now the important thing if you look number 35 right now the beginning it says that the patient must lie flat right remember in pulmonary and cardiovascular at a 45-degree 30 to 25 this one we need to keep them in a supine position we're gonna have him flex his knees bend at the knees and there's arms will I write to his side exposure for our patient if you're in a hospital setting in a clinic setting more than likely you're Narn whatever is working with you already have a patient in the gown and Drake with a sheet so we need to move the gelda I usually take the sheet and again I'm going to kind of move they gallon up just to design point so that I met the xiphoid process needs to be exposed and I'm gonna sheet down just over the super pubic region so I have the full automatic so that is the right position arms at the side knees flexed draped from the xiphoid to the super pubic region all right so I'm going to instruct my patient that like fee delay in the supine position with the knees bent throughout the entire exam and I'm going to take a look what's the first thing we do on any system it's always inspection first so we're inspecting for contour and the symmetry the skin lesions like scars try to go rashes and then we're also looking for pulsations this in the lab you don't have to do it in any exam room I mean excuse me the lecture it actually shows tangential riding it talks about it just like when we're looking for lifts and heaves on the chest wall you can also use tangential line in order for pulsations we talk about whether the abdomen is protuberant rounded we could we talk about also is that abdomen flat or concave you talk about the shapes of the abdomen right so once we've inspected that when we see that they have minutes flat no scars no strike number 38 is auscultation so when we also take the abdomen it's with the dead the die offending sort of diagram first she listens with the diagram that the patient has a complaint in certainly the abdomen gotta be the last place that we actually do our exam so traditional mini gasp no complaints we're gonna starting to the right upper quadrant I'm listening to the diaphragm over the right upper corner Emma listen with the left upper quadrant the left lower quadrant right little quadrants and also talked in class about the four plus three Dom exam so we have the four quadrants is divided superior inferior by the umbilicus and then the left and right side bottom builders the regions right are the three regions we have the epigastric region which lies just inferior to the xiphoid process we have the peri umbilical or the umbilical region right around the bilikiss then we have the hypogastric or the super pubic region which is just above the super pubic line okay so on our exam we're going to do the four quadrants and the three regions so in auscultation most of her bowel sounds which are present okay that's our key indicator of performance and then we're going to listen to the abdominal vessels right so this we have to use the we talked about the first place is going to be the Nordic day Warnock lies just to the left a bit line but just to life then there's the renal the left renal right renal just inferior to umbilicus celiac left iliac then we would mention we'd listen to the femoral pulses top pay for inguinal lymph nodes right so at this point you say that femoral pulse is full and equal bilaterally and there's no England all that aDNA lymph adenopathy no breweries or nothing right percussion now we're going to perk us the general reasons for Tiffany and all four products and there can be some dullness right same regions so right upper quadrant left upper quadrant tiffany blue on the dull side Tiffany at the gastro umbilical super pubic changes you agree [Music] now no one than that I know that I've got a liver over here solid and I don't have a spleen on this side expect this also probably more tympanic does this be my swimsuit so far back so this is probably still tip and a gastric there bubble should be here so Tiffany down here I just got I've got the descending colon down here I've also got the colon on this side I've also got some small bowel around umbilicus why do you think I'm having dullness time I hear a bowel movement BM pcs stool the other class called it breakfast because it's got a - should actually an ascend transverse and descent that's probably breakfast on this side right this is probably lunch there know about digestion right out of the stomach in the house for six hours coming into the small bowel eight hours it's into the large bowel eight to ten hours and then fourteen to sixteen hours of Sun so we expect to find some dullness in those so we've got percussing there Tiffany and dullness right which was done now liver percussion we're going to perk us deliver it in the midclavicular line I told you that for me I like to start because I've found a lot of pathology this way in the liver I want to start around the umbilical region don't that's my first time at all that totally changed Tiffany doll that's not resonant so that's definitely not long right I'm in the mid clavicular line doll tiffany dullness resonance right on so coming from timpani to dullness that is my bottom liver edge my border that's where I make a mental note where I find that right so it's like in the fifth intercostal space midclavicular line on the right side right so now from here because these male I don't have to percuss through a bunch of breast tissue I'm going to start up high bait says start high and go from residents to dullness that's about my fourth intercostal space so he does not have a very large liver measurement right so with my measuring tape he is five centimeters all right in the mid clavicular line okay displayed percussion this happens in this sixth intercostal space we know that the heart border the right atrium the right ventricle the apex of the heart line in the fifth intercostal space the left sternal border that kind of descends all the way up just about to the midclavicular line and then you're applying the apex of the heart right that's fit intercostal space we're gonna drop to the sixth intercostal space which is the space just below it we're going to start in the mid clavicular line looking for a timpani we go from the anterior axillary line to the mid-axillary line which is termed true bow space once we get to the mid axillary and how do you take a deep breath that's perfect cushion sign if it goes from timpani to dull that's a positive sign for a potential enlarged spleen okay is desert so one more time sixth intercostal space take a deep breath in no change so that's played percussion signs when you press over that place when you take the deep breath in so noticeably the magnitudes no to the per tippity now we're going to do our light palpation light palpation will follow the same order that we did auscultation light palpation to be the own two hands and it's more about using the pads and I'm displacing tissue right so that's my right upper quadrant left upper quadrant I've left lower quadrant yeah tinder when I'm palpating looking at his faces as well as see if his face changes like winters or grimaces right so no tenderness in my epigastric area umbilical super pubic region light palpation no tendons I'm going to go a little deeper then right upper quadrant left upper quadrant my left lower quadrant the gastric ring umbilical super pubic or hypogastric region okay so no tenderness elicited okay my deep my rebound turns is whenever I'm palpating my patients belly I get to if he says that this is where it hurts the most sir okay that's the last place we're gonna go when I get over that region right regarding deep palpated everything and I'm like tell me what hurts worse when I push in or when I let go let go this would be rebound tenderness I don't so deep palpation deep palpation deep tell me which one hurts more that or that that's rebound okay so for him though there's nobody beyond tenderness abdominal aorta it's typically less than three centimeters and it should have no lateral expansion but of course it has a lot of pulsations but no lateral expansion meaning that should not be greater than three so when I measure his abdominal aorta I come up to him and remember that a couple of things here if we go too high into the abdomen because of the regular diameter of the chest you got further to go because where does that you are to live it's retroperitoneal right right behind the parents name so we've got to get pretty deep on so I know it just lies left to the mid mid line just a little bit to left so I'm going to put a little pressure here let me know if this hurts and then I'm going to take this finger and I'm going to bring it in here I want to try the lateral try to find the lateral pulsation to my right hand so this finger I found the edge I found the right side of the aortic wall as I move my finger out I'm gonna find the lateral portion where's just a budding my finger my right finger my right index once I find that once I find that that's what I'm gonna mesh make that measurement right that's what I want to take the measure from here to here and he is approximately two and a half centimeters just remember the things you got to remember here is that you need to come down into the abdomen almost lateral to the umbilicus is easiest place go to high you got a lot of more tissue to go through right remember it's retroperitoneal so this light finger stuff it's not going to work you've got a really good deeper find okay so for us we say that they've only worn it is 2.5 centimeters wide without my own expansion liquor mortars right we're looking for a costal margin right in the meat clavicular line you the best way I found was I kind of use the inside the lateral aspect of the index cleaner and the palm because I can cover so much space right and it kind of fits nicely right up into that costal that costal margin so I'm gonna have my patient take a deep breath in that brings one delivered down into my hand and let it out then I kind of slide my hand up into that costal margin I'm trying to feel for a liver edge I don't feel anything you got tender so that is my liver border so livers not palpable and non-tender okay now I'm going to have you late on your right side go to me I'm going to palpate for just so this hand supports his back I'm gonna bring him into my hand if you notice I've got the costal angle again here once again I want to apply pressure okay breathe in that should bring the spleen into my hand I don't feel it and then let it out exhale then I push against at any tenderness no so no palpable spleen or spleen is non palpable I've done the reflexes this is a matter of the milk is actually moving if it will so we're not actually strength but actually cause this sensory the umbilicus should move to one side of the other that doesn't here so he doesn't have a reflux so for that said that's not an admirable finding either number reflexes would mean something to me if he has normal abdominal pain nausea vomiting a fever I suspect a perforated bowel or perforated appendix or some kind of peritonitis then I will definitely not have a reflux in the abdominal reflux right but not having one doesn't mean much to me either especially when it's not associated with anything else okay so for us we're going to say that abdominal reflux is not present remember that we always mentioned that genital urinary exam anytime that we have pain that lies a Roman bilikiss or or inferior to the umbilicus that has pretty much requires pretty much requires genital urinary exam have all kinds of herniation role or indirect hernias that should be evaluated in females you can have PID or some other infectious process in the pelvis and the page is kind of migrates up into the abdomen so you've got to be able to differentiate so any pain that migrates up above the umbilicus will require genital here learning and of course a rectal exam but for automatically zero Mella masses tennis all right so make sure you mention that that's number 50 special tests so on exam day there will be special test class reports to do it'll be one of these six murky sign is first that's what I'm gonna demonstrate first Murphy sign is just where we take our hand applied into that right upper quadrant again take a deep breath in while he inspires at any point he splints meaning that he stops inspiration because it hurt so bad that is a positive Murphy sign or an exhale and it stopped him again that is a sign of a positive Murphy site so it for so cessation of inspiration on that palpation the right upper quadrant would be a positive Murphy Sun they'd only have so assign boat legs for these exams they're both extended I'm gonna have you raise this leg up and I kind of help them put them into that position I want you to hold it right there don't let me push it down push on it does that cause pain in your positive would be a sign of peritonitis typically associated with appendicitis so I'll do this I'm causing a lay up source to bump up against as it flexes bump up against that inflamed appendix ever source top trader internist I'm flexing on his hip flexor man his hip I flex meant the knee then I internally rotate my internal rotation where is the outrageous internist and that worked also do the same concept as nearly up so is causing that most of the flexed against their tendons or an inflamed tissue around the pendant right then there's the old heel tap heel tap I just found out there April I'll lift a month and these stays locked just like that I just give a couple of hits just like that this afternoon that reverberation of those muscles would cause pain okay so that's a heel tap and then the shifting dullness shifting dullness is as simple as this if we're on the side and we have this patient with a protruding belly he's jaundiced for sure his abdomen is kind of rigid too tight right is very distended when I go to this side I'll reach around him and I start for cussing the flank as a percussive like I note that the note is dull it's a dull sound I'm gonna start by cutting up the abdominal wall dog dog dog dog dog until I get to a resonant sound and the reason it's resin is because I've trapped air that is true air trapped in the abdomen so this becomes very resonant right resident resident so I mark that line dullness started here resonance started here okay now I'm gonna roll you up on your right side so as I moved him up what do you think happened between this Domus and this resident no they swap right so it now becomes more resonant top so weird was dull I marked at it's doll or I have a middle mark in my brain it was dull there it is now resonant the air has moved up and the dullness has now shifted to where it was once resonant right shifting dullness so they changed places air comes to the top fluid travels to all right that's shifting dollars way back and the last but not least is the available drops inside Rob Singh sign as I'm moving across if my patient tells me he has pain in his right lower quadrant or left war it doesn't matter but in the right lower quadrant specifically as I'm moving across and doing my deep palpation right I'm in my left lower quadrant pain to the right lower quadrant I think it's appendicitis as I apply pressure and there's that hurt like never really been this tough to spot it's on the other side the minute that I did this number he would actually feel pain in the right lower quadrant that would be a positive rob Singh right it's a deep palpation in the left deep release fast trying to elicit rebound I get the rebound but it's on the opposite side that's a positive prophecy