Skip to 0 minutes and 13 seconds The sixth and final video section covers the abdomen legs and feet. Think about what proprioception tells us. “Are you all right lying flat?” “Yeah.” If you could lie right down for me then and just relax with your arms by your side. I’m going to examine your abdomen next so first I’m going to just have a look.
Skip to 0 minutes and 34 seconds As always the abdominal examination starts with inspection looking for any scars, rushes, distension or pulsations which may indicate an abdominal aortic aneurysm, AAA, however the next assessment is auscultation to listen for bowel sounds in all four quadrants, “That’s Lovely” the next thing I’m going to do is listen to it a little bit, notice that when we examine the abdomen we start with auscultation rather than palpation, the reasoning behind this is two-fold, one to prevent disturbance of the gasses in the gut before we have heard the bowel sounds and two to avoid provoking guarding and rigidity in a peritonitic abdomen.
Skip to 1 minute and 14 seconds Overloud tinkling sound may indicate obstruction or gastroenteritis, lack of sounds may indicate an area of bowel beyond obstruction or a paralytic ileum I auscultate the aorta listening for bruits, then moved to each renal artery and to the iliac arteries. After auscultation the abdominal examination progresses in the usual way. Now I’m going to tap. Percussion of the abdomen will allow me to assess for dullness, possible fat, foetus, faeces, full-size tumors or fluid or more tympanic, indicating flatus now I’m going to feel your abdomen I’m going to just feel it gently to start with, there’s no pain anywhere? I want you to tell me if there’s pain when I’m pressing okay?
Skip to 2 minutes and 20 seconds palpation of the abdomen allows me to feel for guarding over rigidity of the abdomen, indicating peritonitis, locate specific points of pain and feel for any masses or abnormalities including and enlarged pulsatile aorta which may indicate aneurysm. All comfortable? I’m going to go a little bit deeper. Ok. Now I’m going to feel for the edge of your liver and what I want you to do is to take a deep breath and each time and then breathe out again. Using the side of my hand, I palpate up from the right illliac fossa towards the diaphragm, asking the patient take a deep breath, pushes the liver downwards towards my hand which will allow me to feel the liver edge if it is enlarged.
Skip to 3 minutes and 28 seconds This is not often felt at all with a normal liver. Percussing up from the right illiac fossa until the percussion note changes to dull gives me the lower border of the liver, I note the position then percuss down in the mid-clavicular line until the note changes to give the upper border thus we can estimate liver span and the normal range is between six and twelve centimeters. And I’m going to feel for your kidneys. Balloting the kidney between your hands again on a deep breath in, will allow you to feel the right kidney if enlarged, often normal kidneys are not felt and the left kidney is higher into the thorax, so we do not always feel for this routinely.
Skip to 4 minutes and 15 seconds I’m going to feel for your spleen. The spleen lies closely tucked under the left rib cage. When it enlarges it is pushed diagonally towards the right illiac fossa so palpation starts here. I’m going to tap across. Percussion in the left mid-axillary line will elicit a dullness over the spleen. Now that we’ve finished examining your abdomen, I want to examine your legs, and to do that I’m going to sit you up a little bit, alright? If you want to sit forward for me
Skip to 4 minutes and 51 seconds Okay, now shuffle back in the bed and so that you’re comfortable. That’s lovely. I inspect from the foot of the bed at first to ascertain if there’s any deformity to either leg or any obvious muscle wasting. Okay, any pains or problems in your legs? No. First of all, I’m going to feel for the pulses on your feet. From the side of the bed I can assess the skin for lesions, scars or rashes. I check dorsalis pedis and posterior tibialis, if these are not present I move up to palpate the popliteal pulses. And the other one. Lovely. And could you bend your knees slightly for me? I’m just going to feel for the pulse behind your knee.
Skip to 5 minutes and 41 seconds That’s lovely, relax that one down and bend the other one. Ok, and, relax that one down. Now I’m just going to check and see if there’s any swelling your ankles. I check for ankle oedema which could indicate heart failure or kidney problems. And there’s none there. And, there’s nothing there and I’m just going to move the joints around a bit loosely, so if you relax you legs as much as you can.
Skip to 6 minutes and 7 seconds I palpate the legs and feet, assessing warmth, muscle tone of passively moving the joints to assess range of movement any crepitus lovely, then bend your knee and let me take the weight of your leg, I’m just going to move your knee around and now going to move your hip. Out and around. Any pain in that? Lovely. We’ll do the same for the other leg, so let me move your ankle joint around. Bend your knee, relax it, let me take the weight. And then we’ll move your knee and now I’m gong to move your hip around as well, relax it down. So, is there any pain anywhere in your legs? Okay, I’d like you to do some movements for me.
Skip to 6 minutes and 53 seconds Can you lift this leg up straight from the hip and then down again now do the same and don’t let me stop you, ok. And the same with this leg. I assess the active movements of the legs and test strength at the hips, knees and ankles, comparing dorsi flexion. That’s excellent. Now bend your knee for me. And, bring your heel back towards your bottom as far as it will go. Okay, then stretch it out. And do the same movement again, don’t let me stop you. Okay. And while we’re there, can you kick out so the your leg becomes straight again? Lovely, now for this one. If you bend your knee.
Skip to 7 minutes and 43 seconds And, bring your heel back toward your bottom as far as you can. And, then straighten it out again and do the same movement again don’t let me stop you. Pull it back and then again would you kick out and don’t let me stop you. That’s lovely thank you. I’m going to look at your feet so put your feet together and bring your toes up towards your nose. Okay, and then push them down towards the floor, now bring them up towards your nose don’t let me stop you, okay and push them down towards the floor. Now just with your big toe, bring your big toe up towards your nose. And, then down towards the floor and don’t let me stop you.
Skip to 8 minutes and 33 seconds And, again, and, this one up towards your nose, dow towards the floor, don’t let me stop you. Okay. Lovely. I want to test the sensation on your legs. So, I want you to lean back and relax close your eyes and can you feel me touching you? “Yes” Does it feel the same as that? “Yes”. I assess the dermatomes, L2, L3, L5, S1. If any differences are between the sides then use dull and sharp methods of testing. Does it feel the same as that? “Yes” Lovely. While you’ve got your eyes shut and you’re in relaxed position I’m going to move your big toes. I’m going to move them up and down I want you to tell me where it stops.
Skip to 9 minutes and 27 seconds Is it up or down? “Down”. Proprioception or the awareness of your body parts in space, is a function of the upper motor neurons, so a fault in this assessment would show a deficit in this area. “Up”. Lovely, thank you. So now I want to do a coordination test on you legs with this heel Could you put it on that day and run it down your leg and back up again please? The heel to shin test checks coordination of the lower limbs. And, lovely, relax. And now with this heel on this knee. And, down and back. And now relax.
Skip to 10 minutes and 20 seconds That Is the end of our examination, if you just want to swing your legs round to the edge of the bed there. You can now get yourself dressed and thank you very much for your time this morning. Now that we have completed the head-to-toe examination we should write up our clinical findings including the negatives as well as the positive findings.
Head to toe (part 6)
Having covered the respiratory and cardiovascular examinations, watch the sixth and final video, which covers examination of the abdomen and lower limbs (legs and feet).
What does proprioception tell us?
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