek consent
Measure the patient’s height and weight
In the UK, this is performed at the booking appointment, and is not routinely recommended at subsequent visits
Patient should have an empty bladder
Expose the abdomen from the xiphisternum to the pubic symphysis
Cover above and below where appropriate
Ask the patient to lie in the supine position with the head of the bed raised to 15 degrees
Prepare your equipment: measuring tape, pinnard stethoscope or doppler transducer, ultrasound gel
General wellbeing – at ease or distressed by physical pain.
Hands – palpate the radial pulse.
Head and neck – melasma, conjunctival pallor, jaundice, oedema.
Legs and feet – calf swelling, oedema and varicose veins.
Inspection:
Abdomen moves with respiration
Distended or not
Umbilicus (flat,everted,inverted)
Striae gravidarum
Scars
Surgical scars( you have to lift the abdomen and look for CS scars
Hair distribution (if it’s normal for the sex of the patient)
Linea nigra ( put your finger on it to show and trace from where it starts to where it ends. Example maybe from pubis symphysis to umbilicus)
Mention if you see fetal movement at anytime in the exam Fetal movement (>24 weeks)
Surgical scars – previous Caesarean section, laproscopic port scars
Skin changes indicative of pregnancy – linea nigra (dark vertical line from umbilicus to the pubis), striae gravidarum (‘stretch marks’), striae albicans (old, silvery-white striae)
No obvious veins on the abdomen
Palpation:
Light palpation- Check for areas of tenderness and be looking at the patients or dummies face
Check if you feel a mass
Deep palpation:
1.Palpate for the organs:
Liver - for liver palpate till you get to RH region or under the diaphragm and ask patient to take in a deep breath and try to palpate. Say you want to palpate the Epigastric region for the left lobe of the liver or you are palpating for the left lobe of the liver
Spleen- in a more than 20weeks pregnancy or in a big fibroid or in a pregnancy reaching the umbilical region or above it, the spleen enlarges downward so you’ll start from the LH region down to the left iliac spine
So please In obs and gynae exam really note the weeks to see if you’ll palpate down or you’ll do the normal spleen Palpation
Kdineys - ballot kidneys
Since it’s an obs exam, you’ll palpate a mass so say whether there are areas of tenderness or not and say but there’s a mass which I suspect is the Gravid uterus
2a.Focus on the mass. If it’s a fibroid or any mass that isn’t a pregnancy, go through the steps in checking for the mass
Site size(one finger is two cm so from up till down pubis ) shape consistency surface edges differential warmth mobility (longitudinal plane up and down or transverse plane left and right)
Bruits using steth
Attachment- to check if it’s attached to skin, try to lift the skin.
To check if it’s attached to the muscles, let it be contracted or tensed then try to move it. If it can move even while muscles are tensed then it’s not attached to the muscles
So for a pregnant woman ask her to cross the arms on the chest and try to get up. This tenses the abdominal muscles.
Trans illumination, lymph modes(inguinal, other lymph nodes down there) plus any other thing checked
2b. Since it’s an obs exam, you’ll palpate a mass so say whether there are areas of tenderness or not and say but there’s a mass which I suspect is the Gravid uterus
If it’s a Gravid uterus in the question:
Check the SFH first by using one hand to palpate from the sternal region till you feel the fundus ( palpating like you’re palpating for the organs )
Report this as the SFH correlates with the GA or the SFH is smaller than the GA or the SFH is bigger than the GA
Uterus should be palpable after 12 weeks, near the umbilicus at 20 weeks and near the xiphisternum at 36 weeks (these measurements are often slightly different if the woman is tall or short).
The distance should be similar to gestational age in weeks (+/- 2 cm).
Palpate the fundus to check for the part of the body in the fundus whether head or whatever. The fingers should be meeting as you’re palpating
Palpate the lateral aspects or do lateral grip to palpate for the back or the front
Lie
Facing the patient’s head, place hands on either side of the top of the uterus and gently apply pressure
Move the hands and palpate down the abdomen
One side will feel fuller and firmer – this is the back. Fetal limbs may be palpable on the opposing side
Do the pelvic grip
Do the Pawliks grip to check for the presentation
Check for descent
Say you want to measure the fetal heart rate
Mention that throughout the exam you didn’t see any fetal movement
Thank the patient
- Please I will like to Do fluid thrill or shifting dullness for Ascites. For fluid thrill if the fluid is so much you don’t have to put the hand in the middle . Just flick
For shifting dullness, perches from the umbilical region towards the right
What are the causes of SFH more than GA
And SFH less than GA
State two causes of an everted umbilicus and inverted and flat
Smaller than GA:
IUFD
iUGR
Oligohydramnios
Transverse lie
Wrong dating
Constitutionally small baby
Bigger than GA:
Polyhydramnios
Fetal macrosomia
Wrong dating
Multiple gestation
Pelvic masses ( could be fibroids, cancer, etc)
Abruptio placenta
Pregnancy, Ascites, obesity ,umbilical hernia, umbilical granuloma
smiling umbilicus is seen in ascitis
The normal umbilicus is inverted and situated centrally in the mid abdomen. In ascitis umbilicus is transversely stretched giving it a look, like that of a smile. Hence the name smiling umbilicus.
It’s not the only case where a smiling umbilicus is seen
Yes, a Smiling umbilicus can be seen in obese patients and also in pregnant women
Causes of inverted and everted umbilicus :
Everted—Seen in any condition giving rise to increased intra-abdominal tension like ovarian
cyst, pregnancy, hydramnios. severe gaseous distension etc.
Inverted—Normally in health and in obesity.
A flat umbilicus is a rare clinical finding. It can be an isolated anomaly or a component manifestation of Aarskog syndrome
How is a pelvic exam done
(Follow up questions may be if there’s a vag discharge name the ddx investigations and mgt
And then if a mass state the ddx of a mass ( uterine cancer, uterine fibroid, adenomyosis) treatment management
Precautions to take before a pelvic exam:
1.patient must empty bladder
2. Use a chaperone
3. Good source of light
Start:
Rapport
Consent
Wash hands
Ask for chaperone
Ask for good source of light
Ask patient to empty bladder
Wear sterile gloves
Pick up gauze with Savlon with one hand and drop it from a distance into the other hand Clean the left labia first
Discard gauze
Pick up gauze with Savlon with one hand again and drop it from a distance into the other hand
Clean the right labia
Discard gauze
Pick up gauze with Savlon with one hand again and drop it from a distance into the other hand
Use hand without the gauze to push open the vulva and Clean the middle of the vulva
Discard gauze
Pass the speculum by holding the mouth in between your core finger and middle finder
Lubricate it with gel or NS
Turn it to the side when entering the vagina and once you enter, turn it upright and open
Keep the opened speculum in place by screwing the thing
Check for discharges, bleeding, strawberry cervix, anything else
Unscrew the thing, close speculum and bring it out
Biannual palpation:
Enter with middle finger to push the posterior fornix down and enter with the forefinger
Check for cervical motion tenderness by flicking the cervix
Check for adnexal tenderness and masses by using outer hand to press down on the left iliac region and try to push your fingers in the vagina towards the left iliac region. If your hand and finger meet then there is no mass
If they don’t meet then there is a mass
Again,use outer hand to press down on the right iliac region and try to push your fingers in the vagina towards the right iliac region. If your hand and finger meet then there is no mass
If they don’t meet then there is a mass
Check the size of the uterus (The average dimensions are approximately 8 cm long, 5 cm across, and 4 cm thick, with an average volume between 80 and 200 mL. ) by use outer hand to press down on the suprapubic region and try to push your fingers in the vagina towards the suprapubic region. Use your fingers to estimate the size of the uterus. Each finger is 2cm
Pull out and say thank you
How many weeks is the pregnancy at the xiphoid process?
At the umbilicus?
At the pubis symphysis?
There’s a picture so check
The SFH is approximately equivalent to the GA in weeks from 24-36 weeks
Umbilicus 20 weeks
