The idea that drinking cold water must burn more calories developed from the belief that our bodies expend energy to warm up. It is true that your body will work to raise its temperature to 98.6 degrees Fahrenheit, but it will only expend about eight calories to do this.So what about food?Who cares, let's just use every tricks possible to speed up the process and learn along it.
Hot food has more thermal energy than cold food, and thus more small calories, and that means the chemical energy required to digest it is slightly less. But normally this isn't enough to matter at all so it will not show up in diet charts.
To maximize shredding process.
Clinical Examination of Abdomen
From my experience in med school,each lecturer refer to different books and methods.Some are so annoying with their god like self proud.So get to know their preferences but if
you're a doctor,then this can be used freely as a basic guidance.
Hope it helps.For any question,you can send your mail at pranasteya@gmail.com
🤪🤗
After a complete history,it's part B.
B.PHYSICAL EXAMINATION
It consist of two part.
1.General Survey
2.Local Examination of Abdomen
Inspection
(Patient is in supine position with arm extended and exposed from mid chest to mid thigh)
-Shape and contour of abdomen
*Normal /scaphoid/distended
-Umbilicus
*position/normal/deeply inverted/flushed/everted
-Skin over the abdomen
*scar(if operative scar-describe as upper midline/lower midline/upper paramedian/lower paramedian/right or left subcostal incision scar)
*pigmentation
*striae(white striae found in multiparous women is to be describe as striae albicans)
*engorged veins
1.Abnormal prominent veins on abdominal wall suggest portal hypertension(caput medusae) or vena caval obstruction.
2.Umbilicus appear bluish and distended maybe due to umbilical varix.In contrast,an umbilical hernia is a distended and everted umbilicus which does not appear vascular and may have a palpable cough impulse.
3.Dilated tortuous veins with blood flow superiorly are collateral veins due to obstruction of the inferior
-Movements
*respiratory movement whether all region are moving normally with respiration.
*visible peristalsis
*pulsatile movement-usually vascular tumour
-Visible swelling
*site and extent
*size
*shape
*surface
*margin
*moving with respiration or not
*straight leg rising test-whether swelling is parietal or intra abdominal
I explained how to distinguish them below.
-Hernial sites
*any swelling
*any expansile impulse on cough
-External genitalia
Region of Abdomen
The abdomen is normally flat or slightly scaphoid and symmetrical.At rest,respiration is principally diaphragmatic,the abdominal wall moves out and the liver ,spleen and kidneys move downwards during inspiration.The umbilicus is usually inverted.
The normal liver is identified as an area of dullness to rib percussion over the right anterior chest between 5th rib and the costal margin.
The normal spleen is identified as an area of dullness to percussion posterior to the left mid-axillary line beneath the 9th,10th and 11th ribs.
Palpation
Consist of three part-Superficial,deep and organ palpation.
Normal findings on abdominal palpation maybe include the following.
*the liver edge maybe felt below the right costal margin.
*the aorta maybe palpable as a pulsatile swelling above the umbilicus.
the lower pole of right kidney maybe palpable in the right flank.
*faecal scybala maybe palpable in the sigmoid colon in the left iliac fossa.
*a full bladder asing out of the pelvis maybe palpable in suprapubic region.
Superficial Palpation
-Temperature
Examine all the region of the abdomen(compare temperature of the abdomen with the temperature of abdomen with the temperature of chest with dorsum of fingers
-Any superficial tenderness
*Visceral abdominal pain from distension of hollow organs,mesenteric traction or excessive smooth muscle contraction is a deep ,poorly localized sensation in the midline
conducted via sympathetic splanchnic nerve.
*Somatic pain from the parietal peritoneum and abdominal wall is lateralized and localized to the area of inflammation.
*Pain arising from stomach,pancreas and biliary system is localized above the umbilicus.
*Pain from small intestine is felt around the periumbilical.
*Colonic pain from from diverticular disease of sigmoid colon can be felt below umbilicus.
*Pain from hepatic flexure can be felt at upper abdomen,example in right hypochondrium.
*Pain from unpaired structure like pancreas is felt in the midline and radiates to back.
-Feel of the abdomen
*soft and elastic feel is normal
*muscle guard
*rigidity
-Lump palpable
Details of the lump is to be describe under deep palpation.
Deep Palpation
-Deep tender spots(any tenderness over the following sites)
*gastric point-point in the mid epigastrium
*duodenal point-a point in the transpyloric plane 2.5cm to the right of midline
*gallbladder point- a point at the junction of lateral border of right rectus abdominis and the tip of 9th costal cartilage.
*McBurney's point-a point in the right spinoumbilical line at the junction of medial two third and lateral one third.
*amoebic point- a point on the left spinoumbilical line corresponding to McBurney's point on right side.
*renal point- a point at the junction of lateral border of erector spinae and 12th rib.
*murphy's sign-found positive in patient with acute cholecystitis.Usually not demonstrable in chronic cholecystitis.
Palpation of Organs
-Liver
-Spleen
-Kidney
Normally gallbladder is not palpable.
I will cover the details below at liver palpation.
Stomach is usually not palpable.In cases of gastric outlet obstruction ,the distended stomach maybe palpable in epigastrium which disappears with passage of peristalsis waves from left to right.
Normal pancreas is not palpable.
Palpation of any other lump-
*position and the extent in relation to abdominal regions.
*shape
*size
*surface
*margin
*consistency
*mobility-with respiration
*mobility from side to side,up and down
*fixity to skin or underlying structure
*rising test to confirm intra abdominal or pariteal swelling
*knee elbow position and examine the swelling again to decide whether swelling is intra peritoneal or retro peritoneal.
The peritoneum is the serous membrane forming the lining of the abdominal .The outer layer is the parietal while within peritoneum is intra abdominal.
Intra peritoneal means within peritoneum while retro means behind the peritoneum.
PARIETAL VS INTRA- ABDOMINAL
-Can be ascertain by either head rising or leg rising test.
When you lift your head and shoulders,if the swelling disappears or become less prominent,then the swelling inside the abdomen (Intra abdominal). If the swelling becomes more prominent or remain the same then it's parietal.
For lower abdominal swelling,lying on bed and lifting both the legs bring the same interpretation as head rising test.
INTRA-PERITONEAL OR RETROPERITONEAL
Do a knee elbow position .
If the lump disappears or become less prominent,then its retroperitoneal.If swelling becomes more prominent or remains the same, it's intra-peritoneal.
Percussion
*shifting dullness
*fluid thrill
*succussion splash over stomach
*upper border of liver dullness
*upper border of splenic dullness
*percussion over any abdominal lump palpable.
Ausculation
*peristaltic sound
*bruit
*venous hum
*any added sound
*ausculto-percussion-in case of gastric outlet obstruction to delineate the greater curvature of stomach.
Per Rectal Examination
Per vaginal Examination
I will try to cover each methods here.
Palpation of Abdomen.
1.The palpation is done with the patient in supine position,with arms by the side.He will be exposed from mid thigh to just above the xiphisternal.
This was what we were required back in Bangladesh.If it's a female,a female attendent must be there.
2.The patient will be asked to take deep breathing with the mouth open.The abdomen muscle get relaxed during expiration and in the pause between inspiration and expiration.
3.The forearm of the clinician should be kept horizontally at the same level of the abdomen.Palpate with a warm hand particularly during winter.(We don't usually use gloves) maybe it's same worldwide.Hope he or she isn't HPV positive.
If the hands are cooler,rub two hands together to make the hand warmer before palpating the abdomen.
The palpation is best done with the flexor surfaces of the fingers and not with the tip of the fingers.
4.Use your right hand,keep it flat in contact with the abdominal wall and always be at the right side of the bed.
5.Observe the patient's face for any sign of discomfort throughout the examination.
6.Begin with light superficial palpation away from any site of the pain.Ask the patient prior to show you where the pain is and to report any tenderness elicited during palpation.
7.Palpate each region in turn,then repeat during deeper palpation.
8.Test abdominal muscle tone by light,dipping movements with your fingers.
How to Palpate Liver?
1.Patient lies supine with the legs flexed at the hips and knees.
2.Place the hand flat on the abdomen parallel to the right costal margin with the fingers pointing upwards and placed lateral to the rectus muscle.
3.The finger tips are placed to lie parallel to the edge of the liver.
4.Start palpating from the right iliac fossa and move upwards.(1cm at a time guidance can be use if you want).
5.Ask the patient to take deep breaths with open mouth.With each expiration,the hand is moved nearer the right costal margin.
6.If the liver is enlarged ,the finger tip will slide over the edge of the liver.
7.Palpate the edge of the liver and if you feel a liver edge,describe as
-size
-surface-smooth or irregular
-edge-smooth or irregular
-consistency-soft or hard
-tenderness
-whether it is pulsatile
-any audible bruit
8.Using the fingertips,the edge and surface of liver is palpated by changing the position of the fingertips along the surface and edge of the liver.
9.Alternatively,the enlarged liver border maybe palpated with the radial border of the index finger.Start palpating from right iliac fossa towards the right costal margin keeping the radial border of the index finger parallel to the right costal margin.
Describe the enlargement as in cm below the right costal margin.
Gallbladder
Normally gallbladder is not palpable.
1.If gallbladder is distended or there is mass in relation to gallbladder,the gallbladder maybe palpable.
2.In cholecystitis ,feel for gallbladder tenderness.Ask the patient to breathe in deeply as you gently palpate the right upper quadrant of
the abdomen in the midclavicular line.As the liver descends,the inflamed gallbladder,contacts the finger tips,causing pain and the sudden
arrest of inspiration .Its Murphy's sign.
4.Palpable distension of the gallbladder has a characteristic globular shape.It is rare and results from either obstruction of the cystic duct as in a mucocoele
or empyema of the gallbladder or obstruction of the common bile duct.
5.If the gallbladder is palpable in a jaundiced patient,the obstruction is likely to be due to pancreatic cancer or distal cholangiocarcinoma and not gallstones(Courvoisier's Law).
6.In gallstone disease ,the gallbladder maybe tender but impalpable because fibrosis of the gallbladder wall.
How to Delineate the Upper Border of Liver?
1.Start by percussion in the right mid axillary line at 4th intercostal space and if clear resonant note is obtained,percuss downward until a dull note is obtained.
2.This marks the upper border of liver dullness.
3.Remember,in infants below 3 years of age,liver maybe palpable 2-3 fingers below the right costal margin.
4.In healthy thin adult,the liver maybe palpable just below the costal margin.
How to Palpate the Spleen?
Normal spleen is not palpable and become palpable only when enlarged 1 1/2 to 3 times the normal size.The spleen enlarge towards right iliac fossa after emerging from below of the left costal margin.
1.Patient lies supine with the arms by the side of the patient.
2.The left hand is placed over the left lateral chest wall exerting some amount of compression.
3.Start palpating from the right iliac fossa with the fingertips pointing towards the left costal margin.
4.Ask the patient to take deep breaths.At the zenith of inspiration,if the spleen is enlarged ,the tip of the fingers will ride over the edge of the spleen.
5.If the spleen is not palpable by this method,turn the patient to the right lateral position and palpate with the tip of fingers below the right costal margin.
How to Palpate Kidney?
1.For palpation of the right kidney,place the left hand posteriorly in the left loin between the ribs and the iliac crest.
2.Place the right hand horizontally anteriorly in the right lumbar region.Ask the patient to take deep breath and press the right hand backward and press the left hand forward.
3.Kidney is normally not palpable.If kidney is enlarged,it maybe palpated between the two hands(bimanually palpable).
4.The palpable kidney maybe pushed from one hand to the other as kidney is ballotable.
5.The extent of the enlargement ,size,shape,margins,surface and consistency of the swellings are assessed.
6.Palpation of the left kidney is done in the same way by placing the left hand posteriorly in the loin and placing the right hand horizontally anteriorly in the right lumbar region and is palpated as above.
Difference Between Enlarged Spleen and Left Kidney
Enlarged Spleen
Direction of Enlargement-Towards right illiac fossa
Notch-Present in anterior border
Margin-Sharp
Finger Insinuation-Not possible
Bimanually Palpable-Not palpable
Movement with Respiration-Move early more
Percussion-Dull
Enlarged Left Kidney
Direction of Enlargement-Directed downwards
Notch-Absent
Margin-Rounded
Finger Insinuation- possible
Bimanually Palpable-palpable
Movement with Respiration-Lately move(less)
Percussion-Band of colonic resonance
How to Elicit Fluid Thrill?
1.Patient laid supine.
2.Place one hand flat over the lumbar region of one side.Ask the patient to keep the side of his hand firmly in the midline of the abdomen.
3.Tap the opposite lumbar region.
4.A fluid thrill is felt as wave in the palpating hand laid flat in the lumbar region.Fluid thrill is demonstrable in the presence of huge ascites.
How to Demonstrate Shifting Dullness?
1.Patient is asked to empty the bladder and laid supine on the bed.
2.Palpate for any swelling in the abdomen.If a swelling is present,avoid percussion over the swelling.
3. Percuss over the midline from the epigastrium to the symphysis pubis.
4.Percuss the abdomen from the centre of the abdomen towards the flank on one side and mark the point from where the note is dull.
5.Percuss from the centre of the abdomen to the other flank and mark the point from where it become dull.
6.The areas of dullness in both flanks are marked out.
7.Turn the patient to the right side and wait for few seconds.
8.Now start percussion from the left flank towards the right flank.The dull area in the left becomes resonant and the dullness on the right flanks is pushed more medially.
9.The percussion is repeated by turning the patient to the opposite side.
Auscultation of The Abdomen
1.With the patient lying on his back,place the stethoscope diaphragm to the right of the umbilicus and do not move it.Bowel sounds are gurgling noises from
the normal peristaltic activity of then gut.They normally occurs every 5 to 10 seconds but the frequency varies.
2.Listen for up to 2 minutes before concluding that bowel sounds are absent. Absence of bowel sounds implies paralytic ileus or peritonities. In intestinal
obstruction,bowel sound occurs with increased frequency ,volume and pitch and have a high pitched tinkling quality.
3.Listen above the umbilicus over the aorta for arterial bruits which suggest an atheromatous or aneurysmal aorta or superior mesenteric artery stenosis.
4.Now place the stethoscope 2-3cm above and lateral to the umbilicus and listen for renal artery bruits from renal artery stenosis.
5.Listen over the liver for bruits due to hepatoma or acute alcoholic hepatitis.A friction rub which sound s like rubbing your dry fingers together maybe
heard over the liver (perihepatitis) or spleen (perisplenitis).
Succussion Splash
6.A succussion splash sounds like a half filled water bottle being shaken.Explain the procedure to the patient then shake the abdomen by lifting him
with both hands under pelvis.An audible splash more than 4 hours after the patient has eaten or drunk anything indicates delayed gastric emptying such as
in pyloric stenosis.
Rectal Examination
1.Explain what you're going to do and ask for permission to proceed.Offer a chaperone,if the offer of a chaperone is refused,record the fact.Explain that
the examination maybe uncomfortable but should not be painful.
2.Position the patient in the left lateral position with the buttocks at the edge of the couch,the knees drawn up to the chest and the heels clear
of the perineum.
3.Put on gloves and examine the perianal skin ,using an effective light source and looking for evidence of skin lesions,external hemorrhoids and fistula.
4.Lubricate your index finger with water based gel.Place the pulp of the forefinger on the anal margin and with steady pressure on the sphincter ,push your
finger gently through the anal canal into the rectum.
5.If anal spasm is encountered ,ask the patient to breathe in deeply and relax.Use a local anesthetic suppository before trying again.If the pain persists,
examination under general anesthesia maybe necessary.
6.Ask the patient to squeeze your finger with the anal muscles and note any weakness of sphincter contraction.
7.Palpate systematically around the entire rectum.Note any abnormality and examine any mass.Record the percentage of rectal circumference involved by disease
and its distance from anus.
8.Identify the uterine cervix in women and prostate in men.Assess the size ,shape and consistency of the prostate and note any tenderness.
9.If the rectum contain faeces and you are in doubt about palpable masses,repeat the examination after the patient has defecated.That must be a painful scenario for you.😅🤗
10.Slowly withdraw your finger and examine it for stool color and the presence of blood and mucus.
She's sweet but with time,everything might change.
Even she might leave if she's my gf.
😆
🙂🆑
Lonely nights.
Thank you for posting this.
ReplyDeleteVery helpful ����
ReplyDeleteI found your this post while searching for some related information on blog search...Its a good post..keep posting and update the information. Class 6 Assignment 2021
ReplyDelete