In addition, it will demonstrate any irregularities of the abdominal wall (such as lipomas or hernias) and give some idea as to areas of tenderness.ĭeep palpation of the abdomen is performed by placing the flat of the hand on the abdominal wall and applying firm, steady pressure. This will demonstrate the crunching feeling of crepitus of the abdominal wall, a sign of gas or fluid within the subcutaneous tissues. In palpating the abdomen, one should first gently examine the abdominal wall with the fingertips. ![]() Then reassure them that you will try to minimize their discomfort and examine that point last. Ask patients with abdominal pain to point to the area of greatest pain. In addition, palpation may stimulate bowel activity and thus falsely increase bowel sounds if performed before auscultation. Take the history and perform inspection and auscultation before palpation, as this tends to put the patient at ease and increases cooperation. ![]() The patient is positioned supine with head and knees supported, as for Inspection and Auscultation. Also, the mass should be observed for peristalsis, as it may well represent dilated bowel. The mass should be examined for movement with respiration or for pulsation with each heartbeat. The relationship of intra-abdominal organs to these quadrants should be considered in attempting to determine the cause of the mass. Once a mass is determined to be intra-abdominal, its location should be described in relation to the abdominal quadrants ( Figure 93.1). Abdominal wall masses are most commonly hernias (either umbilical, epigastric, incisional, or spigelian), neoplasms (benign and malignant), infections, and hematomas. Useful maneuvers are to have the patient hold his head unsupported off the examining table, to hold his nose and blow, or to raise his feet off the table. A mass of the abdominal wall will become more prominent with tensing of the abdominal wall musculature, whereas an intra-abdominal mass will become less prominent or disappear. It is important to differentiate abdominal wall from intra-abdominal masses. This should be performed from several angles. Next, the abdomen should be inspected for masses. In addition to these large dilated veins, note should be made of any spider angiomas of the abdominal wall skin. Obstruction of the inferior vena cava will cause reversal of flow in the lower abdomen. Above the umbilicus, blood flow is normally upward below the umbilicus, it is normally downward. The procedure is then repeated, but the opposite finger is removed and the vein again checked for filling. A finger is removed from one end and the vein is watched for filling. The fingertips are then slid apart, maintaining compression, producing an empty venous segment between the fingers. This is performed by placing the tips of the index fingers together, compressing a visible vein. The skin of the abdomen should also be checked carefully for engorged veins in the abdominal wall and the direction of blood flow in these veins. Careful note of surgical scars should be made and correlated with the patient's recollection of previous operations. The skin should be inspected for striae, or "stretch marks," and surgical scars. Any areas of discoloration should be noted, such as the bluish discoloration of the umbilicus (Cullen's sign) or flanks (Grey Turner's sign). The abdominal wall skin should be inspected carefully for abnormalities. Similarly, the flanks should be checked for any bulging. The contour should be checked carefully for distention and note made as to whether any distention is generalized or localized to a portion of the abdomen. Good lighting is essential, and it is helpful to have tangential lighting available, for this can create subtle shadows of abdominal wall masses.įirst, the general contour of the entire abdominal wall is observed. ![]() The patient's arms should be at the sides and not folded behind the head, as this tenses the abdominal wall. The entire abdominal wall must be examined and drapes should be positioned accordingly. The head and knees should be supported with small pillows or folded sheets for comfort and to relax the abdominal wall musculature. The abdomen is inspected by positioning the patient supine on an examining table or bed.
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