What does the abdominal examination include?

1. Abdominal visual examination Before performing abdominal visual examination, ask the person being examined to empty the bladder, lie in a supine position with a low pillow, and place both hands naturally on both sides of the body to fully expose the abdomen (from the lower edge of the costal arch) , xiphoid process to inguinal ligament and pubic symphysis). The room must be warm and well-lit, and it is best to use natural light, because certain changes in the skin, such as yellowing of the skin, are often not discernible under light. The light source should come from the head or side, which is helpful for observing the bulge, depression, peristalsis and pulsation of the abdominal surface. The examiner should stand on the right side of the subject and conduct a comprehensive observation from top to bottom. Sometimes the examiner needs to lower his sight to the abdominal plane and observe small abdominal signs in a tangential direction from the side. The main contents of abdominal inspection include abdominal appearance, respiratory movement, abdominal wall veins and abdominal wall skin, etc. 1) Appearance of the abdomen: Pay attention to whether the appearance of the abdomen is symmetrical and whether there is bulging or depression in the entire abdomen or in parts. (1) Normal abdominal appearance: When well-developed young adults and athletes lie down, the anterior abdominal wall is roughly on the same plane from the costal margin to the pubic symphysis or slightly concave, which is called a flat abdomen. When sitting up, the part below the umbilicus is slightly lordotic. (2) Total abdominal distension: When lying supine, the anterior abdominal wall is obviously bulging above the plane of the costal margin and pubic symphysis, which is called total abdominal distension. When the entire abdomen is distended, it is often necessary to measure the abdominal circumference and observe the degree and changes of the distension. The measurement method is to ask the examinee to sit in a supine position after urinating, and use a soft tape to go around the abdomen through the umbilicus. The measured circumference is the abdominal circumference, usually in centimeters. (3) Local bulge: abdominal organ enlargement, intra-abdominal tumors, inflammatory masses, gastric or intestinal flexure distension, localized effusion, abdominal wall tumors, etc. can cause local bulge of the anterior abdominal wall at the lesion, which is called local bulge. Pay attention to the location and shape of the bulge, whether it moves with breathing or body posture, whether there is pulsation, etc. (4) Total abdominal depression: In the supine position, the anterior abdominal wall is significantly lower than the plane of the costal margin and pubic symphysis, which is called abdominal depression. (5) Local depression is less common and can be seen in abdominal wall hernia (white line hernia, umbilical hernia, inguinal hernia or incisional hernia) and postoperative abdominal wall scars. 2. Respiratory movement: In normal people, the abdominal wall rises and falls with breathing, which is abdominal breathing movement. 3. Abdominal wall veins: The subcutaneous veins of the abdominal wall are generally not visible in normal people, but are often faintly visible in people who are thin or have fair skin. 4. Abdominal wall skin: Abdominal wall skin examination includes whether there are rashes, pigmentation, abdominal lines and scars, etc. and describe its location. 2. Abdominal palpation examination Palpation is the main method of abdominal examination. In order to achieve satisfactory abdominal palpation, the examinee should lie on his back with a low pillow after urinating, with his hands naturally placed on both sides of the body, and his legs bent and slightly apart. To relax the abdominal muscles, open your mouth and do calm abdominal breathing, so that the organs under the diaphragm move up and down with breathing. The examiner should be on his right side and his palms should be kept warm during the examination. Palpation generally starts from the healthy part or the left lower abdomen, in a counterclockwise direction, from bottom to top, first left and then right, and gradually moves to the diseased area. Pay attention to the comparison between the diseased area and the healthy area, and observe the reaction and expression of the person being inspected during the inspection. For those who are nervous or in pain, comfort and explanation should be provided. You can also talk to them while palpating them to divert their attention and reduce abdominal muscle tension to complete the examination. 1) Abdominal palpation method (1) Superficial abdominal palpation: The examiner gently places his right hand on the abdomen of the subject, and uses the coordinated movements of the metacarpophalangeal and wrist joints to gently slide and touch. (2) Deep abdominal palpation: You can use the palm of your fingers to move from shallow to deep, and gradually apply pressure to reach the deep part. Deep palpation should result in abdominal wall depression of at least 2cm. When the abdominal wall of the person being examined is thick or the examiner is weak, you can place your left hand on the back of your right hand, overlap your hands and apply forceful pressure and palpation at the same time. ① Deep sliding abdominal palpation: The examiner gradually touches the abdominal organs or masses with the tips of the index, middle and ring fingers of the right hand that are brought together, and makes sliding touches up and down, left and right on the touched organs or masses to detect the organs. or the shape and size of the mass. ② Bimanual abdominal palpation: The examiner places his left hand on the lower back of the examined organ or mass, and pushes the examination site toward the right hand. This not only plays a role in fixation, but also makes the examined organ or mass Closer to the body surface to facilitate palpation with the right hand. ③ Deep pressure abdominal palpation: Use the pointer and middle finger of the right hand to gradually press deeply to detect the location of the disease deep in the abdominal cavity, or to determine the abdominal tenderness point. ④ Impact abdominal palpation: also known as floating and sinking palpation method. During the examination, the 2nd to 4th fingers of the right hand are brought together and bent at an angle of 70 to 90 degrees, placed on the corresponding part of the abdominal wall, and several rapid and powerful impact movements are made to temporarily remove the ascites from the surface of the organs, and the organs will follow. During the impact, there will be a feeling of floating internal organs in the abdominal cavity on the fingertips. This method is generally only used for palpation of liver, spleen, and abdominal masses when there is a large amount of ascites. 2) Abdominal palpation content (1) Abdominal wall palpation ① Abdominal wall tension: Normal people have a certain amount of tension in the abdominal wall, but it is soft to touch and is easier to collapse, which is called soft abdominal wall. In patients with abdominal lesions, the abdominal wall tension increases throughout the abdomen or in parts of the abdomen, and even rigidity may occur. ② Inspection of full abdominal wall veins: Some subjects have full abdominal wall veins or varicose veins. At this time, the flow direction of venous blood should be checked.

To check the blood flow direction of the abdominal wall veins, a section of vein that runs up and down without branches should be selected. The examiner will press the index finger and middle finger of one hand together on the vein, and then push one finger outward along the vein to make a section between the two fingers. The blood vessel collapses due to ischemia. After reaching a certain distance, relax one finger and still press the other finger tightly. If this squeezed vein quickly fills up, the blood flow direction will be from the relaxed end to the compressed finger end. Repeat the same method, relax the other finger, and watch the filling speed of the vein to see the direction of blood flow. ③Tenderness and rebound tenderness: In normal people, the abdomen does not cause pain when pressed, but only a sense of oppression when pressed heavily. Real tenderness mostly comes from lesions in the abdominal wall and intra-abdominal cavity. After the examiner palpates the abdomen with his hands and tenderness appears, he still presses his fingers on the original place for a moment to stabilize the tenderness, and then quickly lifts his hand. At this time, the examinee feels that the abdominal pain suddenly worsens, often accompanied by pain. The expression or groan is called rebound pain. Rebound pain is a sign that inflammation of the abdominal organs has involved the peritoneal parietal layer. When the hand is suddenly raised, the peritoneum is stretched, causing severe pain. (2) Organ palpation ① Liver palpation: One-handed palpation, two-handed palpation and hook finger palpation can be used. One-handed palpation method: The examiner places the right palm flat on the right upper abdomen of the subject, with the three middle fingers together, the metacarpophalangeal joint and wrist joint naturally straightened, so that the radial edge of the index finger faces the costal margin, or the index finger and middle finger Point the fingertips to the costal margin, start palpation from the umbilical level or the estimated lower edge of the liver, and work closely with the examinee's abdominal breathing movements from bottom to top. During breathing, the abdominal wall relaxes and sinks, and the fingers of the right hand apply pressure to the deep abdomen in a timely manner. When inhaling, the subject's abdominal wall bulges, and the fingers touch the downward moving edge of the liver toward the costal edge. Repeat this process, and gradually move the fingers toward the costal edge until the lower edge of the liver or the costal edge is touched. Bimanual palpation method: The examiner's right hand is in the same position as the single-hand method, and the patient's right lower back is supported with the left hand, and the thumb of the left hand is placed on the right rib. During palpation, push the left hand upward to make the lower edge of the liver close to the anterior abdominal wall. It moves downward and limits the expansion of the right lower chest during inhalation to increase the downward movement of the diaphragm and improve the effect of palpation. The hook finger palpation method is suitable for children and those with thin and soft abdominal walls. During palpation, the examiner is positioned next to the examinee's right shoulder, facing his feet, and puts his right palm on the lower part of his right chest and the second to fifth fingers of his right hand. The flexion is hook-shaped, and the examinee is asked to perform deep and slow abdominal breathing exercises. The examiner further flexes the finger joints as he inhales, so that the fingertips can easily touch the lower edge of the liver that moves downward. The contents of liver palpation include liver size, texture, surface and edge conditions, tenderness, pulsation, friction, and tremor. The liver of a normal adult is soft and feels like pursed lips. The surface is smooth, the edges are neat, and the thickness is consistent. There is no tenderness, pulsation, friction or tremor. ②Palpation of the spleen: The person being examined should be in the supine or right-side position. When the patient is lying on his back, his legs are flexed. When he is lying on his right side, his right lower limb is straightened and his left lower limb is flexed. The examiner's palpation technique is roughly the same as the liver palpation technique. Single-handed palpation, bimanual palpation or hook-finger palpation are commonly used. The difference is that during bimanual palpation, the examiner's left hand bypasses the person being examined. In front of the abdomen, place the palm of the hand on the left lower back, with the four fingers naturally close together. The right hand for palpation is placed flat on the left anterior abdominal wall connecting the iliac crest, with the fingers perpendicular to the left costal margin, first along the left midclavicular line and gradually to the left Touch the costal margin. If not, check along the left front axillary line or left parasternal line. Hook finger palpation method: The examiner is located near the left shoulder, facing the foot, and the 2nd to 5th fingers of the examiner's right hand are flexed into a hook shape, facing the left costal margin to touch the downwardly moved lower edge of the spleen.