Assessment of the Abdomen – Advanced

00:01 So, next up we're going to launch into the abdominal exam and like many systems that we're talking about in this course, it always starts with inspection.

00:08 So, starting off from taking a look at her abdomen.

00:11 Things that I really want to attend to, are making sure that there aren't any surgical scars, that didn't already come up when we were talking about her surgical history.

00:19 We might also be looking for any signs of purple striae, which could be an indication of cushing's disease.

00:24 Oftentimes we'll miss, if right underneath the belt line here, there could oftentimes be a scar from a prior cesarean section, that just wasn't mentioned, thus far.

00:33 So, these are all the kinds of things that I’d be looking for in the abdomen.

00:36 In addition, while rare, patients with hemorrhagic pancreatitis or other causes of intraperitoneal bleeding, may have evidence of a, cullen’s sign which is hemorrhage or ecchymosis, around the umbilicus, versus the gray turner sign, which would be some ecchymosis or evidence of a prior bleed over in the flanks.

00:57 Again, those are fairly rare but there are things to look for.

01:01 And lastly when it comes to inspection, patients who have obesity, versus patients who have cirrhosis, with a lot of ascites, the abdomen is similar and can be difficult to tease them apart, but just on gross inspection, typically, a patient with a large volume of ascites, water is much heavier than fat, so, a person with significant ascites will have bulging flanks, that is the protuberance of the belly really pushes out to the sides, as opposed to with abdominal obesity, it tends to be more centrally mounded, so to speak, though of course that's not a an exquisitely sensitive or specific finding.

01:40 Next, we can move on to auscultation.

01:43 It's important to auscultate, before you start pushing around on the belly, because you can certainly get those bowels fired up, if you're if you're palpating, before auscultating, so I tend to auscultate first.

01:54 And the teaching is that we auscultate in all four quadrants, but keep in mind that it is impossible to localize, where particular sounds are coming from in the belly, I think auscultating four quadrants, just ensures that we listen for a sufficient amount of time, but don't be led astray to believe that hearing some percolations, over in this area means that there's some disease up in the splenic flexure, it's just there's no meaningful data gathered in that in that particular way.

02:21 So, auscultating and we're going to characterize, whether there's hyper dynamic or increased bowel sounds, versus decreased bowel sounds, versus absent bowel sounds.

02:32 Borborygmi is that stomach growling sound, that would be characteristic of somebody who's hungry, versus the tinkling sound of a high-pitched sound, of almost like rain water, would be concerning potentially, for an ileus or small bowel obstruction.

02:51 Lastly, we can listen over the great vessels of the abdomen and attempt to listen for any bruits in those areas.

02:58 It's important to remember that the aorta, is going to come down here from the epigastrium, it comes down here to the umbilicus, where it bifurcates into your two uh common iliac vessels, that are then of course going to end up going into your external iliac and your internal iliac and form the femoral arteries.

03:16 In addition, you've got your renal vessels here, so, it's useful to just listen quietly right over the aorta, to see if you can appreciate a bruit in that location and then down here over the iliacs and then you can listen over the renal arteries as well.

03:35 Evidence of a bruit in those locations, would of course go along with atherosclerotic disease more generally.

03:43 Next up, we'll move on to percussion, so, we've already talked previously during the pulmonary exam, about the benefits of percussion and how to perform it, so, we'll sort of just dive in now.

03:54 It's expected when you're percussing the abdomen, to have some areas of tympany, which again, tympany, is that drum like sound with a single pitch.

04:06 And areas of dullness, because if the person's eating, there's going to be stool somewhere in the intestines or you're going to be percussing areas of dullness in those locations, whereas elsewhere, you'll have pockets of air-filled intestines, so, it's normal to have what's called, “Scattered tympany,” that's what you'd expect.

04:23 It's when the entire abdomen is somewhat distended and there's diffuse tympany, that's when we start to worry about something like a small bowel obstruction, with dramatically dilated bowels.

04:35 So, just percussing around the whole area, I hear dullness, a little bit of tympany, a little bit of mixed dullness and tympany, clearly there's tympany there, that's from an empty stomach.

04:48 Tympany over here across the transverse colon, heading into dullness and then of course down here at the flanks, it's expected that we're going to have dullness down there, as we start to head towards the retroperitoneal organs.