DOKTER MUDA BAGIAN/KSM BEDAH FAKULTAS KEDOKTERAN UNIVERSTAS SYIAH KUALA RUMAH SAKIT UMUM DAERAH DR. ZAINOEL ABIDIN Bimbingan Hafidh Maulana Nadya Alivia Jailani Widia Putri 2207501010246 2207501010256 2207501010255 Supervisor dr. Khalikul Razi, Sp.B(K)BD Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Common Complaints Anorexia voniting flatulance Diarrhoea Clay colour stool Black tarry stool Abdominal pain/ lump Hematemesis Epistaxis Nausea Dysphagia REtrosternal Burning Constipation Worms/ mucous in stool Abdominal distension Melena Bleeding per rectum Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Past History Tuberculosis Kala azar Hemolytic crisis Bleeding disorder Surgery Malaria Leukemia Sexual contact H/O Blood transfusion Jaundice Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala General Inspection Nutritional state (wasting) BMI Pallor Jaudice (liver disease) Pigmentation (hemochromatosis) Mental state (encephalopathy) Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Hands Nails Clubbing Koilonychia Leuconychia Palmar erythema Dupuytren’s contractures Hepatic flap Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Palmar erythema Dupuytren’s contractures Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Arms Spider naevi (telangiectatic lesions) Scratch marks (chronic cholestatis Bruising Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Face, Eyes Conjuctival pallor Sclera: jaundice Cornea: kaiser fleischer’s rings (wilson’s disease) Xanthelasma (primary biliary cirrhosis) Parotid enlargement (alcohol) Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Parotid enlargement Xanthelasma Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala And Mouth Fetor hepaticus lips Angular stomatitis Cheilitis Ulceration Gums Gingivitis, bleeding Candida albicans Pigmentation Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Atrophic glossitis Thrush Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Neck And Chest Cervical lymphadenopathy Left supraclavicular fossa (virchow’s node) Gynaecomastia Loss of hair Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Positioning Abdomen can be divided in four quadrants Patient should be lying on supine position Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Regional Division Of Abdomen Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Right Upper Quadrant Liver: right lobe Gallbladder - murphy’s sign Stomach: pylorus Duodenum: parts 1-3 Pancreas: head Right suprarenal gland Right kidney Right colic (hepatic) flexure Ascending colon: superior part Transverse colon: right half Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Left Upper Quadrant Liver: left lobe Spleen Stomach Jejunum and proximal ileum Pancreas: body and tail Left Kidney Left Suprarenal gland Left colic (splenic) flexure Transverse colon: left half Descending colon: superior part Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Right Lower Quadrant Cecum Vermiform appendix Most of ileum Ascending colon: inferior part Right ovary Right uterine tube Right spermatic cord Uterus (if enlarged) Urinary bladder (if full) Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Left Lower Quadrant Sigmoid colon Descending colon: inferior part Left ovary Left uterine tube Left ureter: abdominal part Left spermatic cord: abdominal part Uterus (if enlarged) Urinary bladder (if full) Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Before Examination Ensure that bladder is empty Patient comfort Arms at side or corssed over chest Ask the patient to point to any painful areas; examine last Warm hand and stethoscope Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Inspection Shape and movements Scars Distention Prominent veins Striae Bruises Pigmentation Visible peristalsis -pyloric stenosis - left to right large intestine obstruction - left to right Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Shape Normal Pregnancy Ascites Fatty Abdomen Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Scars Various Abdominal Incision 1. Kocher's incision 2. Midline incision 3. Gridion muscle splitting 4. Battle incision 5. Lanz incision 6. Paramedian incision 7. Transverse incision 8. Rutherfold Morrison incision 9. Pfannestiel incision Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Abdominal Movement Normal Male : Abdomino-thoracic Female : Thoraco-abdominal Infants : Thoraco-abdominal Disease Diaphragmatic palsy : Bulging during expiration Peritonitis : No movement Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Abdominal Pulsation Aortic pulsation- visible in nervous, anemia Aortic aneurysm- expansile pulsation in any position Transmitted pulsation- any mass lying over major artery produce pulsation. On making puddle sign it will disappear. Rt ventricular pulsation seen in epigastric region Congestive liver produce pulsation posteriorly Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Dilated Vein Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Hernial Sites Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Palpation Abdominal palpation in the four-quadrant scheme. (A) Light palpation. (B) Deep palpation. Hsu, Jia-Lien & Lee, Chia-Hui & Hsieh, Chung-Ho. (2020). Digitizing abdominal palpation with a pressure measurement and positioning device. PeerJ. 8. e10511. 10.7717/peerj.10511. Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Palpation Characteristics of an abdominal mass 1. Location 2. Size 3. Shape 4. Consistency 5. Surface 6. Tenderness 7. Movable or fixed 8. Shifting by respiration Tenderness: discomfort and resistance to palpation Involuntary guarding: reflex contraction of the abdominal muscles Rebound tenderness: patient feels pain when the hand is released Tenderness + rigidity: perforated viscus Palpable mass (enlarged organ, faeces, tumour) Aortic pulsation Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala McBurney’s Point 1/3 ASIS to umbilicus Location of AV in retrocecal position Deep tenderness (acute appendicitis) Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Blumberg’s Sign Rebound tenderness Pain upon removal of pressure rather than application of pressure to the abdomen Peritonitis and/or appendicitis Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Fluid Thrill Place the palm of your left hand against the left side of the abdomen Flick a finger against the right side of the abdomen Ask the patient to put the edge of a hand on the midline of the abdomen If a ripple is felt upon flicking we call it a fluid thrill = ascites Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Puddle Sign Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Palpation of The Liver Flex the knee joint Ask the patient to take a deep breath in Start palapting in the right iliac fossa Move hand progressively further up the abdomen Try to feel the liver edge Check for the liver span Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Palpation of The Spleen Roll the patient towards you Start from right illiac fossa Palpate with right hand while using left hand to press forward on the patient’s lower ribs from behind Feel along the costal margin Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Spleenomegaly Traube’s Space boundaries- Left anterior axillary line, 6th rib, costal margin Castell’s-resonating traube’s area Nixon’s method-dullness extends >8 cm Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Bimanual Palpation Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Percussion Dull sound : solid or fluid-filled structures Resonant sounds : structures containing air or gas Shifting dullnes Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Shifting Dullness Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Auscultation Place the diaphragm of the stethoscope to the right of the umbilicus Bowel sounds (borborygmi) are caused by peristaltic movements Occur every 5-10 sec Absense of b.s : paralytic ileus or peritonitis Bruits over aorta and renl a could be a sign of an aneurysm and stenosis Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Other Examination Per rectal examination Inspection Palpation Examination of Hernia Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Few Difference Ascites Spleen lump Asciter Mysentric cyst Kidney lump Ovarian cyst Bagian/KSM Bedah Fakultas Kedokteran Universitas Syiah Kuala Thank You
