PHYSICAL ASSESSMENT- GI & REPRODUCTIVE

ASSESSMENT

ABDOMEN

 Inspection

Stand on the person's right side and look down on the abdomen. Then stoop or sit to gaze across the abdomen. Your head should be slightly higher than the abdomen. Determine the profile from the rib margin to the pubic bone. The contour describes the nutritional state and normally ranges from flat to rounded

Contour: flat, pendulous, scaphoid

 Assess for bulges/masses/asymmetry

Shine a light across the abdomen toward you or lengthwise across the person. The abdomen should be symmetric bilaterally. Note any localized bulging, visible mass, or asymmetric shape. Even small bulges are highlighted by shadow. Step to the foot of the examination table to recheck symmetry.

Ask the person to take a deep breath to further Highlight any change. The abdomen should stay smooth and symmetric. Or ask the person to perform a sit-up without pushing up with his or her hands.

 Note umbilicus: midline, inverted, no discoloration, clean, no hernia and no inflammation.

Normally it is midline and inverted, with no sign of discoloration, inflammation, or hernia. It becomes everted and pushed upward with pregnancy. The umbilicus is a common site for piercings in young women. The site should not be red or crusted.

 Observe skin for:

Lesions

Normally no lesions are present, although you may note well-healed surgical scars. If a scar is present, draw its location in the person's record, indicating the length in centimeters. (NOTE: Infrequently a person may forget a past operation when providing history. If you note a scar now, ask about it.) A surgical scar alerts you to the possible presence of underlying adhesions and excess fibrous tissue.

Scars 

One common pigment change is striae (lineae albicantes)—silvery-white, linear, jagged marks about 1 to 6 cm long. They occur when elastic fibers in the reticular layer of the skin are broken after rapid or prolonged stretching as in pregnancy or excessive weight gain. Recent striae are pink or blue; then they turn silvery white.

 

Pigmented nevi (moles): circumscribed brown macular or popular areas are common on the abdomen

Distended veins

Veins usually are not seen, but a fine venous network may be visible in thin persons.

Pulsations

Normally you may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin people with good muscle wall relaxation. The respiratory movement also shows in the abdomen, particularly in males. Finally, waves of peristalsis sometimes are visible in very thin people. They ripple slowly and obliquely across the abdomen.

Auscultation

The patient is positioned comfortably in the supine position as described in Inspection. The stethoscope is used to listen over several areas of the abdomen for several minutes for the presence of bowel sounds. The diaphragm of the stethoscope should be applied to the abdominal wall with firm but gentle pressure. It is often helpful to warm the diaphragm in the examiner's hands before application, particularly in ticklish patients. When bowel sounds are not present, one should listen for a full 3 minutes before determining that bowel sounds are, in fact, absent.

Auscultation for abdominal bruits is the next phase of the abdominal examination. Bruits are "swishing" sounds heard over major arteries during systole or, less commonly, systole and diastole. The area over the aorta, both renal arteries. and the iliac arteries should be examined carefully for bruits.

Listen for bowel sounds with the diaphragm in all 4 quadrants, beginning with the RLQ.

Listen for Bruits with bell over:

Aorta

Renal arteries

 Iliac arteries

Percussion

Percuss abdomen in all 4 quadrants.

Hollow areas should be tympanic sounding whereas areas containing masses or organs will be dull e.g. liver. Changes in sound such as dullness may indicate masses, and these can be percussed and assessed for size.

For instance, you can map out the size of the liver by percussing from the middle of the right thorax towards the right costal margin until you hear the dullness of the underlying liver mass and mark the spot.

You also percuss from down-up by starting from the umbilical level until again you reach dullness and note that area.

Palpation

 Bend the person's knees.

 Keep your palpating hand low and parallel to the abdomen. Holding the hand high and pointing down would make anyone tense up.

Teach the person to breathe slowly (in through the nose and out through the mouth).

Keep your own voice low and soothing. The conversation may relax the person.

Try “emotive imagery.” For example, you might say, “Now I want you to imagine that you are dozing on the beach, with the sun warming your muscles and the sound of the waves lulling you to sleep. Let yourself relax.”

With a very ticklish person, keep the person's hand under your own with your fingers curled over his or her fingers. Move both hands around as you palpate; people are not ticklish to themselves.

 Alternatively, perform palpation just after auscultation. Keep the stethoscope in place and curl your fingers around it, palpating as you pretend to auscultate. People do not perceive a stethoscope as a ticklish object. You can slide the stethoscope out when the person is used to being touched.

If you identify a mass, first distinguish it from a normally palpable structure or an enlarged organ. Then note the following:

•              Location
•        Size
•        Shape
•        Consistency (soft, firm, hard)
•        Surface (smooth, nodular)
•       Mobility (including movement with respirations)
•        Pulsatility
•        Tenderness

Assessment:- Male Reproductive System

      Demonstrate Penis Examination:

·        

       Inspect the Penis

The skin normally looks wrinkled, hairless, and without lesions. The dorsal vein may be apparent.

The glans look smooth and without lesions. Ask the uncircumcised male to retract the foreskin, or you retract it. It should move easily. Some cheesy smegma may have collected under the foreskin. After inspection slide the foreskin back to the original position.

The urethral meatus is positioned just about centrally. Compress the glans anteroposteriorly between your thumb and forefinger. The meatus edge should appear pink, smooth, and without discharge.

       Demonstrate self-testicular exam:

Encourage self-care by teaching every male (from 13 to 14 years old through adulthood) how to examine his own testicles. The overall incidence of testicular cancer is rare, accounting for about 8000 new cases annually. It is rare before 15 years, but it occurs most often between 15 and 35 years. It is associated with a history of cryptorchidism.

Some groups consider teaching TSE controversial because of the harms of causing anxiety and unwarranted medical costs8 exceed the benefits of selective detection of a relatively rare lesion. However, testicular cancer has no early symptoms. When detected early and treated before metastasis, the cure rate is almost 100%. Therefore, include the teaching but adjust your message to emphasize familiarity with the young man's own body rather than only cancer detection as the goal.

Inspect and palpate scrotum:

·        Lesions

·        Edema

·        Hair distribution/lice

·        Epididymis

·        Spermatic cord

Inspect the scrotum as the male holds the penis out of the way. Alternatively, you hold the penis out of the way with the back of your hand. Scrotal size varies with ambient room temperature. Asymmetry is normal, with the left scrotal half usually lower than the right.

Spread rugae out between your fingers. Lift the sac to inspect the posterior surface. Normally no scrotal lesions are present, except for the commonly found sebaceous cysts. These are yellowish, 1-cm nodules and are firm, nontender, and often multiple

Palpate gently each scrotal half between your thumb and first two fingers (Fig. 24-8). The scrotal contents should slide easily. Testes normally feel oval, firm and rubbery, smooth, and equal bilaterally and are freely movable and slightly tender to moderate pressure. Each epididymis normally feels discrete, softer than the testis, smooth, and nontender.

Palpate each spermatic cord between your thumb and forefinger along its length from the epididymis up to the external inguinal ring. You should feel a smooth, nontender cord.

Normally no other scrotal contents are present. If you do find a mass, note:

·        Any tenderness?

·        Is the mass distal or proximal to the testis?

·        Can you place your fingers over it?

·        Does it reduce when the person lies down?

·        Can you auscultate bowel sounds over it?

Inspect inguinal region for bulge as a person stands and bears down

Inspect and Palpate for Hernia:

Inspect the inguinal region for a bulge as the person stands and as he strains down. Normally none is present. The bulge at the external inguinal ring or femoral canal. (A hernia may be present but easily reduced and may appear only intermittently with an increase in intra­abdominal pressure.) Palpate the inguinal canal.

For the right side, ask the male to shift his weight onto the left (unexamined) leg. Place your right index finger low on the right scrotal half so you carry as much skin as possible as you proceed. Palpate up the length of the spermatic cord, invaginating the scrotal skin as you go, to the external inguinal ring. It feels like a triangular slit-like opening. If positioned properly, it will admit your finger; gently insert it into the canal and ask the man to “bear down.” Normally you feel no change. Repeat the procedure on the left side.

Place your right hand upright on the man's right upper thigh, remembering the acronym NAVEL (Nerve, Artery, Vein, Empty space, Lymphatics). Locate the femoral Artery pulse with your index finger; the empty space will be under your 4th finger. Ask the man to bear down and palpate the femoral area for a bulge. Normally you feel none. Change sides, using your left hand for the man's left side.

Palpate inguinal lymph nodes:

·        Palpate Inguinal Lymph Nodes

·        Palpate the horizontal chain along the groin inferior to the inguinal ligament and the vertical chain along the upper inner thigh. It is normal to palpate an isolated node on occasion; it then feels small (<1 cm), soft, discrete, and movable.

Assessment: Female Reproductive System

Inspect external genitalia noting:

·        Hair distribution/lice

Hair distribution is in the usual the female pattern of an inverted triangle, although it normally may trail up the abdomen toward the umbilicus.

Consider delayed puberty if no pubic hair or breast development has occurred by age 13 years.

Nits or lice at the base of pubic hair.

·        Lesions

No lesions should be present, except for occasional sebaceous cysts. These are yellowish, 1-cm nodules that are firm, nontender, and often multiple.

Drainage

Edema

Assess support of pelvic musculature, with patient bearing down, for any bulging of vaginal wall