DR MUL

KULIAH BLOK
PEMERIKSAAN FISIK
BEDAH DIGESTIF
Dr. Made Mulyawan, SpB-KBD

HERNIA
 The hernia should be examined in a

standing and lying position.
Inspect standing
 Exposure is very important – ensure you can
see from umbilicus to knees at least!
 Look in the groin for evidence of a swelling – if
you cant see one, then ask the patient which
side they have noticed a lump
 Look for evidence of previous hernia surgery –
oblique scar often well hidden in pubic hair line
 Any other obvious skin changes, swellings,
lumps that may be relevant
 Ask the patient to look over their shoulder and
cough (so they don’t cough intoyour face!)
 As they cough, look at the lump to see if there
is a cough impulse
Palpate standing
- Palpate the swelling
- Can you get above it (suggesting originates in
scrotum/spermatic cord e.g.hydrocoele)
- Does it feel soft, fluctuant, Pulsatile etc.
- Ask the patient again to cough, palpating for a cough
impulse
- Ensure that you feel the opposite side, as bilateral
hernias are very common often one being much
more prominent
Auscultate
- Take this opportunity to auscultate the lump, as if it is
readily reducible, therewill be nothing to listen too
when the patient lies down.
Lie the patient down
Inspection
- Again, inspect the groin to ensure
there is nothing missed from standing
inspection.
- Offer to palpate the abdomen for any
cause of raised intra-abdominal
pressure such as ascites or mass,
which can predispose to herniation
Palpation
- Having identified a hernia, the next task is to
assess if it is indirect or direct.
- Ask the patient if they can reduce the hernia, if it
has not done so by being supine – NEVER do this
standing as it is painful.
- Palpate the groin to assess if the hernia has
completely reduced
- Warn the patient that you will palpate some bony
points
- Feel for the anterior superior iliac spine and the
pubic tubercle (delineating the inguinal ligament –
as opposed to the ASIS to pubic symphysis, to
identify the mid-inguinal point, the landmark for
the femoral artery)
- Palpate the midpoint of the inguinal ligament (the
surface landmark for the deep inguinal ring) and
ask the patient to cough
- If the hernia is CONTROLLED by pressure
over the deep inguinal ring, it suggests that
the hernia is indirect.
- In order to confirm that you were in fact
controlling the hernia, ask the patient to
cough without pressure to ensure that the
hernia now appears.
- Offer to examine the scrotum, where you
should palpate the testis and epididymis
(my finals hernia case had epididymal cysts
which were expected to be found)
Hernia Palpation
THREE FINGER TEST (ZIEMANN’S TEST)

- 2nd finger – an interna  HIL
- 3rd finger – an externa  HIM
- 4th finger – fossa ovalis  HF
Hernia Palpation
THUMB TEST
- first empty the sac/bulging
- place tumb on internal anulus
- ask the patient to cough
1. No lump/ bulging  HIL
2. Bulging  HIM atau FM
Video Hernia examination
DIGITAL RECTAL EXAMINATION
(COLOK DUBUR)
 A digital rectal examination (DRE) is

a simple procedure doctors use to
examine the lower rectum and other
internal organs. DRE is done for a
number of reasons :
 diagnose rectal tumors
 obtain feces for the fecal occult blood test
(used as a screening for gastrointestinal
bleeding or colon cancer)
 prepare you for colonoscopy (a procedure
to examine the small bowel) or proctoscopy
(a procedure used to examine the anus,
rectum, or colon
 assess the function of the anal sphincter in
cases of fecal incontinence
 assess the extent of hemorrhoids (swollen
veins in the anus)
 help diagnose appendicitis (inflammation of
the appendix)
 check the status of pelvic organs, especially
among women
Position
What to evaluate :
perianal region, sphingter anus tone, rectum mucose,
prostat (male), uterus/cervix (female),mass (tumour),
handscoon (faeces, blood, mucose)
PSOAS SIGN
 The psoas sign is a maneuver that is often
used to help in the diagnosis of appendicitis
 There are a few possible variations in the
anatomy of the appendix. By moving the
underlying muscles via the psoas sign
maneuver, an inflamed appendix can be
expected to cause pain.
 A positive psoas sign does suggest
appendicitis may be present, but a negative
result should not change clinical decision-
making. It has a sensitivity of 13-42% and a
specificity of 79-97%. Its positive likelihood
ratio is 2.0.
Method 1
 Have the patient lie supine.
 Place your hand on the patient’s knee
and have them flex their hip while
applying resistance to their leg.
 If the pain is recreated, it is a positive
psoas sign.
Method 2
 Have patient lie on their left side.
 Passively hyperextend the right hip to
cause stretching of the iliopsoas
muscle group.
 If hyperextension recreates the pain,
the test is positive.
Video psoas sign
OBTURATOR SIGN
 The obturator sign is a test that is often used
to help in the diagnosis of appendicitis
 There are a few possible variations in the
anatomy of the appendix. By moving the
underlying muscles via the obturator sign
maneuver, an inflamed appendix can be
expected to cause pain.
 A positive obturator sign does not weigh
heavily on clinical decision-making in the
workup of appendicitis. It is said to have a
sensitivity of only 8% and a specificity of 94%.
Likelihood ratios are negligible.
Method
 Have the patient lie in the supine position.
 Passively flex the patient’s right hip and
rotate the leg internally at the hip.
 If the patient feels pain in the right lower
quadrant, it is a positive test.
Video obturator sign
BLUMBERG TEST
 After gradual pressing by fingers on a
front abdominal wall from the place of
pain quickly, but not acutely, the hand
is taken away.
 Strengthening of pain is considered as
a positive symptom in that place.
 Obligatory here is tension of muscles
of front abdominal wall.
Video Blumberg test
THANK YOU

DR MUL

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KULIAH BLOK

Dr. Made Mulyawan, SpB-KBD

 The hernia should be examined in a

THREE FINGER TEST (ZIEMANN’S TEST)

 A digital rectal examination (DRE) is

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