Abdomen, Genitourinary,Anus, Rectum

Abdomen, Genitourinary,Anus, Rectum

1. divided into either four quadrants or nine regions. The four quadrants of the abdomen are the Right upper quadrant (RUQ), Right lower quadrant (RLQ), Left upper quadrant (LUQ), and Left lower quadrant.

   • INSPECTION
     • - Color -Venous pattern -Integrity -Contour -Symmetry -Surface motion
       • SKIN
         • PALPATION OF THE LIVER
           • are two common methods on palpation of the liver and these are the bimanual palpation and hooking method.
             • • Tenderness • Consistency
             • PALPATION OF THE SPLEEN
               • BIMANUAL TECHNIQUE
               • • Size • Tenderness
                 • TEST FOR ACUTE CHOLECYSTITIS
                   • Murphy’s sign Place your thumb or the fingers of your right hand under the costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin. Ask the patient to inhale deeply. Watch the patient’s breathing and note for tenderness.
                   • FEMALE PELVIS
                     • LABIA
                       • Lesions, swelling, excoriation Pubic hair Skin texture Color
                     • URINARY MEATS
                       • Position Color
                       • SKENE’S GLANDS
                         • Openings Discharge Bartholin’s glands
                     • VAGINAL ORIFICE
                       • Hymen Discharge Have client strain down and observe for bulging
                         • POSTERIOR VAGINAL ORIFICE
                           • Swelling Lumps or nodules
                             • CERVIX
                               • Position Surface
                               • SPECULUM EXAMINATION
                               • Color Symmetry Surface Secretions Cervical os VAGINA Color, Surface, Consistency Discharge pH of secretions
                                 • Contour Consistency Mobility Tenderness
                               • UTERUS
                                 • Size Position Shape Consistency
                                 • OVARIES
                                   • Size Shape Consistency Mobility Tenderness
                                 • Rectovaginal septum Posterior uterine wall
                           • INTERNAL GENITALIA
                             • Size of vaginal opening Vaginal musculature Vaginal wall
             • TEST FOR APPENDICITIS
               • Rebound Tenderness Before doing the procedure, explain it to the patient first. Press deeply on the abdomen with your hand. Then, quickly release the pressure. If the patient complains of tenderness when you release, the patient then has rebound tenderness.
                 • Obturator sign Flex the patient’s right thigh at the hip with the knee bent. Then rotate the leg internally at the hip.
               • Psoas sign Ask client to lie supine. Place your right hand just above the patient’s right knee and ask the patient to raise his right leg against your hand. Alternatively, ask the patient to turn onto the left side then extend patient’s right leg at the hip. If patient complains of increased abdominal pain particularly on the right lower quadrant, patient is positive for psoas sign.
     • UMBILICUS
       • -Position ,Color -Color of stools -Observe color of emesis

2. nine regions of the abdomen are the Right hypochondriac, Epigastric, Left hypochondriac, Right lumbar, Umbilical, Left Lumbar, Right iliac, Hypogastric or suprapubic, and Left iliac regions

   • AUSCULTATION
     • assessed using auscultation: 1. bowel motility 2. vascular sounds 3. organ enlargement
       • Start auscultation in the right lower quadrant then proceed in a clockwise manner, covering all quadrants. The diaphragm of the stethoscope must be placed lightly on the abdomen during auscultation.
         • TEST FOR ASCITES
           • Abdominal girth
             • Measure the abdominal girth by using a tape measure at the level of the umbilicus. The ideal position of the patient for abdominal girth measurement is standing. But if this is not possible, the patient should be in supine position. Measurement is taken at the same time each day, ideally in the morning after voiding.
               • ANUS, RECTUM, AND PROSTATE
                 • ANUS Perianal Skin Sphincter tone Tenderness
                 • RECTUM Rectal wall
                 • SACROCOCCYGEAL AREA Color, hair and texture
                 • PROSTATE GLAND Size Shape Surface Consistency Mobility Sensitivity
             • Fluid wave test
               • Ask the assistant to press his hands (ulnar side) firmly on the patient’s abdomen at midline, parallel to the patient’s axis. This pressure would stop the transmission of a wave through fat. Then, place your palm on one side of the abdomen. After which tap the opposite side of the abdomen.
           • Shifting Dullness
             • The patient should be in supine position. To outline the areas of tympany and dullness, percuss the patient's abdomen. Then assist the patient turn to the side. Outline the areas of dullness and tympany again by percussion. If the dullness has shifted to areas of prior tympany, this may be a sign of ascites.
               • MALE GENITALIA
                 • PENIS
                   • Urinary meatus Size Discharge Skin texture
                 • GLANS
                   • Shape Lesions
                   • SCROTUM
                     • Size Color Texture
                     • TESTIS
                       • Location Shape Texture Tenderness Inguinal area Lymph nodes Masses
       • In assessing the vascular sounds in the abdomen, the bell of the stethoscope is used. Note for bruits which are low-pitched resembling heart murmurs.
     • BOWEL MOTILITY may be assessed by auscultation. Bowel sounds are noted for their frequency and character. Normal sounds consist of gurgles and clicks. The frequency of bowel sounds has been estimated to be at 5 to 35 per minute.
       • PALPATION OF THE KIDNEY
         • RIGHT KIDNEY
           • Place your left hand behind the patient just below the 12th rib, with the hand parallel to the rib. Note that the fingertips should just reach the costovertebral angle. Lift this area in an attempt to displace the kidney anteriorly. Then, place your right hand in the RUQ parallel and lateral to the rectus muscle. Ask the patient to take a deep breath.
           • at the peak of inspiration, press your right hand deeply and firmly into the RUQ, just below the costal margin. Attempt to “capture” the kidney between your two examining hands. Ask the patient to exhale then stop breathing briefly. Release the pressure on your right hand slowly, at the same time feeling for the kidney to slide back to its position. Note for its size, contour and tenderness.
         • LEFT KIDNEY
           • must just stand on the patient’s left side, use your right hand to lift the left kidney and use your left hand to feel for the right kidney on the left upper quadrant.
         • Size Tenderness Masses
         • PALPATION OF THE URINARY BLADDER
           • the urinary bladder is not palpable. The urinary bladder is palpated when it is suspected to be distended. Palpation of the distended urinary bladder starts at the symphysis pubis and goes upward and outward estimate bladder borders.
           • Note for a round, smooth and somewhat firm organ extending from the symphysis pubis to the umbilicus. This finding may be further supported by dull percussion notes.
           • Size Consistency
     • loud prolonged gurgles, signifying peristalsis or hyperactivity of the bowel is noted. This is termed as BORBORYGMI
     • -Bowel sounds -Vascular sounds
       • PALPATION OF THE AORTA
         • Palpate firmly deep in the midline above the umbilicus, slightly to the left of epigastrium to identify aortic pulsations. The aortic pulsation is easily felt on most individuals.
         • If an aortic aneurysm is suspected when a well defined, pulsatile mass, greater than 3 cm across is noted. Caution: DO NOT PALPATE a prominent, laterally pulsating mass above the umbilicus with an accompanying bruit
           • • Size • Pulsation

3. Right upper quadrant 1. Liver 2. Gallbladder 3. Ascending and transverse colon 4. Duodenum 5. Head of the pancreas 6. Pylorus 7. Right adrenal gland 8. Right kidney (upper pole) 9. Right ureter

4. Left Upper quadrant 1. Spleen 2. Stomach 3. Pancreas (body and tail) 4. Left adrenal gland 5. Left ureter 6. Left kidney (upper pole) 7. Splenic flexure of the colon 8. Transverse and descending colon divided into either four quadrants or nine regions. The four quadrants of the abdomen are the Right upper quadrant (RUQ), Right lower quadrant (RLQ), Left upper quadrant (LUQ), and Left lower quadrant.

5. Right Lower Quadrant 1. Appendix 2. Cecum 3. Ascending colon 4. Right kidney (lower pole) 5. Right ovary and fallopian tube 6. Right ureter 7. Right spermatic cord

   • PERCUSSION
     • identify ascitic fluid, solid, fluid-filled masses, as well as gasfilled bowel and abdomen. The liver, and sometimes the spleen, is also measured using the method of percussion.
     • should be done in all quadrants and may proceed clockwise or up and down over the abdomen. Tympany usually predominates in hollow organs because of the presence of air.
     • Hollow abdominal organs include the stomach, intestines, bladder, aorta, and gallbladder. Dullness is noted over slid organs such as the liver, spleen, pancreas, kidneys, and uterus. Unusual dullness may be a clue to an underlying abdominal mass.
     • Percussion tones
     • LIVER SPAN
       • Percuss in the right midclavicular line (MCL) downward from the chest until a change from lung resonance to dullness is noted. This is marked as the upper border of the liver. The lower border is identified by percussing in the right midclavicular line at the level of the umbilicus.
       • From this point upward, find the area of liver dullness and mark this as the lower border. The distance from the upper border to the lower border is the liver span. Liver span ranges from 6 to 12 cm in the right MCL in the adult. Generally, it is greater in men than in women, in tall individuals than in short ones.
         • To elicit tenderness over the liver, blunt percussion is performed by placing the left hand flat against the patient’s lower right rib cage. With the use of the ulnar side of the right fist, strike the left hand. Normally, there is no pain nor tenderness when this is performed.
           • Liver span In MCL In midsternal line
             • SPLEEN
               • located under the curve of the diaphragm just posterior to the midaxillary line. Percussion for the splenic location is not usually done unless an enlargement is suspected. When a spleen enlarges, it does so anteriorly, medially and downward.
                 • Begin posterior to the left mid-axillary line (this area is normally tympanitic) and percuss downward, noting the change from lung resonance to splenic dullness
                   • Splenic percussion sign: Ask client to take a deep breath and hold it. percuss lowest interspaces at left anterior axillary line.
                     • Location Splenic percussion sign

6. Left Lower quadrant 1. Sigmoid colon 2. Descending colon 3. Left kidney (lower pole) 4. Left ovary and fallopian tube 5. Left spermatic cord 6. Left ureter

7. In midline Epigastric 1. Stomach 2. Pancreas 3. Xiphoid process 4. Duodenum

8. Hypogastric 1. Distended bladder 2. Pregnant uterus

   • KIDNEY
     • BLUNT PERCUSSION of the kidney is performed to elicit tenderness when obstruction and infection is suspected. With the patient in a sitting position, the left hand is placed flat against the costovertebral angles over the 12th posterior ribs with the ulnar side of the right fist striking it. Normally, there is no tenderness
       • Kidney punch test (Goldflam’s sign)
         • PALPATION
           • GENERAL PALPATION
             • Light palpation is performed to identify areas of muscular resistance, some superficial organs and masses and abdominal tenderness. The patient's facial expression is considered to be the most sensitive indicator of tenderness. Therefore, watch the patient’s reaction not your hands when performing the procedure. Voluntary or involuntary guarding may also be present. After light palpation, proceed to deep palpation to delineate abdominal masses.
             • LIGHT PALPATION
               • performed by placing the hand and forearm in a horizontal plane. Using the pads of the fingertips with fingers together, lightly and gently palpate the abdomen in a dipping motion. The area to be palpated last will be the area with abdominal tenderness or pain. Normal findings would reveal a soft abdomen with no areas of tenderness.
               • DEEP PALPATION
                 • Compress the area to be palpated to about 5 to 6 cm using the palmar surface of the fingers. If deep palpation is difficult probably because of obesity or muscular resistance, two hands may be used, one hand on top of the other. Pressure will be exerted on the outer hand while the inner hand feels for the abdominal structure or abnormality.
                 • • Tenderness • Guarding • Masses
               • • Tenderness • Consistency • Masses