Examination: Abdomen

Introduction
  • 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

Inspection - General
OSCE-Aid Tips

Take your time to have a good look! In this station the diagnosis is often given away by careful initial inspection e.g. CLD, renal transplant etc.

  • 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:

Chronic liver disease

Splenomegaly

Renal transplant

- Tattoos (Viral hepatitis)

- Needle prick marks

- Skin pigmentation (haemochromatosis)

- Xanthelasma (PBC)

- Obese (NAFLD)

- Bruising (lymphoproliferative disease)

- Jaundice (haemolytic anaemia e.g. hereditary spherocytosis)

- Rutherford Morrison ‘Hockey stick’ incision

- Nephrectomy scar (on back)- polycystic kidneys

- Needle prick marks on fingers (capillary glucose in diabetes)

- Malar rash (SLE)


Hands
  • 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.

Eyes
  • 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)

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

Chest
  • 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.

Abdomen

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

OSCE-Aid Tips

Peritonism is indicated by: Rebound: Pain elicited on palpation is less severe than pain when hand rapidly removed from abdomen Guarding: Involuntary tensing of abdominal musculature due to local or generalised inflammation

  • 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

OSCE-Aid Tips

In advanced cirrhosis, the liver may not be palpable as it shrinks with time- do not be disheartened!

  • 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.

Auscultate
  • 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’)

Complete

‘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.’


written by: george_thornton, first posted on: 10/11/15; 19:55

Downloads / Links

size: 284.64kb

Comments:

No one has left a comment yet. Be the first - see below.

Make a Comment:

Please login before posting a comment. If you don't yet have an account on osce-aid.co.uk, you can register for FREE by clicking here.