Examination: Abdomen

• Wash hands
• Introduce yourself and ask permission
• Any pain?
• Position/Exposure: Lie flat, hands at sides, blanket to cover legs
• Examine from the patient’s right

• Stand back and look carefully, make this obvious to the examiner or state ‘I am just going to have a look from the end of the bed’
• Look for 3 main things from end of the bed
  • Chronic liver disease (spider naevi, gynaecomastia, loss of hair, scratch marks, bruising)
  • Decompensation of liver disease (ascites – distended abdomen, jaundice)
  • Scars (hockey stick- renal transplant, multiple – could this be IBD?)
• For extra marks: Look for underlying cause:

• Examine nails for clubbing (chronic liver disease, IBD, coeliac), koilonychia (spoon shaped nails in iron deficiency anaemia), leuconychia (white nails-low albumin in CLD)
• Look at both hands for Dupuytren’s contracture, palmar erythema, spider naevi
• Feel both palms, early Dupuytren’s may be palpable as a nodular area in the palm.
• Check for Asterixis: Ask the patient to ‘place your arms out in front of you and cock your wrists back’. Asterixis is a course flapping tremor which is present in hepatic encephalopathy and thus, unlikely to be present in your exam.

• Ask to pull down one eyelid looking for anaemia, scleral icterus (jaundice seen in the eye)
• Look around the eye for xanthelasma (Primary biliary cirrhosis, NAFLD)

• Look briefly in the patient’s mouth for
  • Smooth tongue, angular stomatitis (iron deficiency)
  • Aphthous ulcers (IBD)
  • Pigmented freckles (Peutz-Jeghers syndrome)

• Inspect for:
  • Loss of male hair distribution
  • Gynaecomastia
  • Spider naevi: if present count them: more than 5 is abnormal.
• Ask the patient to lean forward: use opportunity to examine neck and supraclavicular fossae for lymphadenopathy: examine from Feel above the left clavicle for Virchow’s node (sign of intra-abdominal malignancy)
• Inspect the back for more spider naevi and look for scars e.g. nephrectomy incision in loin.

Inspect

• Re-inspect more closely (this will give you time to think!). Think about what you have already found and what you would expect next. Look for
  • Abdominal distension (ascites, constipation etc)
  • Scars (Hockey stick: Renal transplant, Mercedes-Benz: Liver transplant, scars from laparoscopic surgery, drains etc)
  • Caput medusae (Veins radiating from umbilicus- a sign of portal hypertension)
  • Striae (‘stretch marks’): May be normal but if marked could represent Cushing’s syndrome (e.g. due to steroids used in IBD/renal transplant)

Superficial & Deep Palpation

• Looking at the patient’s face, warn the patient (ask again if any pain) and gently palpate (using the flat of your hand) in all 9 areas, starting away from any painful area and working towards it. You are looking for evidence of pain and peritonism (guarding, rebound)
• Palpate more deeply for any masses (try to think what this might be: where is it, how does it feel (smooth, hard, craggy), is it attached to surrounding structures etc. (see ‘examination of a lump)
• If there is a ‘hockey stick’ incision: feel for an underlying mass (the kidney transplant).

Liver

• Place the flat of your hand on the right lower quadrant with the index finger side of your hand towards the patient’s head.
• Ask the patient to take deep breaths in and out.
• Move up the abdomen towards the right costal margin. Feel as the patient breaths in, move up as they breath out
• If there is liver enlargement you will feel the liver moving under your fingers.
• Quantify the enlargement with ‘number of finger breadths’ below the costal margin.
• Try to feel if it is smooth or craggy.
• Confirm the enlargement by percussing from RIF up to right costal margin. The liver will be dull to percussion.

Spleen

• With the same technique and starting in the right iliac fossa, slowly move diagonally to the left costal margin feeling for a spleen.
• Use a flat hand but the tips of your fingers, rather than the margin of your index finger.
• If the spleen is palpable, then it is
• Features of the spleen (to distinguish from kidney):
  • You can not get above it
  • Dull to percussion
  • Moves with respiration
  • Splenic notch
• Confirm the enlargement but percussing in the same direction.
• If impalpable when lying flat, ask the patient to lean onto their right hand side and palpate deeply in LUQ.

Shifting Dullness

• Percuss from the midline to the patient’s left side – moving left will make the next stage easier!
• If ascites is present, the resonance in the midline will be come dull laterally
• If dull, ask the patient to lean to their right side while keeping your finger in position.
• Wait 20s, then percuss. If the previously dull area is now resonant, this is shifting dullness, and a sign of abdominal fluid (ascites)

Kidneys

• While patient is still in position (on right side), place your left hand behind them onto their back and ask them to roll flat.
• Using your right hand palpate deeply in the mid-left side of the abdomen
• Ballot the left kidney by pressing sharply upwards with your left hand (on their back), an enlarged kidney will be palpable on balloting.
• Perform the same manoeuvre to palpate for the right kidney.

• Listen for bruits:
  • Abdominal aortic aneurysm: just above umbilicus
  • Renal 2.5cm above and lateral to umbilicus (renal artery stenosis)
• Bowel sounds (listen in right lower quadrant, ‘over the ileocaecal valve’)

‘I would like to dipstick the urine, examine the external genitalia and perform a digital rectal examination’.

NB: This is the standard suggested completion sentence. This can be adapted if necessary to the condition in question. For example, for a renal transplant you may wish to ask to ‘dip the urine for protein, check the blood glucose and to know the blood pressure.’

Downloads / Links

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Zap says...

POSTED ON: 07/06/22, 07:49

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