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Rebecca L. Alsip, D.O. Charlotte A. Ebner, D.O. VCOM Carolinas September 18, 2012 Demonstrate in the correct order an abdominal exam on a patient which includes the following: Observation/Inspection Auscultation Percussion Palpation Describe the autonomic innervation to the lower GI tract. Integrate a complete osteopathic approach for a patient with post-op atelectasis and ileus which includes both abdominal and structural exam and findings. Demonstrate on your partner the OMM techniques taught for post-op atelectasis and ileus. Inspection Auscultation Percussion Palpation Special Tests Inspection Symmetry Contours Jaundice Cyanosis Erythema Bruising Striae Ascites Scars Masses/Hernias Movement Auscultation Normal Decreased (peritonitis) Increased (gastroenteritis) High-pitched, tinkling (early obstruction) Decreased/absence No sounds in 5 minutes Bruits Percussion Percuss all four quadrants Assess for increased gas or ascites Assess for size of organs Liver – midclavicular line in RUQ Spleen – midaxillary line in LUQ Palpation Detect organ size, muscle spasms, masses, fluid and tenderness Start light in all 4 quadrants, then advance to moderate and deep palpation Rebound Guarding Special Tests McBurney’s Point Murphy’s Sign RUQ (pain on palpation during inspiration) Rovsing’s Sign RLQ (1/3 distance from ASIS, 2/3 distance from umbilicus) LLQ (pain in RLQ on palpation of LLQ) Iliopsoas Test Somatic Dysfunctions Chapman Points Abdominal collateral ganglia Stomach Acidity – EG junction – left 5th intercostal space Peristalsis – left 6th intercostal space Pylorus – anywhere along center portion of sternum Liver – right 5th and 6th intercostal spaces Gallbladder – right 6th intercostal space Pancreas – right 7th intercostal space Small Intestine – right 8th-10th intercostal spaces Appendix – distal tip of right 12th rib Colon – along iliotibial bands Sympathetics Greater Splanchnic Nerve T5-9 – Celiac Ganglion Lesser Splanchnic Nerve T10-11 – Superior Mesenteric Ganglion Distal Duodenum, Jejunum, Ileum, Ascending Colon, Proximal 2/3 of Transverse Colon Least Splanchnic Nerve T12-L2 – Inferior Mesenteric Ganglion Distal Esophagus, Stomach, Liver, Gallbladder, Proximal Duodenum and portions of Pancreas Distal 1/3 of Transverse Colon, Descending Colon, Sigmoid Colon, Rectum Parasympathetics Vagus Nerve: Esophagus, Stomach, Small Intestine, Ascending Colon, Transverse Colon Sacral nerves S2-4: Descending Colon, Pelvic organs Chief Complaint History of Present Illness Onset, Provocation/Palliation, Quality, Radiation, Severity, Timing PMH/PSH Medications/Allergies Family History Social History REVIEW OF SYSTEMS Vital signs Cardiovascular Pulmonary ABDOMINAL EXAM Rectal exam if indicated Use of stool guaiac card Differential Diagnosis (minimum of 3) Plan Diet/lifestyle modifications? Imaging? Labs? Medications? REASSURANCE! Always introduce yourself to the patient Wash your hands Drape the patient appropriately Always listen to the heart and lungs Fully expose the abdomen Arms at side with legs flat, if possible Examine painful area last Always give your patient an explanation in non-medical terms, a plan and follow up instructions PRACTICE TIME! Atelectasis Ileus Wound infection Pneumonia Renal Failure Peritonitis Empyema ARDS Peritonitis Incomplete expansion of the lungs due to alveolar collapse Most frequent pulmonary complication after surgery Natural response of patient after surgery is abdominal wall splinting and shallow breathing This prevents full diaphragmatic excursion, so alveoli at the lung bases are not expanded, decreasing oxygen exchange in these areas Clinical presentation Low O2 saturation Increased respiratory rate Respiratory distress Increased respiratory secretions Decreased mental status Acidotic Treatments Incentive Spirometer Oxygen for hypoxemia CPAP for increased respiratory effort Mucolytics/suctioning for respiratory secretions Bronchodilators for bronchospasm OMT! Treatment Regions OA: Muscle energy, suboccipital inhibition C3-5: Counterstrain, Soft tissue Diaphragm: Myofascial release Ribs: Rib raising Pt supine, D.O. sitting at head Form a “V” with thumb and index finger on the transverse processes of the atlas, other hand grasping the head and engage the restrictive barrier (all 3) Instruct pt to straighten head, while D.O. provides counterforce, hold 3-5 seconds Have pt relax 2-3 seconds, re-engage the new restrictive barrier, and repeat 3-4 times, each time re-engaging the new restrictive barrier Objective: decrease suboccipital muscle tone D.O. at head of table; patient supine Pads of fingers just beneath superior nuchal line in the suboccipital tissues Lift head slightly so its entire weight is supported on fingers Can apply a slight traction Hold until a softening of tissues is noted Functional inhibition of propulsive bowel motility Thought to be due to 3 pathways Due to visceral sensory afferents in the splanchnic and pelvic nerves that increase inhibitory sympathetic activity in the GI tract Post-operatively due to an inflammatory response from intestinal manipulation during surgery that results in muscle dysfunction Inhibitory neurotransmitters such as nitric oxide and substance P slow gut motility Clinical presentation Abdominal distention Diffuse abdominal pain Nausea and/or vomiting Inability to pass flatus or stool Inability to tolerate PO diet MUST rule out mechanical small bowel obstruction, as this may require surgical intervention Imaging, such as KUBs or abdominal CT scans, will help differentiate between the two Treatments Keep patient NPO (“nil per os” – nothing by mouth) Start IV fluids NG tube placement if persistent vomiting or abdominal distention to decompress the stomach Limit opioid pain medications due to constipation OMT! Treatment Regions OA: Vagus nerve S2-4: Pelvic splanchnic nerves T10-11: Superior mesenteric ganglion T12-L2: Inferior mesenteric ganglion Abdominal mesenteries Colonic milking Sacral Rocking Thoracolumbar Supine Soft Tissue Remove somatic dysfunction Stimulate or relax tissues Reduce tissue edema or congestion Remove or modify pain Permit compensation Allow treatments in other parts of the body unit to be more effective Improve immune function Improve respiration by improving soft tissue diaphragm function Positive to negative pressure gradients=better transfer of gases OA OA C3-5 Sacral Doming the Diaphragm Rib raising rocking Thoracolumbar soft tissue Collateral ganglion release Mesenteric release Colonic milking References Cashen, Constance; Ross, Sydney. “Chapter 27, General Surgery”. Foundations for Osteopathic Medicine, 2nd Edition. Ward, DO, Robert C., Exec. Editor, Lippincott Williams and Wilkins (2003), p. 399-407 CCOM Faculty. Osteopathic Manipulative Medicine. OMM/CCOM Procedure Manual. 2006. Dorland’s Pocket Medical Dictionary, 26th Edition. W.B.Saunders Company (2001), p. 91, 424. Johnson, MD, Michael, Conde, MD, Michelle. “Overview of the management of postoperative pulmonary complications.” UpToDate, www.uptodate.com, July 2012. Kidz Medical Services. http://www.kidzmedical.com/k-id-z/a.html#atelectasis Litkouhi, MD, Babak. “Postoperative ileus.” UpToDate, www.uptodate.com, August 2012.