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Gauge guys in the questions and answers. Or if you have any questions, you can either use the chart function or you can just um you can directly speak so the recording started, so you can go for Dennis, you just need to show your screen in yeah, we can see you now okay, Hi guys, my name is Dennis, I'm a third year medical student. I'm currently on my placement at doing my make a placement, uh which is a g. P, and I'll be going through the abdominal examination with you guys today uh. So hopefully, by the end of this, uh talk you guys were masters at doing the abdominal exam uh. Also apologies for my voice. I've also had the flu for the past few days, so so here's what we'll be covering. We'll be going over the abdominal examination will be covering service anatomy, referred pain, you're a terek stones, triple a's hernias um I've included x rays here, but um I don't think we'll be covering in this lecture, but if you do feel fill out the feedback form. At the end, you'll get access to um a summary of this lecture plus how to interpret abdominal x rays, so I guess we can get started, So the structure of the donor exam, it's mainly six uh stages uh the introduction uh the positioning uh inspection, uh pal, patient percussion, and auscultation in and within each step, there are certain things that you need to be able to perform, so we'll start with the introduction, um So when you have your when you go into your cPA, exam, the examiner will prompt you to introduce yourself and uh this is probably the easiest way to do it. You have to state your name and roll you say hello, my name is uh and I'm a second year medical student you confirm the patient's full name and date of birth, So you ask them can, I confirm your full name and date of birth now. I find it easier to ask at the beginning because in real life, if you're if you want to perform an examination on the patient, it's just better to make sure you have the right patient initially just to avoid wasting time with the wrong patient. Uh You state the purpose for meeting with the patient, so you can say something along the lines of I've been asked by the doctor today to examine your tummy. This will involve me having a look feel and listen to your tummy is that okay um Because the term abdominal might be a bit confusing to some people, it's better just to use layman's terms um And you have to gain verbal consent, you have to say is that okay and you have the patient has to say yes that's fine for you to proceed. Um you say, thank you and you wash your hands and you have to do that before. Uh you proceed with the examination and you have to wash your hands after you've finished as well, so positioning an exposure, you want the patient to lay completely flat on the bed and be exposed from the waist up words um So you would say something like for this examination. I require to lay completely flat. I also require you to be exposed from the waist up words. Would you would you be ok, removing your top if it's a female, you say you may keep your brown um If the bed is not flat, you can say mayor, just the bed for you, and before you begin you must make sure to know if the patient's in any pain because that will guide your examination further after. Um you should be able to see those iffy stirred um to the pubic synthesis and you have to mention that the examiner will act as a chaperone because arguably this is somewhat of a semi intimate exam. You're examining a patient's tummy and it requires them to be exposed pharma, so in terms of inspection, you'll be looking for uh you'll be looking at the abdomen, the examiner might prompt you and say uh just inspect the patient for me, so the abdomen is is usually flat and symmetrical and respiration is mainly diaphragmatic, and uh these are the signs you'll be looking for uh scars um for any previous surgery, symmetry, or masses um Does anyone wanna type in chat or um mute themselves and say what they think they're looking for in terms of symmetry and masses. Anyone it's okay you guys don't have to be shy, it's fine symmetry, masses, what you guys thinking okay uh so you'll be looking for things like hernias, uh masses could be a sign of maybe a tumor or cancers, but that's very unlikely costumers aren't going to grow to that big of a size. They usually felt on bowel patient. Um you'll be looking for ascites and diffuse swelling, so diffuse swelling could be a sign of bowel obstruction uh drawn this could be a sign of some sort of reno, uh hepatic pathology, sorry, um the umbilicus, so is it everted, is it inverted are there any hernias around the umbilicus um and distended veins um just a tip about inspection. Just you have to inspect the ab, the abdomen enthusiastically so make sure to actually look at the abdomen uh bend down from the sides. Um You don't need to like try really hard to remember all of these signs, but you should be able to recognize them. If you actually see them, it's unlikely you'll get a patient in the cpa with these pathologies, um but it's important that you try and do it enthusiastically. Um In terms of the distended veins, can anyone tell me uh the sort of the medical term for that yep cap it medicine, thank you tony, that's good cap it medicine, distended veins on the surface of the abdomen cool um So yeah these are just the start of some things you can look out for an inspection very simple um All right, we'll move on to power patient uh Some people some physicians tend to do auscultation before palpations or percussion in order to prevent any like bowel sounds being disturbed by deep deep, our patient. Um You'll be prompted to do these in the, to do any of these in this in the exam, so you've got light power patient deep power patient palpating the liver, spleen, kidneys, and the abdominal aortic pulse. Um You must know the nine regions of the abdomen because if you are prompted to uh to palpate uh perform power patient on a patient, then the examiner might ask you to name each of the regions that you're palpating but let's go ahead and first try and uh label these planes, so can anyone tell me what one is one is. It's a good guest in a thorough thoracic uh one is a trans, the transpyloric plane uh anyone for two ok sorry we can just go through them uh to, is uh the sub costal plane just underneath the 10th costal cartilage, uh three is the super crystal, um four is the inter tubercular plane, five is the ASIS between the anterior superior iliac spine and six is the umbilicus at the level of L3 L4. Uh The nine regions of the abdomen simple, epigastric, umbilical, superpubic or hipaa gastric, and then you've got the hypochondriac, lumbar and inguinal regions on the left and right hand sides uh The nine regions of the abdomen are uh made by the to midclavicular planes and the sub costal plane and the inter tubercular planes for the horizontal mhm, i'm moving on to light pal, patient, um So you perform like power patient in each abdominal region with the palmer surface of your fingers and the ACT together um the palm of your hand should be molding over the abdominal surface while your fingers flex at the metacarpal phalangeal joint, so at your knuckle joints, uh and you shouldn't press too deep and you will be looking for any tender areas or any lumps in the abdominal structure in each region, um how patient of the abdomen may may be facilitated. If the patient is asked to flex the hip and knee joints, so if you ask the patient to bend their knees while you're performing the examination. It might extreme, it will relax the abdominal wall muscles and make power patient easier. If they are in any pain, you should start furthest away from the pain and you must keep looking at the patient's face. You you have to like let the examiner know that you are paying attention to what the patient how the patient is responding to how when you're palpating because it just shows that you're you're a good clinician. Um In terms of deep our patient, it's the exact same thing keep looking at the patient's face start furthest away from where the patient's reported pain you use both hands um uh where the upper hand usually the left is used to exert pressure, so I'm right handed, I would place my right hand on each region and I place my left hand on top and I palpate deep and the most sensitive part of your finger is the radial surface of the four finger, so if you want to press down like that and each quadrant uh then that should be uh good enough um and you should be palpating for edges of organs as well if you can, but mainly you're looking for any tenderness or masses. So the signs you're looking for in palpation tenderness, tenderness is um a sign of underlying pathology, uh tenderness with minimal pressure over like a wider area of the abdomen may be due to peritonitis, uh which usually causes rigidity or in some cases that might be just due to anxiety or uh yeah just anxiety um guarding. It's um it's when the abdominal wall contracts voluntarily when powell, patient causes pain, you're looking for rigidity as well, which is in voluntary guarding, uh which is a sign of inflammation of the parietal peritoneum, also called peritonitis, uh and it's a reflex contraction and you're also looking for rebound tenderness, um which is after you like after you release your hand when pressing on the abdomen, patient reports pain that's a sign of peritonitis and that's quite dangerous, it needs to be investigated further palpating the liver. Uh You start in the right iliac fossa um and you ask the patient to take some deep breaths at their own pace. Uh You place two fingers on the abdomen parallel to the right costal margin, and when the patient exhales, you relocate closer to the liver by maybe 1 to 2 centimeters upwards. Um When the patient inhales, you push down on the abdomen to try and feel if the organ will touch you. If the liver will touch the border, the liver will touch your finger and you finish at the right costal margin. Um The liver is usually not felt in a healthy individual, but it may be a smooth or irregular or soft or hard, could be tender. It could be pulse, it'll which could be indicative of a range of different pathologies. Uh For the spleen is the exact same you start the right iliac fossa you, but the only difference with this is that you end at the uh left costal margin um The spleen has to enlarge three times before it's palpable and it's usually found on percussion before before pal, patient, um the spleen is in the left upper quadrant um and it's superficial so you can't and you can't get on top of it because it's covered by the costal margin, uh but if it's enlarged, uh so if there is any splenomegaly, there'll be a notch that is close towards the umbilicus, so yeah that's pretty much similar to palpation of the liver palpating. The kidney is a little bit more complex. Uh You would place your hand under the flank into the reno angle. Um Basically all you need to do to locate the reno angle is just go under the left flank, which is on at the level of the umbilicus with your left hand um The angle is made by the by the posterior median line and the lower border of the 12th rib. So you place your right hand on the abdomen. So remember you have your left hand underneath and you'll use your right hand um as a guide to feel for the kidney. So you use your left hand as a guide to feel for the kidney. You press down with both hands, so this is by manual pal, patient and you ask the patient to take some deep breaths I/O and you'll try to feel the kidney as it moves down with inspiration. Uh You repeat the same thing um again with your left hand on the, on the other side, um There's another technique for palpating the kidney, which is what I prefer uh you keep your left and right hands where they are and you fleck you keep the right hand flexed at the metacarpal phalangeal joint, so on top of the abdomen, you keep your right hand flexed and you ask to take the patient to take a deep breath in and you swiftly flex the index and middle fingers at the metacarpal phalangeal joints in order to, to push the lower pole of the kidney anteriorly to strike the right hand, the one that's palpating and you sort of do sort of do like a blotting motion. While the patient is taken deep breath in and it's important to note that you have to ask them to hold that breath so that you can balat the kidney um so populating the abdominal a. Water. Uh This one's pretty straightforward you just put place your hands down uh with the palms facing downwards, with the pads of your fingers pressing deeply into the abdominal wall your uh little fingers so your pinkie fingers should be uh parallel to the right and left costal margins um and pointing towards the epigastrium, so you press just above so uh just above the umbilicus to the right um and you do this when you suspect uh So when would you suspect a triple A, is if the, when you power pay, if it's expulsion, it'll and expansive. If you feel your fingers are moving and the, the pulsation is pushing your fingers up and out, then you would suspect a triple triple A and um that would need to be referred to hospital to do an ultrasound scan percussion of the liver and spleen uh so we're moving on to percussion now. Um Does anyone have any questions about the uh palpitation no okay, so percussion of the liver and spleen, we'll start with the liver first. Um you have to start at the fourth intercostal space at the midclavicular line, so what you do is you'd have to locate the jugular notch, the sternal notch in the sternal angle and you move to the right of that that's your second intercostal space and you move to down and that's your fourth intercostal space and you have to start the midclavicular line. You asked the patient to take a deep breath in and hold because intrathoracic pressure uh pushes the liver down um because the diaphragm moves down. Um you percussed down noting the change in percussion note from resonant to dull, so the first change would be at the fifth intercostal space, which is the top border of the liver and you work your way down the intercostal spaces and you'd end at just below the right costal margin and once you percuss, that should be resonant because you've just got bowel and air in that space, that's how you know. Um The liver is not enlarged, but if it's adult to percussion just beneath the border of the costal margin, then that could be a sign of hepatomegaly. Um For women, you should not percuss over the breast and you may start percussion from the right iliac fossa and work your way up puts for the spleen. You follow the left costal margin to its trough, so it's basically just underneath the 10th intercostal space at the left anterior axillary line. As you can see here, um you would percuss, and then you ask the patient to take a deep breath in and then you'd percuss again uh. Initially it should be resonant if it turns dull after inspiration, that means there could be a sign of splenomegaly and that's abnormal moving on, two per cussing uh percussion of um shifting dullness um Can anyone tell me why we do this uh Why we do this percussion. What does this. What is this for the site is good. Yeah fluid in the abdomen yeah exactly that's exactly what it is so so what you do is you place your hand on the midline of the patient's abdomen with your fingers parallel to their body now. I know this this diagram doesn't really show it well. You'll be standing on the right, so you always be on the right side of the patient, so, in the exam, if they ask you to percuss for shifting dullness, I place my fingers just on top of the midline of their abdomen with my fingers facing towards their feet, and I'd start per cussing from the midline toward myself. So you percuss from the midline out to a flank and you note a change from resonant to dull because a lot of the fluid um is on the sides, I think and it should be quite resonant at the top because it's just full of air. So you percuss from the midline out into the out to the flank towards yourself or away from yourself wherever you prefer, but I think it's easier to percuss towards yourself um. Then you mark the spot once you've percussed out to the flank, and you asked the patient to turn to their side, so you hold your finger at that spot and you ask the patient to to do a maneuver so could you roll on your side for me, so you ask them to roll onto the left side. You would wait 10 seconds and you'd percuss again, If the if on percussion, there's a change from dull to resonant that would be positive for a society's um it would be a positive test, but due to time constraints, you'd have to tell the examiner you ideally wait for 30 seconds and then then you'd percuss again, so how does cirrhosis cause societies. Um So essentially cirrhosis is a sign of end stage liver failure. You've got a healthy liver here um that undergoes some sort of fatty change, some chronic fibrotic changes, and then cirrhosis is essentially a sign of end stage liver disease, so a scerotic liver can cause a lot of scar tissue. The position, therefore you can get portal hypertension and that can cause backpressure on the portal venous system and that increased hydrostatic pressure can cause fluid extra visitation into the peritoneal cavity cavity leading to ascites. Um Another way is that if you have end stage liver failure, you could all your liver isn't making enough albumin, so you can get something called hyper alba anemia, and this can lead to reduced oncotic pressure in the blood vessels and you need oncotic pressure to retain fluid in your blood vessels and if you're not doing that, then fluid will extra visit into the peritoneal cavity and that can cause ascites as well, so it's complex uh processes happening all together at once other mechanisms include or other causes include heart failure, a nephrotic syndrome, and uh liver cancer moving on to auscultation. Uh This is probably the easiest um to remember how to do you literally just place your diaphragm, the the diaphragm of the stethoscope anywhere on the abdomen and you listen for sounds and you do this for at least two locations. You listen for less than 30 seconds on each location, but you would do it for uh 3 to 4 minutes without time constraints. So you tell the examiner ideally, I'd like to listen to this patient's tell me for around 3 to 4 minutes. Normally you will hear gurgling sounds of peristalsis, so just normal bowel sounds um can anyone think of a cause of high pitched and frequent tinkling, so uh tinkling sounds does anyone have any idea any guesses mild obstruction, very good, tony, nice, yeah, so it's bowel obstruction uh High pitched tinkling sounds. I think it's also called boba regmi. It's a sign of bowel obstruction uh Typically, I think small bowel obstruction and can anyone tell me what a reduced or absent sounds are a sign of Delius yes, very good alias bought peritonitis, but yeah ileus main one, so that's pretty straight forward with the oscal oscal stating the bowels. Um There's some other things you need to know for auscultation. In you can auscultate for breweries, which is due to turbulent turbulent flow of blood due to a narrowing of a vascular lumen, so there's a pneumonic um I like to use um and this was given to me by uh mohammed, abu, Eed, It's I really like sarah a lot, um and we'll go through these oscal, take the iliac arteries in the iliac fossa, a renal arteries which are 2 to 3 centimeters superior and lateral to the umbilicus. You could auscultate for liver tumor's because liver tumor's are highly like, can be highly vascularized. You can they can sort of be auscultated as breweries, um the superior mesenteric all cilic arteries, in the epigastrium and the abdominal a water just above and left of the umbilicus, so pneumonic for that is, I really like sarah lot iliac arteries, reno arteries, liver tumors, superior mesenteric, all cilic arteries, abdominal aorta okay so what we've covered so far is positioning an exposure for the abdominal exam. The patient needs to like completely flat and be exposed from the waist upwards inspection. We've gone through inspecting the umbilicus, respiration, veins, masses, and swelling power, patient light and deep uh palpating the liver and spleen uh palpating the kidneys by manual and balloting and triple a um percussion. We've gone over the liver and spleen, spleen and shifting dullness and for auscultation, we've gone over bowel sounds and prove these uh we'll be moving on to the surface anatomy next, but does anyone have any questions about that could be, anything could be what we've covered so far or the abdominal examination. The Cpa exam okay that's fine we can move on uh so uh the surface anatomy is just something you need to is something you need to go and like memorize. Uh There's no easy way to do it you just look and you study it, but we can go through it, So if the examiner asks you, uh can you give me the surface markings for the liver. You could start in the sort of go in a clockwise where you start with the superior border being at the right fifth rib at the midclavicular line, which passes underneath the end of the sternum to the left fifth intercostal space at the midclavicular line, which then goes down to the costal margin at the Rite Medical Theory line and joining rejoining again at the right fifth rib at the midclavicular line. Um Can anyone give me some causes of hepatomegaly, just put in the chat, or a mute yourself, if you're feeling brave, mhm, I'll call abuse. Yeah, I guess cirrhosis can cause uh and then large liver um so hepatitis, alcoholic or viral congestive heart failure. If you have right sided heart failure, you can get hepatomegaly because of the back pressure from the right side of the heart to deliver the spleen. You can also get a dema, peripheral edema with congestive heart failure um and tumor's and cirrhosis, which is a start a sign of uh late stage. Um In these conditions, the lower board of the enlarged liver becomes palpable palpable below the uh the costal margin and it's um normal to feel liver in children. Um In terms of the gallbladder, gallbladder pain can be, is referred to the epigastrium and it migrates to the right upper quadrant. Um uh Anyone know any causes of uh gallbladder pain because this diet is very good, stones yes perfect literally, that's what I'm looking for gallstones, colelithiasis, and uh information call cystitis perfect um Does anyone want to tell me what murphy sign is, does anyone know what murphy sign is yep very good, so murphy sign is a sign that's seen in acute cholecystitis. You would uh press uh the costal margin the right subcostal area. You uh palpate that area and you had asked the patient to take a deep breath in um they would take a deep breath in, but there'd be a sudden cessation of breathing because of the pain and that that would be indicative of the gallbladder hitting your finger. They can no longer breathe them because it's too painful for them because of their gallbladder being inflamed. Uh Service anatomy of the spleen. Um This one's quite simple. The spleen sits behind the 8th and 9th and 10th rib posteriorly between the midaxillary line and the lateral border of director spinal muscles. Again, something you just have to remember for the exam because you may be asked um And the spleen is separated from the rib cage by the diaphragm and the cost of diaphragmatic recess. Again, it must be enlarged 3 to 4 times its size to be palpable, um but can be indicated by a percussion uh moving on to kidneys and the ureters surface anatomy. Uh So you need to learn these again, um So the kidneys are they sit at the level of L1 uh. In the reno angle said, the L1 verse well plane. Uh the highland uh are about 4 to 5 centimeters from the posterior posterior median line, so it's around 4 to 5 centimeters. The adult kidneys are about 9 to 12 centimeters long and 5 to 7 centimeters wide. Um The superior pole of the kidneys are covered by the 12th rib and the inferior paul's about 3 to 4 centimeters above the iliac crest. Um. The ureters are marked by drawing a line between two points that's five centimeters lateral to the posterior median line at L1 and the pieces, which is a skin dimple uh called the posterior superior iliac spine. Uh In general, uh it's it's just good to know how to locate L1, so we we can talk through that easiest way to locate L1 is to locate the tip of the night costal cartilage anteriorly, so it from the front, so that's where the costal margin intersects the lateral border of rectus abdominus, so the lateral border of your abs, that that would be the level of l. L. One, so you can extrapolate that pastilles really and that should be L1 harder method of locating L1 would be to go to to locate the inferior border of the scapula, so the inferior angle of the scapula and you locate the uh the highest point of the iliac crest, the midpoint between that is uh t 12, so you just have to move one down, but it's easier just to locate the tip of the ninth cost of cartilage and work your way backwards yes and the ureter runs along the tips of the transverse processes of the lumbar vertebrae moving on to referred pain. Uh The examiners love to ask uh students questions about referred pain um and it's important to know because parts of the abdomen, abdomen um the visceral innovation could be quite poor, uh so localizing pain can be quite difficult. Um So you need to know where pain can be referred to uh So does can anyone tell me where pain from the forgot is referred to mm, So if you think of the digestive tract from the mouth to the anus, uh it can be divided into three parts, so the four cut is the um the third uh the 1st 3rd, um it ca is two thirds, and the hindgut is the final, the final part of the digestive tract so pain from the four gut, which does include the stomach and part just a part of the duodenum. The duodenum is referred to the epigastrium, which is at the level of t 78 um Pain from the mid gut is referred to the umbilical region um and pain from the hind gut is referred to the super pubic region or the hipaa gastrium, so in the exam peter, uh the examiner might ask you uh where is pain from the mid gut and hind got referred to and you have to say the mid gut pain from the mid gut is referred to the umbilical region and the pain from the hindgut is referred to the super pubic region. It is something you need to know you're a terek stones. We should we'll be talking about common sides of obstruction due to narrowing of the euro to at these particular sites. Um the pelvi, you're a terek junction um the pelvic brim so where the ureters crossed the sacroiliac joint right here that's a common side of obstruction and you've also got the vehicle ureteric junction down here, which is where the your ita connects to the bladder. Um urinary tract calculi, so ureteric stones are excruciatingly painful and they usually present with a colicky loin, loin, two groin pain, so it usually starts off with loin pain because uh the stones usually they begin in the kidney and that's why you get loin pain and patient's present with colicky pain, the bat in their back and when the stone is dislodged into the Euro. To pain from the urata can be referred to the groin, and that's why that's when it becomes really painful. Um Typically, the management of your it, eric stones depends on the size of the stone. If the stone is less than five millimeters, they usually manage expectantly and they give the patient fluids and analgesia, hoping that the stone will pass within a few days or weeks. If, if the stone is greater than five millimeters and less than two centimeters um Management changes they might do ureteroscopy if the patient is pregnant, which involves inserting a stent up the Euro to, to allow the stone to pass. If the patient is not pregnant, they can perform something called a shockwave lithotripsy where they shock the, they deliver shockwaves to break up the stone into many pieces and allow that allows it to pass or if the stone is very big and complex. They can do a percutaneous nephrolithotomy, which is a surgical procedure where they make an incision at the back, they remove, remove the stone surgically moving on to abdominal aortic aneurysms um So in males, the abdominal aorta is around one point the normal size of an abdominal aorta is 1.7 centimeters and for females is 1.5 centimeters. Usually an abnormal dilation of the aorta is at least 1.5 times it's a, it's normal diameter or above three centimeters. Um A patient presenting with something like this with might report seeing a ripples of water when they're in the bath, which is known as wave sign or they might be aware aware of some sort of abdominal pulsation, but most patient's are a symptomatic um in terms of screening for abdominal aortic aneurysms, it starts at the age of 65 it's usually a one off ultrasound scan so they just do one ultrasound scan at the age of 65 uh Unless the aorta is enlarged, then depending on the size of the aorta, they do they continue to screen um throughout the year. Um decision to operate is made if the abdominal aorta is greater than 5.5 centimeters or if it's increasing by more than one centimeter a year, and that's when they need to refer to um a two week wait to a vascular surgery to either in insert a stent or surgically uh clamp the aorta. Um a ruptured triple triple A presents with a trial of back pain uh or flank pain, so um patient's might present with a really bad central abdominal pain radiating through the back and they might be they, they'll probably be him a hemodynamically unstable and hypertensive um and the pulse it'll expansive abdominal mass will be felt and palpitation. They'll be sweaty and cold with the weak thready pulse um and uh there's likely to be a pulse to expansive hamas, um and the aim of surgery, then it's urgent they have to have surgery straightaway is to control the bleed before repairing that annual the aneurysm. It's important to know, I'm not sure if this is relevant for your exams this year, but it's it's very important to know that ruptured triple A can present as loin two groin pain and may mimic your a terek colic. So if a patient has loin to growing pain uh It's important to do observations obviously to make sure they're not hemodynamically unstable and perform uh triple A examination to make sure too, so you can rule that out her news. Um So hernias are a passage of the peritoneum through a defect in the abdominal wall uh so possibly with abdominal context, uh contents, and it can either be uh direct or indirect, so we're talking about inguinal hernias that can be either direct or indirect. Um They're usually a symptomatic lumps, which can which can enlarge on coughing or straining. Um inguinal hernias are located super remedial to the pubic tubercle, and femoral hernias are inferolateral to the pubic tubercle. Um A non reducible hernia um is called an incarcerated hernia is that risk is at risk of strangulation and needs to um need surgical intervention urgently. Um In terms of risk factors, obesity is a risk factor, um can anyone else think of any risk factors for hernia other than obesity, weight lifting really good yes yes, pregnancy, mhm, brian surgery, awesome yeah very good, yeah so pregnancy yes because uh stretching of the abdominal award can make the abdominal weaker, heavy lifting yes, can predispose you to hernias, chronic coughing, can increase abdominal pressure, intra abdominal pressure, previous surgery weakening the fascia yes. Um Family history can be one smoking because of a connective connective tissue defects. Over time, age, In general is a risk factor. Um In terms of identifying whether hernia is direct or indirect, I've been told by a surgeon that it's not clinically relevant, you probably won't be able to tell if it's direct or indirect usually hernias that a symptomatic, they're usually patient's are put on a very long waiting list, They have to wait maybe, up to 7 to 9 months to get on the uh to get a surgery for the, for the hernia, and the elective lists are, have such a long waiting times, but if if if a hernia is incarcerated, meaning that you can't reduce it, or if a hernia is strangulated that is usually a surgical emergency. Usually when the hernia strangulated, the blood blood supply is cut off to the, the herniated structure, So if if we take bowel for an exact for example, um and that the bowel starts to die. It's usually accompanied by abdominal pain, nausea, and vomiting, and the lump might appear red or purple with swelling and adama um so that needs urgent surgical repair. Depending on how long the hernia has been strangulated, the surgeon might actually decide to remove that part of bowel because it might be a scheme, Ick sorry, I'm just reading the chat, direct, doesn't descend compared to indirect yeah yeah, I guess so, I guess if it's indirect, it's more likely to go into the scrotum cool all right. We'll do some practice questions. Uh We'll start with the first one what are the six steps of the abdominal examination. It's part put into the chart. We start with introduction okay, so it's introduction, position, inspection, palpations, percussion, and auscultation um pain from the four gut and hind gut are referred to which abdominal regions see if you guys were paying attention very good, epigastric, superpubic nice uh A patient has loin, two groin pain. They are also hemo, dynamically unstable, what is an important differential to consider yes ruptured aortic triple A, so if it's a ruptured, so yes triple A ruptured triple A um is it is correct, Aortic dissection yes. Potentially, if it's a class B aortic dissection, it can potentially present as that because I, if I'm if I'm not incorrect type B aortic dissection can be due to a split in the lumen of the descending aorta, so it could potentially I guess I might have to look into that um What are the three commonest sites of your a terek stone obstruction, you can give me one if you are okay um the pelvic pelvic oh you're a terek junk junction, the sacroiliac joints or the pelvic brim, uh or the Visa core ureteric junction. Those are the three um Final question is more of a uh yes per ureteric junction uh. The final question is more of a clinical case. It's more clinical medicine. I thought you guys might enjoy trying it 55 year old female. Patient comes to edie, with diffuse abdominal distention and abdominal pain for the past three hours. She has not opened her bowels or passed flatus and has vomited the yellow liquid a few times. Her past medical history is significant for cesarean section at the age of 33. What is the most likely diagnosis you take a guess, it's, it's, it's yep ok we've got uh one answer. Bowel obstruction secondary to adhesions. Small bowel obstruction. Does anyone else have any other answer. No uh need chest x ray driven sucks, uh told me you you are on it today. This guy is on it very good, yeah so it's a small bowel obstruction likely secondary to adhesions after having cesarean section. Um The diffuse abdominal distension is a giveaway as well, the fact that she hasn't opened her bowels or passed flatus. That's a sign of absolute constipation uh seen in bowel obstruction and the fact that her vomit is bilis, is indicative of it being small bowel rather than large bowel um and her past medical history as well really good. Um summary, uh we went over the surface anatomy of the liver and gallbladder, the spleen, the kidneys, and your ettus. We went over referred pain. We talked about your a terek stones and common obstruction sites. We talked about abdominal aortic aneurysms and uh ruptured triple a's, and we have also talked about hernias today. Uh Thank you very much for coming to this talk on the abdominal exam. I hope you guys enjoyed that. Um Please feel free to email me if you have any questions. Um I've also created a summary sort of a summary for this session uh including how to interpret abdominal x rays. So if you fill out the feedback form, you'll get access to everything about this session plus how to interpret abdominal x rays, so yeah, thank you. I hope you guys enjoyed that. If you have any questions in the chat, please feel free to ask them. Yeah Thank you so much Dennis that was that was definitely definitely very useful. Please guys make sure it's filling the feedback form is, It's very beneficial for Dennis and if you do have any questions the chat or a mute and uh that will give you access to the recording slides and a very useful summary as well, so I'm just gonna stop the recording now and we'll stick around for a few minutes to answer questions.