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right. So high, guys. Good evening on. Welcome to today's second essential examinations lecture. I'm Steven on going to be talking to you about the abdominal exam today. And, uh, what you'll be burning, Uh, in a few moments. Let you guys live. What? What the continent today's letter will be. But I just want to reiterate again how we have got this really awesome series give away at the end of all of our lectures. Well, we required for you to enter. This score is to fill out a few back form on. What we will do is we'll kill it. All of your names and to lucky students will win the price one or price tea. Uh, now you might see that price one has got both of the places actually have got attendances attached to them or the the conditions are attached to the attendant. I can tell you know that we've scrapped that. And so what we will do instead is anyone who, uh, attends Electra. And however many lectures, um, that someone attends, we will collect all of your names on rather than one name. Um, we'll have, For example, if you tend to date lectures. We will have your name each times into the goal. Therefore, increasing your likelihood of winning one of these awesome prices. Um, and we'll be letting the winners know towards the end of July after our last event. And yes, I would just like to, um, appeal to you to please keep attending a live lectures. Please fill out a feedback form. It's always very useful for us. Um, Andi, you guys can win something really awesome at the end of this series. Um, in terms off, uh, sponsors on about partners just like to say, a big thanks. Teo. All of our partners at the bottom is you can see, um, you have kindly and very generously donated. Um, some of these gifts, um, for you guys or toe win, So yeah, further it do. Right. So today's lecture. So today's lecture is going to Teo cover the abdominal exam. Now, in this abdominal exam, um, I will be talking to you about the general inspection. Um, after that, I will be talking to you about breaking down on the inspections from from all the way to the from the head or the way to the to the chest and then the abdomen of sleep. Then we'll talk a little bit about inspection and population of the abdomen, followed by the cash in, uh, then Auscultation and we'll finish things up. Uh, just discussing the PR example correcting exam on. And finally, we will If there's any questions. I'm always happy to want the questions and then send the feedback fallen to the track. You guys can fill it out on a Z I mentioned to Lucky to like the students can win two places, which which really, really nice. So general inspection. So what do we do in the general spectrum? So the first thing that we should do is we should always get the patient Teo, sit on the bed and they should be nice and relaxed. Onda, we should inspect them from the end of the bed on what we will be assessing here is will be assessing their mental awareness. Um, for those of you who were there for our first neurological exam lecture, I did talking about mental awareness. And the guy's got a coma scale. So first thing is always to gauge how mentally aware the person is. Are they confused on in context off? Uh huh. They're they're the abdominal exam. Confusion could be a really, really common feature off liver disease on your hepatic encephalopathy is well, the next thing you need Teo, talk about these other in discuss visible on. Is the patient in any pain? Um, are they really uncomfortable? Where is the pain on? But there's the patient. Mind if we were to examine them? Yeah, From that, we will be talking about distention. So distention may suggest, for example, the presence off ascites or even organomegaly on also a balance obstruction was Well, then, um, it's always useful to assess the patient's skin color. So, for example, are they pail? Are they drawn deers there? Hyperpigmentation. Um, so for example, um, a pale color of the skin could suggest anemia. This anemia could be caused by gastrointestinal bleeding on even malnutrition. It is important meant that healthy people can also have, um, no pale skin or kill complexion. So I'm not everything or not every patient that you see with pale skin is anemic. But as I mentioned before, a demon typically presents on the limbs on. It can be a pedal edema, or it could be a tibial edema as well. This is usually associate it with liver cirrhosis on. As a result, it's always incredibly important to assess the patients lower legs. Whether there is pitting edema, which could possibly suggest, um, high carbon Neemia on and then typically liver cirrhosis, protein using enteropathy and things like that. The next thing is, is the patient cachectic eyes that kicks you so Cachexia is ongoing muscle loss that is not entirely reversible. Even with nutritional supplementation on get checks is usually associate it with malignancies and also advanced liver failure. Do Teo dysfunction creating proteins, um, and things like that. And then the last thing is other, any kindness present. So how you could be possible on it usually is very, very evident, Lee visible from the end of the bed. So in the following slides, I will be talking to a little bit about her knees. Um, you might have noticed from the contents that there is no anatomy of the start of this lecture on The reason behind that is I'm going to be adding snippets of anatomy throughout the lecture. Um, and I think it will better eight your knowledge as electric is on. This is general inspection. The next life we're going to discuss each of these inspections in a little bit more detail. So first thing here you can see is, um, Scott's. So I'm not gonna get into teach each and every one of these scars and the indications, but it's very important. Teo. Visualize this scheme, for example, Patient's abdomen. So in the top left corner here, just usually where the liver and the gallbladder is associate, you can see there's a copy. Is incision here? If, um if if you make an incision along the left of the right costal margin and also on the left cost margin that is known as a rooftop incision and all of these in usually for complex cage Phoebe Hepatopancreatic Billy operations in the midline, we can see that there's a midline incision. There's a parent Bill Icals, etcetera, etcetera in the right iliac fossa. We can see a typical grid. I'm incision, which is usually what where the incision is made to take out and appendix Um, so it's usually an open appendicectomy lens once again dependent on Theo and topical variation of the appendix. Fallon Steel, which is for which is what you've used by obstetricians and gynecologists for cesarean sections and, uh, and yet is also Rutherford Morrison, which is more complex bell surgeries. It's very important to you be able to identify these incisions and then two correctly name the type of incision, especially when you're writing down notes and explain to her doctor the next thing is skin. So as I mentioned, you know well on the left side here, we can see that this is usually healthy. Skin looks like. Absent, this patient looks a little bit more pale and on the right side. Conversely, you could say it looks more tender. I've been doing this, but John, this is, I think most of the time it's very easy to spot, and it's very blatant to spot on on day, I guess. If you were correlating it with your with your blood's a bilirubin of your more than 30 it's usually clinically evident, is well from June. This is I mentioned. You have a yellow greenish skin, and then the the whites of the eyes, usually yellow is well right onto inspection of the face. So, uh, how do you mean split things? First thing we should do you When we when we inspect faces, break it down into three eyes and then the mouth. So in terms of I, we we asked the patient or we ourselves gently pull down the lower eyelid on when we pull down the lower eyelid, we are assessing the color off the conscience. Conjunctival on payments of the conjunctiva is usually suggestive of underlying anemia. Um, also, it could be joined us as I mentioned the whites of the eyes, and it's the white of the eyes and yellow. That's usually one of the first signs of joined this, um, and next thing is exempt a lesbian. So example. Asthma is yellow raised, cholesterol rich deposits around the eyes on this is typically linked with hypercholesterolemia. In the next slide, I will be showing you these images of what the example level looks like and the final thing we need to look for in terms of the eyes case of flesh things. So these are dark rings, which basically encircled the virus on their associating with loosens disease. Um, Wilson's disease, which we know is theater room elation off copper in the liver, and then also various other organs and tissues that this in this image you can see here what I mean. So this is the cholesterol deposit around the eyes, which chilling with high cholesterol. So this is example less, Um a Yeah, uh, this example is, um it can, um, can sometimes in jaundiced patient be quite hard to identify a Z. I said if you correlate it real of the bloods on. But if you inspect possibly with the light, the's findings might be a bit more easier to see. A swell and then on the bottom. Right. Um, I have a picture of the i e. But, uh, these ring rings here, Especially in this. In this part of the region are loners, Kaiser Fleischer, wings on, um, these usually linked with Wilson's disease, which is a metabolic disorder off abnormal copper accumulation. Right. So as I mentioned, we going to be talking about eyes in the mouth. Here's the next thing that we need to inspect. It is the mouth. So usually with this, we you asked the patient Teo, open their mouth. Um, and we inspect the corner of the mouth for any signs of iron deficiency. Usually this the'yre deficiency here. What, like three lesion? He, which is usually a long corner of the mouth, is usually knows angulus dermatitis. So this is quite common inflammatory condition Ms is linked with many deficiencies are designed efficiency, loss of malabsorption. Next thing is enlargement of the tongue Say, is that glossitis? Um glossitis is, um, smooth, uh, smooth Read like, uh, enlargement of the tongue, which is associated with anemia, is once more so usually seen an iron deficiency anemia, B 12 and folate deficiency. So the microcytic anemia is, um, typically present with enlargement tongue. None of thing is can we see any pulses? Um, what type of ulcers are we talking about here we're talking about, um, Appetite's else is so after this ulcer's can either be round or they could be frugal. Um, and they usually are carrying on the mucous membranes inside inside the mouth. Um, and these up this ulcers are usually typically benign due to local trauma, um, or stress sometimes. But they can be associated with within limits. Well, alongside crone's disease, hyperpigmented macule, which I'll be shown an image off the next next slide, which are highly indicative off pewter joy get syndrome I'd seen. You know, if you drink a syndrome is a genetic disorder, particularly or so more dominant, which results in the development off polyps in the gastrointestinal tract. So these are the four things that we're looking for around the mouth and in the mouth, which could be suggestive off the gastrointestinal pathology. And, uh, here, in this image, you can see top left. Um, these are the the inflammatory type lesions, which, um, usually seen in angulus. Dermatitis can be seen forms of anemia on be on the bottom line. Thiesmann cure her type lesions, Um, which are very suggestive on pap economic or pizza joint gets angry. We've we've inspected the the face in there with the head. The next thing that we need, Teo, inspect the other hands so the hands can provide a lot of clinically relevant information. Um, and that's why you should always stress on having a focused on be structured assessment to really properly assess if there is underlying pathology. So, inspection boys, um, palms. What are we looking for on the palms we're inspecting for any paleness of Palo. Any red nous? If there's an your femur, Um, and also, if there's any contractures. So no, no one quite knows why. Um, contraction is such a Dupuytren's contracture. I'm going to have gastrointestinal disease is But But there are in terms of power my therapy me, um, can be linked with chronically of the disease. Um, just one of the more significant signs off liver disease and then the parents off the palm suggestive off malignancies G I t bleeds and amount of Christian now for the for the nails eso We're inspecting them. If there's any colon Kia so cool along here is when the nail is spin shipped it It's very round, um and this is once again associate it with iron deficiency anemia, Uh, for example, malabsorption in chromes disease whereas, uh, new conchita is whitening of the nail bed, um, which is associate it with a low protein usually seen in end stage liver disease and also protein using and toe up finger clubbing, finger clubbing. We usually ask that out. How do we assess for think we asked the patient Teo, place the nail alongside another name as I as I show you here. Um And what what usually happens is finger clubbing usually involves a uniform soft tissue swelling off the the terminal phalanx. Um, of the digit on day when there is some swelling on the digit, there is usually loss off the normal angle between the nail and the nail bed. And as a result of that, there is a curved care type appearance off the name. Um, once again, this is, I think, the themes for gas into this time of allergies a quite repetitive, um, and this can be seen in IBD celiac disease on deliver cirrhosis. The final thing which happened, kids very important. Um, is that, uh or the final thing, which is very important, is assessing for Asterix or a flatten criminal, which is what most people call it. So what? What what is aspects? And, uh, how do we How do you inspect So asterixes is a type of negative my clothes, um, which is usually, uh, call where it usually causes a flap emotional hands. Um, and it's usually seen in underlying causes off the hepatic encephalopathy, or your anemia, which is usually due to due to be north failure. And the way that we assess this is we get the patient to stretch their hands So if you're looking at me, we get the patient, Teo, stretch their hands. And we asked them to cock their hands at the wrist. We have it back on. And what should happen is if the ourselves, if they are strange signs of a packet and cephalo pretty her should flat, which is four automatically, um, like this. So we get them Teo copy of their hands and the wrist on if they are, you know, there's mean Okay, be in there. Is that showing signs of you remedial on. If there's hepatic encephalopathy, either hands will start flapping like this like a criminal. And usually we we do ask the patient to hold or two o'clock the list of the hand for about 30 seconds if they can, on if they can't discuss or CVS. Right. That's exactly what I just mentioned. Um, And here and here is a visual image of representation off finger clubbing here, um, on but the flapping criminal, the gastric says Aziz demonstrated for you. Next, we're on to arms and neck selling. So for the arms, is there any signs of bruising? Um, which could be suggestive off liver disease, especially clotting clotting dysfunction, which is usually quite common in cirrhosis. Um, other any excoriations. So excoriations are described this scratch marks that may be caused by the patient who was trying to trying to relieve themselves from all of the itching. Um, on this can usually suggest college Stasis, uh, which is usually caused you, Teo. We've been irritating the skin. Another thing that we should rule out or try. Teo identifies other. Any needle marks, especially in the case of IV drug use is I need you. Um, obviously, you will know that taking IV IV drugs off the street kind of demonstrating risky behaviors is a risk off parental infections. Um, And in terms off guess abdominal context, we're G. I context the main infection that we're worried about his hepatitis. Um, just to make sure that everyone is is alive and focused can concern, please comment. Which hepatitis is we were worried about in IV drug users and also other infections. Um, which were right about an IV drug. Use this, please. Um, next thing is the excellent. So in the Exelon, are there any signs of hyper pigmentation? Was there thinking, um, hyperpigmentation, um or campus acanthosis nigricans is usually suggestive off type two diabetes or stomach malignancies. A swell, um, can also maybe help us. Um, hair loss is is very suggestive off, um, of anemia on. We'll say malnutrition. Just check the check it. Yeah, everyone is focused on the Let. That's great. Thank you. Everyone for coming. This is a campus is on. Americans would just hyper mean hyperpigmentation that now this image here is just off the off the Exelon. What you need to know is that this could be almost any curve ass of the body. It could be in the creases of the coins. It could be on the bag to be behind the knees as well. Um, so it's always good. Teo, try and analyze the skin. Obviously, the Exelon we're looking for is in such a this into the next. So dumb. The head. Um, we've done the done the hands and the arms. Now we're into the neck. So inspection of the neck. You really have Teo know you're not just for this. Why do you need to know you in afternoon? What is, um, the most important aspect of a net? Um, you know, So why it's important to know I anatomy is so we can palpate each region of the loads for limp and knock it so as we know that there's numerous number of lymph nodes in the head and neck region. But we all know that these lymph minutes or drain different parts or different organs as well. The most important lymph node here is usually in the super critical of faucet, So the Super Club Picula Faucet contains virtues. Birchers node. But isn't it on and enlargement of virtues Lymph node A Z you can see in in the image here of this of this lady is usually the first clinical sign off metastatic intraabdominal malignancy, most commonly gastric cancer. Um, so you know, just just assessing the lymph nodes, especially the super curricular lymph nodes. Birchers know it's very important in trying to identify the diagnosis. And in general, people obviously limp a lot incentive infections, um, and things like that. So these are the lymph nodes in the head and neck reading, driving 10. Usually you can honestly see that there's a pre auricular lymph nodes. There's retroauricular. There's occipital on the cervical, and right at the end there's the super particular alongside implanting in the mandibular region onto the chest. So what are we looking for in the chest? We're looking for Spider Baby, um, which is usually associated with liver cirrhosis. Um, but, uh, they can also be due to high levels with Easter. So don't be alarmed. If you see a spider in the Navy in pregnant females or women's taking the wall or contraceptive pill, it's quite normal. How do we define Spider in the evening? So, Spi, the navy usually skin lesions that have a central red pop you on. They have fine headlines like spider webs through the course by the TV. I'll show you an image in in the following slide, but but the red pack yknow type lesions. Next thing Ganic and last year. So what is going to give you estimate? Gynecomastia is enlargement off the male breast tissue. It's a once again caused by high levels of estrogen, but it can also be due to side effects of drugs type of drugs that we're talking about. He jokes in on spironolactone, which is a diuretic. Yeah, a lot of things in his hair loss weight. Obviously, I think we we will be able cabin now share last time before that. Malnutrition. It can also be due to high levels of Eastern. Well, all right. So these are the despite in the navy. Um, I think this one is quite the sleeve. This's obviously someone's chest. Um, and this here is, you know, the red lesion red popular tight lesion, which is more dense in the center has fine red lines which branch off it like spider webs. This is highly indicative of liver cirrhosis. Right, So done. Done. The head. We've done the face mouth armed arms now onto the funding, Second onto the abdomen. So, as I mentioned before in the general inspection, yeah, the the types of things that we need to look for I'm going to be revisiting some of those in a bit more detail. So once again, we asked the patient to lay flat on the bed with their arms by their side and way asked him to relax. Obviously, in the hospital environment, with numerous students around you can be quite daunting, so as relaxes the Candies is really great. This what are we looking for? So we're looking for scars. A zypre viciously mentioned that the numerous different types of abdominal scars that can provide, uh, accuse as to you the patient's past surgical history. We're looking for distention as well. Distention can usually be caused by the six efs. A good pneumonic for all of you students. Listen so fat fluid flatus feces or fetus or or a massive formalin mess. Um, six know Fine. Uh, and these are the six efs, which are usually would usually two abdominal distention could be pattern pathognomic signs as well. Um, for pancreatitis, I discuss those lesions in the next few slides. Also, other pathognomic signs could be a couple of Medusa. So capital Medusa is engorged or that they are engorged, um, paraumbilical rains, which is usually associate it with portal hypertension due to liver cirrhosis. You may also see strike. So Strayer quite normal. Nothing wrong with stray. But these stretch marks and sometimes we do to your ascites Because of the increased abdominal pressure, it can be due teo legacies. Um, because off the paraneoplastic effect, uh, they can also be due teo Cashing syndrome pregnancy as well, Hearns, which I'm going to mention now to examine them types of trainees and then finally Stoma, which we didn't really mention. And another thing we did not mention, which I'm remembering. Remembering now is so so very, very important to also checking and tubes or any greens, um, touch to the patient on along. Along with that, I think it's also important to, um, inspect whether they have a urinary capital. Um, sometimes if the patient is when they clothes, you can see the abdomen. You may not see that they catheterized because the capital reservoir bag is on the bed rather than on the side. So these are all things to be cautious about and alert to gonna be talking about stemmers, um, a little bit later on as well in the next few times. Say, these are the discards that I mentioned. Try to memorize them if you can. It's not the end of the day if you compromise, and but I think it's always useful on. If you can visualize this image. Be great fuel your ward would based learning. This here is the, uh, distended um, tummy. So, as I mentioned for that, abdominal distention can be caused by a wide number of things. Um, can be caused by your due to being fat could be due to fluid. Could be due to abs of lettuce and farting. Um, and then also the feces fetus, if you're pregnant on also, if there's a malignancy or formula mass. Okay, are the signs, um, which, uh, pep anomic for pancreatitis. So on the left side, you can see coming signs Come sign is bruising off the tissue surrounding the umbilicus, which is associated with hemorrhagic pancreatitis. Um, this is not, um a acute Sinus is late, but if you see this, it's It's very, um, tiny indicative off pancreatitis on the right. There's great turn a sign. So great turn a sign is more on the flank, Um, and is bruising of the flank, which is associated with hemorrhagic pancreatitis. Uh, which is once again, Let's sign. This would not be acute sign. Um, perhaps one of you may be able, Teo, tell me in the chat box Different after pancreatitis, we have a lot and yeah, just once again to make sure everyone is a lot. And it's focused as I mentioned before, we will talk about a little bit of a lot to me, but not too much to me. um I think what's really important about hernia is more about how to how to examine it. Um and I think the most important. Honey, you really need to know how to examine this thing. Guana hernia. Um, how the we can apply the same structure that I'll discuss? Um, you know, Teo other hand is a swell, but in terms of a going well here in here, uh, you need to inspect it for us. So is there any swelling? Um, is there any any red nous, uh, patient in any pain as well? Because of the hernia. The second thing is the patient, or can we ask the patient to cough? And can we see the hernia bulge through to the opening in the abdomen? Uh, are they also any scars present? Might be thinking. Why scars? Uh, but that's because it could be due to what could be in relation to a previous open repair, um, in the groin, which could be a laparoscope, um, or previous laparoscopy, which caused the incision once again, which didn't quite heal on deft weaking in the abdomen, abdomen for the hernia t protruding to Once you've inspected this, then you know we can. We can actually copy it. So, as I mentioned, lost a patient. If there is any pain, Um, and let's examine the lump itself by asking the patient cough on and then, if you would be expense expensive coughing polls due to the increased in crab domino pressure. Next thing, we can try to reduce the hernia. If it's reducible, then we know that it is not, uh, you know, incarcerated or it's not strangulated uh, which is usually a good sign for hernia, then then we should try to relate it and tonic, please. Um, so you might be thinking, You know what? Why do we need to really related? And that's because we need to know. You know, what type of hernia is this? Is this a hernia, which is in the indirect, is an indirect hernia or is it a direct own? So the way we do this is we apply our finger on the pubic tuberculum and asked the patient cough. So if, um, if it's an ongoing, no hernia usually is superior and medial, um, to our finger. Whereas if it's from or it's inferior and electoral Now, once we've identified whether it's a formal, offered some guy, no hernia, as I mentioned before. Then we need to figure out whether it's a direct and it's Linda attorney. So the way we identified this is we place two fingers at the midpoint between the interior, um, superior need explains that that's there. And this is our public tuberculum, and we put both of us thing Is that the midpoint here You could you could say at an angle. And you you might be Why the angle it with that? Because the ring is running along in that same same same same same degree in same angle. Um, and you know what we asking? So if, um, what you would do is, um if at three in the mid point between the superior Yeah, explaining the people tuberculum if there is a, uh, an impulse about there, it's usually in the internally, Um, and usually, um, if it's in the internal ring on and if people hands, they're usually prevents the bowel from actually protruding, whereas if it's on the direct with it a direct inguinal hernia, then even if you put our finger there, honey would still appear. And finally, we need to ask, quoted, Why do you need to ask or tea? Because we need to make sure if there's any any bowel sounds present, because if the bow is tract in a hernia, which is irreducible or not all it is reducible. But the bowel is there. We need to figure out the bowel dysfunction. Um, if the bowels Paris static movements are okay Because if not, then this condition would be a sign of, you know, crosis, um which could easy need to sepsis. So he, um here is you can see here is the what? This is a direct time. So, as I mentioned before, we put two fingers at an angle. We're really we're usually hanging them at the same angle off the off, the wandering, they're perpendicular. So if there's a defect in the posterior wall, um, off the abdomen and bowel her knees, too. That's a direct hernia, right? It's a direct hernia. If the bow is, um, entering through the deep ring, which is lateral and then crabbing subinguinal going through the superficial ring that is an indirect home and an indirect hernia can quite easily travel into the scrotum on that can also present a scrotal swelling, and it's very painful. It's a very critical situation. So that was a little bit about her knees. Just a reative. Great. The first thing you always do is you always Inspector Hanya, you palpate a hernia on. Then you relate it to the the and Mark that the land marks with any boney landmarks in the final thing, you always auscultate for any bowel sounds to make sure of it. Um, how is functioning okay on desire, different types of her and use toe gastric going by the medical hand years, um, spaghetti in, which is which is a rare home here, uh, for more hernia. Now for more hernia are very different to the other home is because they have an increased risk of strangulation. Um, so if a patient example presents with a strangulated hernia, as I told you before, if when When we place off being on the pubic Bertel and if the the coffee impulses felt in few relax really little more on that point, we should take extra precautions and extra care to make sure that formal hernia doesn't progress to a strangulation. And as I mentioned and inspection of the abdomen. Um, some patients. Yeah, a lot of patients have got stoma bag, so you can see here. I'm not going to go into what the stoma is. This's strictly essential examinations, but a stoma is usually a a a pouch, which is artificially created due to due to about being removed. That's a much as we're going to go into a statement. What the definition of one is. What's important here is we need Teo. You assess a few characteristics of the stomach. So where is the location of this stuff? Um, you know, the location of the stoma can provide clues as to the type of stomach that we're dealing with. Eso colostomies Carlos things with Conan stomach, Uh, typically located in the left. Yet force it. Where is your in your stoney's on your stomach from the bladder. I usually locating the right medial left is a colostomy. Right Is in the ostomy and your stomach. So once you distinguish the location and you know the type of about that is what probably involved in the stomach, we can then, you know, assess the stool on the contents in steamers. This could be the other stool Oh, this could be You're going. What's important here is that we need We try to assess the consistency off the story. Is it liquidy, or is it solid? Um, and he's usually quite suggestive off the status of the patient Now, in terms of spout, so colostomies are usually flush, um, flush to the skin we most spelt I spell. I mean this through it's a little part of the bowel which is actually hanging outside. It's not inside the body or attach to. This came from outside, um, and usually in Ileostomies and your stomach is there's a spelt, but for colostomies, they're they usually flushed this skin without without a spot. Right? So when that we've we've actually recovered the inspection of the of the abdomen completely on. Then we can weaken. Begin that the palpitation off the abdomen. But before we palpate, we need Teo. Make sure once again that the patient is is lying flat on the bed. Um, that they have relaxed on their arms. Besides, well, a lot to the side way also need to ask the patient, probably preferably before, and actually, um, the point. Well, the side of the pain, if there is pain I d you should you shouldn't need beside the bed. Um, I'll pay. Uh, this could be Uh huh. This this is sometimes not the easiest of things to do. Because if you're not confident while sleeping in terms of palpating and also observing the patient eyes and face to the's, um, it can be something to do. So it's okay. Just tend. Well, um, initially the stuff, but do try to kneel a swell on, then examine. Uh, as I mentioned, we should always obviously observe the patients based throughout. That's because they could show no signs of tenderness or guarding. But, you know, their face could be grimacing. For example, if you took a particular spot, know if the patient can't relax. What we usually do is you asked the patient to turn the head away from from the side. That were if one if one the right side we get the patient left on, That usually does relax. Makes them. And last but not least, before we begin the palpitation, we should work by region. So left up, right up weight by cordon by corporate. Okay. Uh, I'm not sure you can see this is very clean. Um, I apologize for this, but a Z you can quite me see on the right side you have the court of the abdomen broken down quadrant on the left side. Uh, you have the, uh, the line line quarter of the line regions. So, you know, above the stomach, it's usually the epigastric from biblical central by the umbilicus and then under the umbilicus is obviously gastric. And all of these regions contain parts off organs or the only parts of the organs. And therefore, if there's any tenderness in that region or, uh, potential messes, it's it's very, very easy to identify. War organ is affected, or what you're feeling is well so, pal, patient of the abdomen. Um, what we should always do population of the of the abdomen is we should start off with a light palpations first and gradually build it up to a much more deeper palpations. So, in terms of the light palpations, we're gonna pop it each of the nine abdominal regions of four quadrants. Um, and we will assess thumb for tenderness, um, to see if there's any any regional pain. Um, if there's even rebound tenderness as well, which is usually when after the abdominal has been compressed slowly. Um, you know that there's a shop release about the pain. Did you see a sign of power tonight? Is if there's any gardening. Gardening is involuntary tension in the abdominal muscles that cares on palpations, which is usually once again associate it with peritonitis. Then also, you know, if they're any messes with the science of lobster, sign off the drops. Think something is historically. And, uh, it's the most well known sign, which has mean Teo Pen the site is on. It's usually do Teo Palpations off, um off the left left iliac fossa, which causes pain to be experienced in the right iliac fossa. Now see, have McBurney's point is, well, which is more specific for the appendix after, like Power Painter. Then we can, you know, help it the abdomen a bit more deep. So once again, same concept with palpating each region. But we're playing a bit more great pressure. Um, better feel for masses. Um, and you know, if you feel a mess, then what's important is we describe the, uh way, describe the characteristics of them, so we need to note the location. Which regions? If we find out what part off the off the over the sink, it could be, um yeah, it's size and shape. Approximately, um, usually this using off things. Um, your consistency is it Smooths it soft, hard with the regular. Um, is it a mobile? Can you move it? Um, okay. You know, and you know, finally, if if it's off basket or origin is a positive can, can you feel a pulse? Um, usually in the abdomen. This is usually, um, centrally, um, felt if it's a postcoital. Mercy is usually an abdominal aortic aneurysm. It's a power patient off the first organ. So you would start off with the liver. So we deliver you me, we begin the prevention in the right iliac fossa. Um, you know, starting at the edge of the superior, really explain using the flat edge of our home. So the flat edge of our hand is basically the rating side of a hand. So using this side, if this is the abdomen were using the flat end, and we're basically how pleating the abdomen like this, but with the radio edge off of hand, then I lost my mouth here. Uh, then we are, See? And we asked the patient to take a deep breath in on apply pressure to the and then we apply the pressure to the abdominal wall with a hand to try and carpet the liver. If you cannot palpate deliver, you should move our hand one sent into closer to the costal margin. Um, this might mitigate best. Um, if we feel a liver, which is, um, you increased in size. Um, it's usually it's usually and it's a pattern medically, uh, and you know, many different causes of hepatomegaly, uh, which I won't go into. Um, but it's always used to know mass is once again liver masses not usually common for for primarily of the disease, but usually more for secondary nervous. And if this tenderness to you yet and if this if this tenderness, um, you know, it could be hepatitis, for example. It's tender. So this is how how we palpate the liver. Here. We're starting from the right mediate, but superior to be yet, since your b e explain on using the flat radio edge of a hand palpating. Yeah, so after liver, you know who common logic even would try to pop it the goal bladder. So in terms off palpating the gallbladder, usually if if you're healthy, individual, it's not palpable. And it shouldn't be palpable. Um, however, if you, um if if there is a palpable gold bladder usually suggest enlargement secondary to biliary flare obstruction so this could be go stones could be infection. Cholecystitis uh, it could also be pancreatic malignancy, A swell. Usually we attempt the palpitation of the gold bladder at the right costal margin. Um, usually in the midclavicular, uh, which is usually the tip of the ninth rib. Um, Andi way. If if we If the goal that is enlarged, um, usually it is a well defined round mess that mute that moves good respirations. So this could be when you take a deep breath, Gold better is actually more palpable. It's moving. Nervous, dear. They have mentioned we're assessing for tenderness and messes as well. Um, there is a specific sign. Associate it with the gold better, which is his math me sign, which is a indicative for cholecystitis Here you can see Murphy sign. So Murphy sign is ah, Teo to try and somebody's help you pop it Murphy's sign. We would position our fingers at the right costal margin. The mid could be once again and ask the patient to take a deep breath. Um, and once they take a deep breath, we will be able to pop it go bladder. And this would usually give us that the sign that this is an acute cholecystitis case on to the spleen. Um, if you're healthy, uh, you really should be able to help it. Many of the organs to be completely honest. Um, so So, yeah, the speed is no different. Should be able to palpate it. However, if we are palpating for this bean, well, once again, we should begin the palpations the right knee get lost so far away from the cost. A margin. Once again, we using the flat edge of a hand on be asked the patient to take a deeper and then we pop it in a region with our fingers aligned with the left cost, um, margin. If it's not palpable once again, we move one sent to closer, and, uh, the reason why we palpate this being a stiff. There's any splenomegaly, which is what is usually with hepatic um, Once again, the cause is of spending big alone again. That could be a poor type. Attention. Give your anemia's. Well, um, hot radio except central. This is a perfect heart. Palpitates be spleen starts coming, right? Iliac fossa again. Box in the patient to take a deep breath in, um and then we're palpating me kidneys. So usually with the kidneys, we are using both of our hands, and as a result, we call this by manual palpations balloting. Balloting is in use, commonly used to be by my palpations, uh, as I just to repeat myself, Low organ is usually palpable if everything is okay, um, and the kidneys also no different. But if on individual is aesthetic very thin, um, they have a low B or mine. The kidneys can be felt on the way that we start by my new, um uh, palpations use by placing one hand behind the patient's kidneys below the rib on, and then you press upwards, whereas with the other hand, we we press down words from the abdominal side on. Usually what we're trying to do here is trying to feel the lower pole off the kidney whilst the patient takes a deep breath to assess the the shape, size and the consistency off the kidneys. Um, we're trying to assess if there if there is enlargement of the kidney, so it causes when large kidneys could be polycystic kidney disease, it could be you to do two renal tumor, um, and the number of different reasons. Well, here's a palpitation or by manual pal patient. So, as I mentioned, one hand is to the back of repressing up, on the other hand, pressing down on the abdominal side, going to feel the love know a pole of the kidney. This is one of my favorite things. Quite quite. Um, quite a lot of students. Favorite thing to do is in around the image heads. It's really a fist, but you can karate chop it as well. This is usually for percussion. More palpitation. Um, but we we performed this thing karate chop or percussion, um, for the kidneys to see whether there is whether there is an infection off this increased sensitivity and tenderness. Uh, which is usually seen in pyelonephritis. Um, so this is the fist percussion in this image, but, uh, you can call it a karate chop is well on down to the car patient your in your bladder. So what's important before we start, actually, palpating the bladder in, um, you know, irritating the patient. We should ask the patient whether they would like to go to the toilet. Because as I mentioned performing the examination after after it, the patient may have, uh, the urge Teo go to the toilet because he is quite uncomfortable. It's not usually palpable in healthy patients have. If you have a full bladder, um, in the form of your distention, uh, retention on dubstep shin is well in the urinary tract. Came can cause bladder distention in the suprapubic area. His, uh I couldn't find a very good image of someone. Um how Painting for the urinary bladder. But I think you can use your imagination here to find out where you where you palpate in a man and a female. Um, the bladder on. Then the final thing that will be palpating is Theo aorta. So for the A water, we're going to use both of our hands on what we're going to do is we're going to perform a deep palpations superior to the umbilicus in the midline with both of our hands, um, to try and pop it able to, um, usually post Asians are normal because it's it's the abdominal aorta of it, a Zaveri high blood flow rate on. And as a result, there will be a pulse possible, Um, that there will be a pulse felt other. Uh, however, if our hands move outwards when we're deeply palpating the water, this is usually indicative, um, of inexpensive mess. So then this next pencil mess is usually aortic aneurysm. Um, and it's the whole palpations be you A of the water is quite a crude clinical test, and as a result, you definitely need, um, you know more extensive investigations to confirm the diagnosis of, um, abdominal aortic aneurysm. But if you can palpate the or trailers and expense relax. This is usually, um, usually gives us the go ahead to investigate. In this next thing, you can see what what we do with our hands. Um and how Where is she palpating in superior to the umbilicus in the midline and deep palpation mother in the like purple. With that, palpations of all of the abdominal organs is done. Um, now we can be one to percussion. So percussion is, um, important. Um, part portion part of the abdominal exam. And it consists of tapping on the on the body wall and trying to elicit a sound which is different pictures, um, for different structures on the changes in the pitch different depending upon the organ. You the cost. So, um, how doing? Because I asked the patient delay and relax on the bed once again with the arms aside and using Ah, non dominant hand is you can quite nicely sealed on the image here. Um, using a non dominant hand is the base on using a dominant hand way tack on the dorsum of the middle finger here twice. Usually, um, on, you know, Then we let me access for you know, any dullness, Um, or if there's any shipping and dullness is Well, um, and tapping, uh during percussion can also cause the movement of fluid. So that's usually why's option to to because every single area or every single legion, um, of the abdomen. And now what we're going to it's going to discuss a little bit about your percussion off a few organs in the abdomen So in terms of the liver, you usually need me percuss upwards, uh, usually 2% at one time from the right iliac fossa away towards the costal margin. Teo. See if there's any percussion. No changes, um, at all to see if there's an influence in that region on Be keep on the custody all the way up to the upper liver border. Um, did you try and see if there's any kind of liver as well, not just in front or more secure and period to it? Um, that's what we do for the liver. For the spleen. Once again, it's It's the same concept. You kind of make sure that there's no fluid posterior superior, um, interior inferior as well. Um, four, Uh, just in terms of shifting anonymous, have mentioned here, shifting dullness is usually a sign of ascites, so percussion can obviously be used for any fluid. In ascites is his food. So the question is very useful for assessing the presence of ascites and what we usually do is we we because from the umbilical region to the patient's left flank and then you know, by stress into the other side, or for 30 seconds. Um, and what happens is if if ascites is is present, the area that was previously dull should now be resident due to the shifting of the donor, it's because we're tapping on it. The fluid is moving to the other side. Um, and the other side is remaining. Don't. This is shifting bonus. Usually we use it for assessing ascites Here. You can even see a nice visual representation of a doctor cussing or the regions of the abdomen and the and the quadrants all right, onto, uh, into the final few topics. So the penalty one is going to be auscultation off the abdomen. So oscal take a shin is usually under taken over to random points, uh, on the abdomen on. But it's gonna be anywhere in the abdomen. If this sounds in normal, they sound like gardening or guard me. Order Haven't really described it very well, but I think you know the sound inmates Very good. Very. There's thinking, um, this could be linked with obstruction if they're completely absent. Uh, this usually implies dysfunction in Paris Telesis, which is suggesting medias, um Andi, and be obviously there. There's many different causes of ius uh, could be GTO. Recent surgery could be because of electrolyte abnormalities as well. And to be And to be able to confident me, say, to a patient anti to report to a doctor that you couldn't hear about sounds you really need to auscultate for about 30 minutes. Um, so this is probably one of the most time consuming parts of this exam. Very important that you do it properly. Um, they were not just auscultated the bow when we talk about the abdomen more so auscultated for vascular structures as well, such as the aorta and the renal arteries. Eso auscultated for the aorta usually is taken 1 to 2 centimeters superior to the umbilicus once again in the midline in a brute here, which is a harsh, um, terrible in blood flow, eyes usually associate it with a triple A, a renal, a renal brutal vascular taking the renal artery running pathologies usually be once again auscultated superior to the umbilicus, but but more lateral to the to the midline want again. A brute here with the tablet blood is usually associate it with renal artery stenosis. Here you can you can see a nice image of the of a doctor auscultate in the bowel. On down on the right, you can see the land marks, which I just mentioned for the aorta of the aorta is wanted to. Sentiment is superior to the umbilicus here, and the renal artery is once again more on 22 centimeters, superior to the umbilicus but a bit more lateral to the midline. And and that is the area for Oscar taking the vascular scrunches now on to you. The last the last topic. Um, it's certainly the last topic, but it's not the least of any, um, of any of the stages of the examination that we've talked to you on. It's a It's a very important part of the exam, but it can also be very awkward to describe on land, to perform, confident me and effectively. Uh, just because it's awkward shouldn't avoid it, and also because way students who were not really exposed to it many, many contexts way. We're not usually allowed to do this, so we shouldn't show away from it. But if you can, I would. It's a very important thing to learn and into master, Um, and just because it's, um, awkward and unpleasant for the patient should also not avoid it because it's very important, you know, for patients with symptoms of PR bleed tell his Mursal change in bowel habits and things that so the first thing before anything that you used to do, which is in, uh, that that that or that there is potentially impact for patient. We should explain the procedure on we should gain the content. Uh, so, you know, we should we should explain what we're going to do. Um, how we're going to do it, Why we need to do it and then ask the patient if they consent to us doing it. What can sometimes alleviate concerns is if we offer a chaperone, so that can sometimes come the patient, and they can be a bit more cooperative after that. After that, we should get our equipment. We should get the gloves, uh, do broken some pictures as well. Um, possibly in a tray is what? Okay, which will also make sure that there's there's good enough lighting on. That's because, uh, there could be some lesions around around the area which which may not be identifiable if is if there's not good enough like and then before we we inspect And when the patient has just put the trousers down Little what? Whatever. We should consent again before it's only I can't keep harping on about how important it is, um, to gain consent for this procedure on, but usually when when the patient has uncovered themselves on the waist to the needs. We usually ask patients to lion in the left lateral position and we try and get him to bend their legs on Bring the legs were up to their chest with the knees up to the chest. Uh, Steve, he relaxes the maintenance. Um, law on D allows the the doctor to to write sleek seven, the rectum in the region. So, as I mentioned for, we need good lighting because for to inspect the perianal area before, uh, before we play something is inside the Penis with inspecting the vision's a wart, Um, for example, for any viral infections and what you've done that, then we can we can put our finger inside beings. Um, we can assess me to tone eyes that good turns their poor turn once again, if you'd like to know more about it, owns. You can head over Teo, the Neurological Lecture, which was the first one in our Scuse to better understand about your muscle test. It's going to turn. After that we were take our finger covering the 4, 360 degrees to assess the entire region to make sure there's no lesions. There's no mobile masses. There's no nothing that we can help it. And when we're done, um, obviously pull our figure out. You should never be club quickly. We should always inspect the globe. Um, after for any signs of blood feces? Well, mucus is well, so here is um very Ah, yeah, very descriptive. Itchy Could say off. How are PR is performed? I apologize for the anatomical. Well, for me, not providing a nimit for a female is well, but the anatomy's it's not too dissimilar off silly. Must make sure that we're not palpating the liver, you know, instead of being, uh um, but I think that we'll intelligent individuals here on be we would know what's what's what. Um and yeah, P. R. Is very important. As I mentioned for her, PR bleeds any of those or two bowel habits. It symptoms but also in urology for palpating the prostate as well. Yeah. And with that, I think that's the end of the lecture. Um, thank you for your attention. Um, I've also added my email here. If any of you would like to you to get in touch, um, if you have any particular questions about this exam with the neurological exam or anything else in general up, and I'll be more than happy to help you, Um, in terms of what we have lined up next, I'm really excited to say that we will be talking about Pete's next week in the form of the general pediatrics exam. We will be joined by another UK doctor. Um, and, uh, Doctor Jervis will be describing the pediatrics in a really simplistic way. So, um, they'll be really, uh, useful for everyone lined in pediatrics was having respiratory exam, uh, coming up. And, uh, we also have cardiovascular exam in a few weeks and a day by day, we can find more and more events went into June July. I would just like to take a moment to once again. Thank are fantastic sponsors and our partners, um, football of their support and generosity s. So, for example, awesome plants. My suit, quest med on estimates metal on, um, part cases. Well, I scrubbed in very thankful for their support and the moment that most of your probably being waiting for their feedback for that. So here is the link to you to the feedback form. I will also add it to the chat. Um, okay, yeah. If if you can hold a scan, this is QR code to then fill out the feedback form. And also what might be entered into our price store at the end of July. Um, I'll be very, very nice and way Appreciate that greatly. So with that, um, I will stop sharing my screen. Um, and it just like to say thank you, everyone giving up their their evening towards this lecture. I hope this is really informative. Help you find this useful. This will be up there down to YouTube when you finish. Yeah, you can watch it many times as you want. We'll also be updating the slides on to meddle. I'm also the video recording of this and Yeah, thank you very much for all of your of your participation on I hope. See you the next one next week for pediatrics. So thanks very much, guys On. I have a great evening. Thank you.