ADVANCED HEALTH ASSESSMENT BREAST, AXILLAE, ADBOMEN

1. By
Mr.A.Sanjaikumar, M.Sc Nursing, PhD
Fellow
Medical Surgical Nursing
Critical Care Department
Associate Professor
School of Health Sciences
Madda Walabu University
Bale Goba.

3. Objectives
Extracting history of risk factors for breast ,
aexillae and abdomen abnormalities.
Perform physical examination on breast ,
aexillae and abdomen.
Interpreting findings after the assessment of
breast , aexillae and abdomen.

4. Anatomy and Physiology
Paired mammary glands within
the superficial fascia of the
chest wall Female breast
extends vertically from the 2
nd
or 3rd rib to 6th or 7
th
Laterally from sternal margin
to midaxillary line. Breast is
usually divided into 4
quadrants

5. Breasts and Regional Lymphatics

6. Topography of Breast
• 4 quadrants to describe
clinical findings
• The upper outer
quadrent is the site of
most breast tumors

7. Breast Lymphatic Drainage

8. 8
Internally the breast is composed of
(a) glandular tissue containing 15-20 lobes radiating
from the nipples, lobules and alveoli that produce
milk.
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9. 9
(b)The suspensory ligaments fibrous bands to
attach breasts on chest wall muscles.
• They become contracted in cancer of the
breast, producing pits or dimples in the
overlying skin
(c) Fatty tissue that surrounds the breast and
predominates both superficially and
peripherally.
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10. 10
 The breasts may be divided in to four
quadrants by imaginary horizontal and
vertical lines intersecting at the nipple.
 Which is helpful in describing clinical
findings.
 The outer quadrant is the site of most
breast tumors (axillary tail of Spence).
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11. 1104/03/2019

12. 12
• The breast has extensive lymphatic
drainage.
• Most of the lymph drains in to the
ipsilateral axillary nodes.
• There are four groups of the axillary
nodes.
• These are the nodes that you palpate
during assessment they include:
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13. 13
1. Central axillary nodes- high up in the
middle of the axillae. Over the ribs and
serratus anterior muscle.
2. Pectoral (anterior)- along the lateral edge
of the pectorals major muscle, just inside
the anterior axillary fold.
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14. 14
3. Scapular (posterior) – along the lateral
edge of the scapula deep in the posterior
axillary fold.
4. Lateral – along the humerus inside the
upper arm.
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15. Examination
• Introduce yourself to patient
• Undress to waist, sit on couch at 45 degrees
• Maintain patient dignity e.g. Bed sheet
• Assess in following positions
– Patient’s hands behind their head (accentuate
lumps, asymmetry, tethering)
– Pushing against their hips (accentuate lumps
attached to pectoralis muscle)
– Patient leaning over side of bed (accentuate
abnormalities in large breasts)
• Exam good breast first, then the ‘diseased’ breast

16. History collection
Presenting complaints
Lump enlargement
Pain
Is it cyclical? Is the lump painful?
Nipple discharge; ascertain
Colour, Quantity, pattern, frequency
Previous breast disease
Was it investigated / treated

17. Family history
Genetics; 5-10% are inherited dominantly
They have early onset & associated with other tumours
e.g. Bowel, ovarian.
BRCA1 (chromosome 17q21)
BRCA2 (chromosome 13q24)
P53 gene chromosome 17
Medications; HRT, pill
Gynae / Obstetric Hx;
Menarche, menses
Breast fed?

18. 18
• Subjective Data-
• Ask for any breast pain, lump , discharge , rash,
swelling, and history of breast disease.
• Any surgery or any axillary tenderness, lump or
swelling rash, self care of behaviors , Breast self –
examination.
• Objective data-
• Equipment's- small pillow , ruler in cm and teaching
aid for B.S.E.
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19. 19
• The best time to examine the breast is
one or two weeks after menstruation.
• The techniques used are inspection and
palpation
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20. Inspect the breasts- Inspection
20
 Breast
 size
 symmetry
 shape of breast
 skin colour
 lumps
 skin tethering
 prominent veins or oedema
of the skin with dimpling like
orange skin (peau d’orange)
 Nipples
 everted, flat, or inverted
(note if recent change or
longstanding
 cracking or ‘eczema’
 gross deviation of the nipple
 bleeding or discharge
 Areola: observe for
 abnormal reddening
 thickening
 The patient should be undressed to the waist and
seated with arms by side

21. • Nipple signs; 6 D’s
Paget’s Disease Depression Deviation
Discharge Displacement Destruction

22. Inspection II
 Ask the patient to raise her arms above her
head (this is particularly important for
inspection of the axilla and axillary tail)
 Ask the patient to place hands on hips and
to apply downward pressure to the hips
whilst leaning forward slightly.
 An inspection of the breasts should also be
made once the patient is lying flat, as
abnormalities may become more apparent
when the tissue falls against anterior chest
wall
22

23. Inspection III
23
 These positions will:
 Stretch the breast tissue and overlying skin
 Exaggerate abnormalities of contour and skin
 Muscle tethering may be apparent
 In health women may have some slight
asymmetry of the breast and nipples

29. Palpation of the breast
Breast
Mammary gland
Areola
Nipple
11/14/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 29

30. • Palpation
– Ask about pain and if patient has a lump.
– Examine good breast first then diseased breast
– Patient puts hand behind head on exam side
– Check for temperature change
– Use following with lumps;
• Surface
• Edge
• Consistency (hard, firm, soft)
• Fixity to skin and underlying structures
• Fluctuance
• Pulsatility and expansility
• Transilluminability
• Reducibility

31. • Palpate using palmar surfaces of index, middle
& ring fingers of both hands, sweeping down
clock face positions.
– N.B. Most carcinomas present in upper, outer
quadrant

32. • Remember;
– Inframammary fold
– Axillary tail of Spence
– Nipple discharge (explain important to check for
discharge, gain permission, gain permission)

33. Systems of breast palpation I
 The examiner zigzags up
and down the breast
ensuring all tissue is
palpated.
 This method was the
preferred method for self
examination
 It is preferred by some
clinicians as the breast
tissue remains in contact
with the chest wall during
palpation.Pictures from the American association of plasticsurgeons
33

34. Systems of breast palpation II
 The breast tissue is
examined using a
concentric circular
approach
 The examiner starts
at the periphery and
ends at the areola
and nipple
Pictures from the American association of plasticsurgeons
34

35. Breast palpation II
 Examine each breast systematically covering the whole cone
of breast tissue using one of the following methods: zig zag,
concentric, or radial paths
 A systematic, methodical examination of all the breast tissue
(covering the four quadrants, axillary tail and areola/nipple)
ensures that small lesions are not missed
 With large or pendulous breasts, use one hand to steady the
breast on lower border whilst palpating with other
 Breast tissue should be palpated against the chest wall
35

36. Systems of breast palpation III
 The examiner divides the
breasts into a series of
segments
 The quadrants are
examined methodically in
turn from periphery
towards nipple
 The examiner traces a
pattern similar to a clock
face ensuring each
segment is overlappedPictures from the American association of plasticsurgeons
36

37. Breast Palpation II - the axillary tail
 To examine the axillary tail of
Spence, ask the patient to rest her
arms above her head
 Feel the tail between thumb and
fingers as it extends from the upper
outer quadrant towards the axilla
 If you feel a breast lump examine
the mass between your fingers
 Unlike fat the breast has distinctly
lobular texture which may be tender
to palpation
Pictures from the American association of plasticsurgeons
37

38. Breast palpation III - the nipple and areola
38
 To examine nipple; hold the areola behind it
between thumb and fingers
 Gently compress, attempting to express any
discharge
 Note colour of any discharge and send
samples for cytology and microbiology
 On completion cover the breasts or offer the
patient the opportunity to put their bra back on,
either after or before examining the axilla

46. UW Medical School's Patient, Doctor, and Society course for second year medical students

48. Maneuvers to screen for Retraction
48
• First ask her to lift the arms slowly over the
head.
• Both breasts should move up symmetrically.
• Next ask her to push her hands on to her hips
and to push her two palms together.
• These maneuvers contact the pectoralis major
muscle.
• There will be a slight lifting of both breasts
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49. 49
• Ask the woman with large pendulous breast
to lean forward while you support her
forearms.
• Note the symmetric free forward movement
of both breasts.
• N.B. Retraction signs are due to fibrosis
in the breast caused by neoplasm.
• The fibrosis shortens and there will be a lag
in movement of one breast.
• Note a dimpling or skin retraction.
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50. Nodules
• Location (by quadrant or clock)
• Size in cm
• Shape
• Consistency
• Delimitation
• Tenderness
• Mobility

51. SIGNS OF BREAST CANCER
Elevation
Asymmetry
Bleeding
“Orange
Peel” skin
Nipple Retraction

52. STEPS IN BREAST SELF
EXAMINATION
•Inspection before a mirror
•Palpation: Lying Position
•Palpation: Standing or sitting

53. Breast Self Exam
• Detects the majority of
breast abnormalities
• Potentially life-saving
• Monthly exam, at end
of menses
• Start in front of mirror

54. Inspection before a
mirror
• Stand and face a mirror
with your arms relaxed at
your sides or arms resting
on your hips; then turn to
the right and left for a side
view look. (look for any
flattening in the side view

55. Inspect for:
• Skin changes
• Redness
• Visible bumps
• Nipple crusting
• Symmetry

56. Raise Arms Up
• Breasts should rise
evenly
• Watch for dimpling or
retraction

57. Feel for Lumps
• Raise the arm
• Feel with opposite hand
• Feel for a “marble in a
bag of rice”

58. Use the Middle of Your Fingers
• Fingertips are too
sensitive (all breasts
are somewhat lumpy)
• Palm is too insensitive
• Middle portion of
fingers is just right

59. Move your hand in small circles
• Stay in one place
• Press in while circling
with your hand
• Feel for thickenings the
size of a marble

60. Then move to another location
• Work your way around
the breast in a clockwise
fashion, using small
circles of the hand as you
go.
• Make sure the entire
breast is felt.

61. The “Tail” of the Breast
• Breast is not perfectly
round.
• A “Tail” of breast tissue
normally extends into
the armpit.
• Make sure to feel for
lumps in that portion of
the breast.

62. Feel the Armpit
• Use the same circular
motions.
• Feel for breast lumps and
lymph nodes.
• Normal lymph nodes
cannot be felt.
• Enlarged lymph nodes
are about the size of a
pencil eraser, but longer
and thinner.

63. Try to Express Nipple Discharge
• Strip the ducts towards
the nipple.
• Normally, one or two
drops of clear, milky or
green-tinged secretions.
• Should not be bloody or
in large quantity,
squirting out or staining
the inside of a bra.

64. Now Check the Other Side
• Follow same
maneuvers.
• Raise the arm above
your head.
• Feel for lumps or
masses.

65. Palpation: Lying Position
 Place a pillow under your right shoulder and place
the right hand behind your head. This position
distributes breast tissues more evenly on the chest.
 Use the finger pads (tips) of the three middle fingers
(held together)on your left hands to feel the lumps.
 Press the breast tissue against the chest wall firmly
enough to know how your breast fells. A ridge of
firm tissue in the lower curve of each breast is
normal.
 Use circular motions systematically all the way
around the breasts as many times as necessary
until the entire breast is covered.
 Bring your arm down to your side and feel under
your armpit, where breast tissues are also located.
 Repeat the exam on your left breast using the
right finger pads of your right hand.

66. Palpation: Standing or Sitting
•
•
•
Repeat the examination of both breasts
while upright with one arm behind your
head. This position makes it easier to
check the upper part of the breast and
toward the armpit.
Optional: Do the upright BSE in the
shower. Soapy hands glide more easily
over when wet
Report any changes to your health care
provider

67. Triple Assessment
1. Imaging; Mammography
roentgenography of
breasts without
injection of contrast
meduim. It is most
sensitive.
• 3 views
• Craniocaudal
• Mediolateral
• Axillary

68. 2.Clinical Breast Examination - clinical breast
exam is an examination by a doctor or nurse,
who uses his or her hands to feel for lumps or
other changes
3.Breast self-exam. A breast self-exam is when
you check your own breasts for lumps,
changes in size or shape of the breast, or any
other changes in the breasts or underarm
(armpit).

69. 4. Tissue Sampling;
- FNAC (cytology exam of aspirate, can have 95%
sensitivity)
- Core Biopsy
- Open Biopsy

70. BIOPSY
• is a medical test involving the removal of cells or
tissues for examination.
a) Aspiration – a syringe and g 18 needle is used to
aspirate tissue from the site which is under local
anesthesia. The specimen is spread on a glass slide,
fixed, stained and sent to the laboratory
b) Incisional – a piece of tissue is obtained in the
operating room, sent to the laboratory fro frozen
section which is the stained and examined under
the microscope.

71. • Classify as benign or malignant
– Benign aetiology classified as Aberrations of
normal development and involution (ANDI)
Peak Age
(years)
15-25 Development Fibroadenoma & excessive Breast
development
25-40 Cyclical Hormonal Cyclical nodularity & mastalgia
35-55 Involution
Lobular:
Ductal:
Epithelial:
Cyst
Duct ectasia & periductal mastitis
Hyperplasia & fibrosis

72. Classification of Breast Tumors and Preferred Method of
Treatment
Clinical Anatomic Observation Treatment
Stage I
Breast Mass Localized; all nodes
negative
Radical mastectomy preferred by surgeons.
Some prefer simple mastectomy plus or without irradiation.
Stage II
Breast Mass Localized; axillary
nodes positive
Radical mastectomy preferred with or without postoperative
irradiation
Stage III
Breast Mass locally extensive;
axillary supraclavicular and
internal mammary nodes positive
Variable depending on extensiveness:
2. Simple mastectomy with radiation
3. Simple mastectomy with excision of large axillary nodes
4. Radiation therapy alone if tumor is fixed to the chest wall
Stage IV
Distant Metastasis
Variable depending upon nature of metastasis, such as bone, sofe
tissue, etc.
2. Radiation therapy to primary lesion or metastasis
3. Hormonal theraphy, hypophysectomy, adrenalectomy
4. Chemotherapy
5. Oophorectomy

73. The axillae
73
Inspect and palpate the axillae.
• Examine the axillae while the woman is
in sitting position.
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74. 74
• Inspect the skin noting any rash or
infection.
• Lift the woman’s arm and support it
yourself, so that her muscles are loose and
relaxed.
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75. 75
• Use your right hand to palpate the left
axillae.
• Reach your fingers high into the axilla
and move them in four directions:
down the chest wall in a line from the
midaxillary,
the anterior border of the axilla,
the posterior border and
the inner aspect of the upper arm.
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76. 76
• Usually nodes are not palpable, although
you may feel a small, soft, non-tender node
in the central group.
• Note any enlarged and tender lymph nodes.
• Nodes enlarge with any local infection of
the breast, arm, or hand and with breast
cancer or metastases.
• A Visual Guide to Physical Examination
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77. Examination of axilla 1
 With the patient sitting
facing the examiner
 The patient’s arm is
raised and supported
 The slightly cupped
fingers of the examiners
opposite hand are
inserted into the apex of
the axilla
77

78. Examination of axilla 2
 The patient’s forearm is rested across the
examiner’s forearm
 The examiner feels for each group of
lymph nodes, whilst steadying the
shoulder with the other hand
 Apical
 anterior (posterior surface of
anterior axillary fold)
 medial (on the chest wall)
 lateral (against the humerus)
 posterior (anterior surface of
posterior axillary fold)
78

79. Examination of axilla 3
 An alternative is to ask the
patient to rest their hand on the
examiner’s shoulder
 The examiner then methodically
feels for each group of nodes,
whilst steadying the shoulder with
the other hand
 Also examine the
supraclavicular and
infraclavicular areas for
nodes
79

83. ABDOMINAL
EXAMINATION

85. Structure and Function
 Surface landmarks
 Borders of abdominal cavity
 Abdominal muscles
 Internal anatomy (viscera)
 Solid viscera
 Liver
 Pancreas
 Spleen
 Adrenal glands
 Kidneys
 Ovaries
 Uterus
Slide 21-85

86. Structure and Function
(cont.)
• Internal anatomy (viscera) (cont.)
– Hollow viscera
• Stomach
• Gallbladder
• Small intestine
• Colon
• Bladder
Slide 21-86

87. Internal Anatomy
Slide 21-87
© Pat Thomas, 2006.

88. Deep Internal Anatomy
Slide 21-88
© Pat Thomas, 2006.

89. Structure and Function
(cont.)
• Abdominal wall divided into four quadrants
– Right upper (RUQ)
– Left upper (LUQ)
– Right lower (RLQ)
– Left lower (LLQ)
Slide 21-89

90. Quadrants
Slide 21-90

91. Subjective Data—
Health History Questions
• Appetite
• Dysphagia
• Food intolerance
• Abdominal pain
• Nausea/vomiting
• Bowel habits
• Medications
• Nutritional assessment
Slide 21-91

92. Objective Data—The Physical Exam
• Preparation
– Lighting and draping
– Measures to enhance abdominal wall relaxation
• Equipment needed
– Stethoscope
– Small centimeter ruler
– Skin-marking pen
– Alcohol swab
Slide 21-92

93. Objective Data—The Physical Exam
(cont.)
Inspect the abdomen
• Contour
• Symmetry
• Umbilicus
• Skin
• Pulsation or movement
• Hair distribution
• Demeanor
Slide 21-93

94. Contour
Slide 21-94

95. Objective Data—The Physical Exam
(cont.)
Auscultate the abdomen
 Bowel sounds
 Vascular sounds (bruits)
Percuss the abdomen
 General tympany
 Liver span
 Usual technique
 Scratch test
 Splenic dullness
 Costovertebral angle
tenderness
 Special procedures
 Fluid wave
 Shifting dullness
Slide 21-95

96. Objective Data—The Physical Exam
(cont.)
Palpate the liver
 Measures to enhance muscle
relaxation
 Light palpation
 Deep palpation
 Bimanual palpation
 Normally palpable structures
 Liver
 Usual technique
 Hooking technique
 Spleen
 Kidneys
 Aorta
Slide 21-96

97. Special Procedures for
Advanced Practice
• Rebound tenderness (Blumberg’s sign)
• Inspiratory arrest (Murphy’s sign)
• Iliopsoas muscle test
• Obturator test
Slide 21-97

98. 9804/03/2019

99. 99
Another naming is also:
• Epigastria an area between the costal
margins
• Umbilical – Area around the umbilicus
• Hypo gastric or supra pubic – Area above
the pubic bone.
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100. 100
Right upper Quadrant w/c contains-
• Liver, gall bladder, duodenum, right
kidney, hepatic flexure of colon, part of
ascending and transverse colon.
Left upper quadrant contains-
• Stomach, spleen, pancreases, left kidney,
left adrenal gland, splenic flexure of the
colon and part of transverse and
descending colon.
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101. 101
Right lower quadrant
• Appendix, right ovary and tube, right
ureter and right spermatic cord, distended
bladder, cecum, portion of ascending
colon, loops of small intestine
Left lower quadrant
• Part of descending colon, sigmoid colon
left ovary and tube, left ureter, left
spermatic cord,
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102. POSITIONING
 Patients hands remain
on his/hers side
 Legs, straight
 Head resting on pillow –
if neck is flexed, ABD
muscles will tense and
therefore harder to
palpate ABD

103.  INSPECTION
 AUSCULATION
 PALPATION
 PERCUSSION

104. INSPECTION

105. INSPECTION
 Shape
 Skin Abnormalities
 Masses
 Scars (Previous op's -
laproscopy)
 Signs of Trauma
 Jaundice
 Caput Medusae (portal H-T)
 Ascities (bulging flanks)
 Spider Navi-Pregnant women
 Cushings (red-violet)

106. 106
Inspection
• Inspects the contour, symmetry, umbilicus, skin,
pulsation or movement and hair distribution.
Contour- stand on the right side and look down on the
abdomen.
• See the profile from the rib margin to the pubic
bone.
• The contour describes the nutritional state and
normally ranges from flat to round.
Abnormal protuberant abdomen as in pregnancy,
scaphoid (concave), and abdominal distension (the
7 Fs- fat, fluid, faeces, foetus, fetal growth,
fibroids, flatus)
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107. 107
• Symmetry - the abdomen should be inspected, symmetric
bilaterally.
• Note any localized bulging, visible mass or asymmetric
shape.
Umbilicus
• Normally it is midline and inverted with no signs of
inflammation.
• It becomes everted and pushed upward with pregnancy.
• Pulsation or movement could be peristaltic waves or
abdominal aorta.
• Marked pulsation could be aortic aneurysm or
increased peristaltic.
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108. Hands + Mouth
 Clubbing
 Palmer Erythmea
 Mouth ulceration
 Bad Breath or
halitosis

109. 109
2. Auscultation
• Auscultate bowel sounds and vascular sounds
• Auscultate abdomen next because percussion and
palpation can increase peristalsis.
• Use the diaphragm – end piece because bowel sounds
are relatively high pitched.
• Hold the stethoscope lightly against the skin pushing
too hard may stimulate more bowel sounds.
• Begin in the RLQ at the ileocecal valve because bowel
sounds are always present here normally.
• Since the food after absorption is exchange through
the ileocecal valve.
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110.  Use stethoscope to listen to all
areas
 Detection of Bowel sounds
(Peristalsis/Silent?? = Ileus)
 If no bowel sounds heard –
continue to auscultate up to
3mins in the different areas to
determine the absence of bowel
sounds
 Auscultate for BRUITS!!! -
Swishing (pathological)
sounds over the arteries (eg.
Abdominal Aorta)
 ...

111. 111
Bowel sounds
• originate from the movement of air and fluid
through the small intestine.
• They are high pitched gurgling occurring from
5-30 times before deciding bowel sounds are
completely absent.
• Do not bother to count it.
• Judge for presence, hypoactive or hyperactive
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112. 112
• one type of hyperactive bowel sounds which is
common is hunger or diarrhea which is
hyperperistalsis known as “borborygmi” and
perfectly “silent abdomen” is uncommon you
must listen for 5 minutes before saying absent
bowel sounds.
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113. 113
Abnormal
• Hyperactive sound are loud, high pitched, rushing.
• Hypoactive or absent sounds following abdominal
surgery or with inflammation of the peritoneum.
• Vascular sounds -note the presence of any vascular
sounds or bruit using firmer pressure check over the
aorta, renal arteries, iliac and femoral arteries, esp.
with hypertensive case
• Usually there is no such sound.
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114. 3. Percussion
114
• Percuss general tympany, liver span and splenic
dullness.
• Percuss to assess the relative density of
abdominal contents to locate organs and to screen
for abnormal fluid or masses.
• General Tympany first percuss lightly in all four
quadrants to determine the prevailing amount of
tympany and dullness.
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115. 115
• Tympany should predominate because air in
the intestine rises to the surface when the
person is supine.
• Abnormal dullness occurs over a distended
bladder, adipose tissue, fluid or a mass.
• Hyper resonance is present with gaseous
distention.
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116. 116
Liver span-
• Next percuss to map out the boundaries of
certain organs.
• Measure the height of the liver in the right mid
clavicular line (mid-way between the
acromioclavicular and sternoclavicular joint)
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117. 117
• Begin in the area of lung resonance, and
percuss down the interspaces unit the sound
changes to a dull quality.
• Mark the spot usually in the fifth intercostals
space.
• Then find abdominal tympany, and percuss up
in the mid clavicular line .
• Mark where the sound changes from tympany
to a dull sound, normally at the right costal
margin.
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118. 118
• Measure the distance between the two marks.
The normal liver span in the adult ranges from
6-12cm.
• The height of the liver span correlates with the
height of the person (tall : longer liver; male -
larger liver span than female of the same
height).
• Abnormal- enlarged liver span -hepatomegally.
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119. 119
Splenic dullness
• Located by a dull note from the 9th to 11th.
intercostals space just behind the left mid
axillary line.
• The area of splenic dullness normally is not
wider than 7cm in the adult.
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120. 120
• Now percuss in the lowest interspace in the
left anterior axillary line.
• Tympany should result.
• Ask the person to take a deep breath. Normally
tympany remains through full inspiration
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121. 121
Abnormal
• A change in percussion from tympany to
a dull sound with full inspiration is a
positive spleen percussion sign.
• Splenomegally in malaria or hepatic
cirrhosis.
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122. 122
Costovertebral angle tenderness.
• to assess the kidney, place one hand over
the 12th rib at the costovertebral angle
on the back.
• Thump that hand with ulnar edge of your
other fist.
• The person feels no pain.
• Abnormal sharp pain occurs with
inflammation of the kidneys
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123. Percussion
• Systematic route
• To assess size and
density of organs
• To distinguish gas,
ascites, cystic or solid
masses
• Tympany= air. Usually
high pitched/musical
• Dullness=organs or
masses. Short, high-
pitched with little
resonance.

124. Percussion of Liver
• Important to define borders, especially in
diseased patient
• Normal measurement 6-12cm in adult
• Check for nodules, tenderness, irregularities
• Report liver size via span and extent of
projection from costal margin.

125. Percussion of liver
• When percussing the liver you are
measuring it’s size, start at the
right mid-clavicular line where you
will start with lung resonance and
percuss down the sound changes
to dullness. Then percuss up
starting in the mid clavicular line
level with umbulicius and note
where the sound changes.
Measure between these two
points .

126. Percussion of Spleen
• Percuss for dullness as usually tympanic! (so if
hear dullness (+) finding!)
• Typically from 6th to 10th rib
• Have patient inspire while percussing….if
spleen enlarged, tympany changes to dullness

128. 4. Palpation
128
• palpate surface and deep area, liver edge,
spleen and kidneys
• Perform palpation to judge the size,
location and consistency of certain organs
and to screen for an abnormal mass or
tenderness.
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129. PALPATION
 ALWAYS ASK IF PAIN IS PRESENT
BEFORE PALPATING!!!
 Firstly: Superficial palpation
 Secondly: Deep where no pain is
present. (deep organs)
 Assessing Muscle Tone:
- Guarding = muscles contract when pressure
is applied
- Ridigity = inidicates peritoneal inflamation
- Rebound = Releasing of pressure causing
pain

130. 130
To enhance complete muscle relaxation
• Bend the person’s knees.
• Keep your palpating hand low and
parallel to the abdomen.
• Teach the person to breathe slowly (in
through the nose and out through the
mouth).
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131. 131
Use light and Deep palpation
• Begin with light palpation.
• With the first fingers close together,
depress the skin about 1cm.
• make a gentle rotary motion sliding the
fingers and skin together.
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132. 132
• Then lift the fingers and move clockwise
to the next location around the abdomen.
• The objective here is not to search for
organs but to form an overall impression
of the skin surface and superficial
musculature
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133. 133
• Abnormal: involuntary rigidity is a
constant board like hardness of the
muscles as in peritonitis.
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134. 134
• In deep palpation push down about 5-
8cm. moving clockwise explore the
entire abdomen.
• In case of very large or obese abdomen
use a bimanual technique.
• Place your two hands on top of each
other.
• The top hand does the pushing, the
bottom hand is relaxed and can
concentrate on the sense of palpation
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135. Liver
135
• Place your left hand under the person
back parallel to the 11th and 12th ribs and
lift up to support the abdominal content.
• Place your right hand on the RUQ with
fingers parallel to the midline.
• Push deeply down and under the right
costal margin.
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136. 136
• Ask the person to take a deep breath.
• It is normal to feel the edge of the liver
bump your fingertips as the diaphragm
pushes it down during inhalation.
• Often the liver is not palpable and you
feel nothing firm.
• Abnormal- liver palpated more than 1-
2cm below the right costal margin is
enlarged.
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137. Liver
 PALPATE:
- from R.iliac fossa up towards and under the last
rib whilst the patient is breathing in deeply.
 ASSESSING:
Regulatrities
Smoothness
Tenderness
 PERCUSSION:
- Outline of liver (norm: 8-12 cms)
- In Mid-Clavicular Line from 2nd rib downwards
 Hollow ---> Dull ----> Hollow

138. Palpation of Liver
Palpation of the liver should
be performed by placing
your hand on the right upper
quadrant, with index finger
in line with the costal angle.
Ask patient to breath in and
push hand inwards and
upwards. A liver edge should
be felt.

140. Spleen
140
• normally the spleen is not palpable and
must be enlarged three times its normal
size to be felt.
• Rich your left hand over the abdomen and
behind the left side at the 11th on 12th ribs
• lift up prominence support and place your
right hand obliquely the LUQ with the
fingers pointing to ward the left axillae
and just inferior to the rib margin.
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141. 141
• Push your hand deeply down and under
the left costal margin and ask the person to
take a deep breath you should feel nothing
firm
• When enlarged the spleen slides out and
bumps your fingertips
• It can grow so large that it extends in to
the lower quadrant.
• When this condition is suspected, start low
down so you will not miss it.
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142. Spleen
Only palpable if enlarged; splenomegaly
– indicated by Castell's sign (bulge of
U.LQuadrant).
Patient on
his/her
Right Side
& palpate
from
behind.

143. Palpating the Spleen

144. Kidneys
144
• For the right kindey, place your hands
together at the person’s right flank.
• Press your two hands together firmly and
ask the person to take a deep breath.
• In most people, you will feel no change.
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145. 145
• The left kidney sits 1cm higher than the
right kidney and is not palpable normally
• Search for it by reaching your left hand
across the abdomen and behind the left
flank for support.
• Push your right hand deep in to the
abdomen and ask the person to breath
deeply.
• You should feel no change with inhalation
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146. Palpation of the kidneys
To examine the kidneys place
hand on right side of abdomen
below the costal margin, above
the umbilicus and the left hand
under the back below the liver.
Press firmly up with the left hand
and down with right. Repeat on
the left hand side. If enlarged the
kidney will be palpable.

147. Renal angle
• Percuss the renal angle with your fist with
moderate force.

148. Special procedures
148
1. Rebound tenderness
 Done with abdominal pain or tenderness during
palpation.
 Choose a site away from the painful area.
 Hold your hand 90 degrees or perpendicular to
the abdomen
 push down slowly and deeply, then lift up quickly
 a normal or negative response is no pain on
release of pressure
 do at the end of the examination because it
causes sever pain and muscle rigidity
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149. 149
2. Inspiratory arrest (murphy’s sign)
–Normally, palpating the liver causes no pain
–In a person with inflammation of the gall
bladder or cholecystitis, pain occurs.
–Hold your fingers under the liver border.
–As the descending liver pushes the inflamed
gallbladder on to the examining hand, the
person feels sharp pain and abruptly stops
inspiration mid way.
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150. MURPHY'S SIGN
 Indication:
- pain in U.R.Quadrant
 Determines:
- cholecystitis (inflam. of gall
bladder)
- Courvoisier's law –
palpable gall bladder, yet
painless
- cholangitis (inflam. Of bile
ducts)

151. METHOD
 Ask patient to breathe out.
 Gently place your hand below the costal margin on
the right side at the mid-clavicular line (location of
the gallbladder).
 Instruct to breathe in.
 Normally, during inspiration, the abdominal
contents are pushed downward as the diaphragm
moves down.
 If the patient stops breathing in (as the gallbladder
comes in contact with the examiner's fingers) the
patient feels pain with a 'catch' in breath.
 Test is positive.

152. 152
3. Iliopsoas muscle test
– Perform this test when acute abdominal
pain or appendicitis is suspected
–With the person supine, lift the right leg
straight up, flexing at the hip; then push
down over the lower part of the right
thigh as the person tries to hold the leg up.
When the test is negative, the person feels
no change
–Abnormal - pain in the right lower
quadrant indicates appendicitis.
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153. 153
4. Obturator Test
•When appendicitis is suspected with
the person supine, lift the right leg,
flexing at the hip and 90 degrees at
the knee.
•Hold the ankle and rotate the leg
internally and externally
•Negative or normal response is no
pain
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154. 154
5. Fluid wave of shifting dullness
•When ascites is suspected and
tympany will be changed to dullness.
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155. Fluid wave test / Iceberg Sign
 Test for ascites.
 Have patient push their
hands down on the midline
of the abdomen.
 Then you tap one flank,
while feeling on the other
flank for the tap.
 > 1 litre of fluid allows the
tap to be felt on the other
side.
 ...

156. BLUMBERG'S SIGN
 Determines:
- peritonitis
- appendicitis
 ALWAYS START OPP. SIDE TO
WHERE THE PAIN IS !!!!
 ABD is compressed slowly and
then rapidly released.
 Pain upon removal of pressure
rather than application of
pressure to the abdomen
 Pain present = positive.

157. McBURNEY'S POINT
 From ASIS (anterior
superior iliac spine) to
the umbilicus.
 Determines:
- location of appendix (varies)
- deep tenderness @ point = acute
appendicitis
NOTE: McBURNEY'S PUNCH SIGN = Tenderness is presented when
gently tapping the area of the back overlying the kidney producing pain in
people with an infection around the kidney (perinephric abscess) or
pyelonephritis.

158. Carnett's sign
 Abd. pain remains unchanged or
increases when the muscles of
the abdominal wall are tensed.
 Positive = Abd. wall is the
source of the pain (e.g. due to
rectus sheath hematoma).
 Negative = pain decreases when
the patient is asked to lift the head;
this points to an intra-abdominal
cause of the pain
 ..

159. HEPATO-JUGULAR REFLUX
 Pressing enlarged liver ---> Increases
Jugular Filling ----> Hepatic congestion
(R.Heart Failure)

160. Head of Pancreas
 De Jardins Point:
- MCL
- 9th Costal Cartilage
- Right Side
 Indication:
- Pancreatitis/Tumour @ head

161. Ultrasound imaging: What does it look like?

162. Computed Tomography Scan
• computerized
tomography
(CT) scan combines a
seriesof X-ray images
taken from different
angles around your
body and uses
computer processing
to create cross-
sectional images
(slices) of the bones,
blood vessels and
soft tissues inside
your body.

163. Paracentesis - Technique
Patient
position
Ultrasound
evaluation
Needle
insertion
site

164. Paracentesis - Technique
Necessary tools
Z-technique

165. Magnetic Resonance Imaging (MRI)
• Tumors and other cancer
related abnormalities.
• Blockages or
enlargements of blood
vessels
• Diseases of the liver, such
as cirrhosis, and that of
other abdominal organs.
• Diseases of the small
intestine, colon, and
rectum

166. • Endoscopy is the examination and inspection of the
interior of body organs, joints or cavities through an
endoscope to allows physicians to peer through the
body's passageways.
Endoscopy

168. THANK YOU FOR YOUR ATTENTION