Abdominal Examination

1. Abdominal Examination • Dr Shadab Nayeemuddin • Dr Trixy David

2. Overview • Structured approach to performing an abdominal examination • Questions asked by the examiner at the end of the station • Communication skills • Practical demonstration

3. Introduction • Introduce yourself: Elicit name, age and occupation. • Consent: Explain the examination to the patient and seek consent • Position: Ensure the patient is lying flat and expose the patient appropriately • Wash hands

4. General inspection • Stand and observe the patient from end of the bed for: a) scars b) distension c) masses d) stoma (ileostomy/colostomy) e) hernias f) discolouration (jaundice) g) indwelling catheters • Note any movements including gastric persitalsis or pulsations • Describe the abdominal contour as flat, scaphoid (sunken) or protuberant

6. Examination of hands • Look for Clubbing (liver cirrhosis, coeliac disease, IBD - crohn’s disease, ulcerative colitis) • Look at nails for Leukonychia (whitened nails - cirrhosis, hypoalbuminaemia), Koilonychia (spoon shaped nails - iron deficient anaemia) • Look for palmar erythema (chronic liver disease) • Feel for Dupuytren’s contracture (liver cirrhosis) • Check for flapping tremor (liver failure)

8. Face and body • Look at eyes for signs of jaundice and anaemia • Look around lips for brown freckles (Peutz-Jeghers syndrome) • Inspect mouth for central cyanosis, macroglossis (hypothyroidism, acromegaly), atrophic glossitis (iron, folate, B12 deficiency), dry tongue (dehydration), Ulcers (Crohn’s, Coeliac), Breath (ketosis, ethanol). • Inspect trunk for Campbell de Morgan spots, striae and signs of chronic liver disease (spider naevi, gynaecomastia and caput medusa), Cullen’s and Grey Turner’s sign (pancreatic haemorrhage)

10. Palpation • Feel for Virchow’s node in left supraclavicular fossa (gastric carcinoma) • Ask if patient is tender in abdomen then perform light palpation starting away from site of pain looking at patients face. Feel for tenderness, rebound tenderness, guarding or rigidity. • Perform deep palpation feeling for masses (size, shape, edge, consistency, percussion note, bowel sounds, thrill) or deep tenderness. • Abdominal distension causes 8 Fs: Fat, Faeces, Fluid, Flatus, Fetus, Full sized tumours, Full bladder, Fibroids

12. Useful signs • Murphy’s sign - apply pressure over right hypochondrium then ask patient to breathe in. Acute cholecystitis causes intense pain. Conclude test by demonstrating absence of pain over the left hypochondrium. • Rovsing’s sign - apply pressure in the left iliac fossa. In appendicitis the pain will experience more pain in right iliac fossa when this is done. • Right iliac fossa mass - Appendix mass/abscess, colon cancer, Crohn’s disease, transplanted kidney, tuberculosis mass.

13. Palpation of internal organs • Liver - palpate from right iliac fossa to the costal margin. Ask patient to take deep breaths and press firmly inwards and upwards using a flat hand. If liver is enlarged describe its edge (smooth, irregular), size (cm below costal margin), consistency (soft, firm, hard), nodularity and tenderness. • Spleen - Use same technique as above starting from right iliac fossa towards left hypochondrium for a notch, size, consistency and tenderness. NB. spleen has to be 2-3 times larger before it is palpable. • Kidneys - ballot the kidneys on inspiration positioning one hand below and other hand above abdomen. Attempt to push kidney with lower hand onto fingertipsof the resting hand. Look for tenderness or enlargement. • NB. kidney is smooth, moves late in inspiration, resonant percussion note, directed downwards and can get above it. Spleen has notched edge, moves early in inspiration, dull to percussion, enlarges towards right iliac fossa and can’t get above it. • Aorta - Feel for an abdominal aortic aneurysm by placing two fingers along the midline above the umbilicus and feel for an expansile pulsation.

14. Causes of organomegaly • Hepatomegaly: Infective - hepatitis, liver abscess, malaria, Neoplastic - HCC, lymphoma, myeloma, Cirrhosis, metabolic - fatty infiltration, amyloidosis, Drugs and toxins - alcohol, poisoning, Congenital - polycystic, haemolytic anaemia, Others - RVF, Budd-Chiari syndrome • Splenomegaly: Haemolytic anaemia, Infectious mononucleosis, Haematological malignancies (leukaemias) • Enlarged kidneys:Bilateral - Polycystic kidney disease, amyloidosis, hydronephrosis, Unilateral - nephroblastoma, hydronephrosis

15. Percussion • Liver - Percuss the upper and lower liver borders. Determine the upper border from the 4th intercostal space and lower border from the costal margin. Liver will have dull percussion note. • Spleen - Percuss the spleen starting from right iliac fossa. Spleen will have dull percussion note. • Ascites - Assess for shifting dullness. Percuss from umbilicus away from you towards the the flank noting the point of dullness. Roll patient towards you and leave your finger in same position. Wait for 30 seconds then percuss again and note will be resonant. • To assess for fluid thrill ask patient to place his hand along midline of abdomen. Place your detecting hand on one flank whilst flicking the opposite flank with your other hand feeling for a fluid thrill suggestive of severe ascites. • Bladder - Percuss the suprapubic area for dullness suggestive of bladder distension.

16. Auscultation and conclusion • Auscultate over abdomen for peristaltic bowel sounds. Determine if they are normal, tinkling (bowel obstruction) or absent (peritonitis, paralytic ileus) • Auscultate over aorta for bruits (atherosclerosis, aneurysm) • Auscultate over renal arteries, approx 2-3cm supero-lateral to umbilicus for bruits (renal artery stenosis) • To conclude - Hernias (feel for a cough impulse over hernial orifices as patient coughs), feel for enlarged inguinal lymph nodes, request to perform a inguinal scrotal and PR exam, opthalmoscopic exam (diabetic retinopathy) and dipstick the urine. • Thank the patient and summarize your findings

17. Thank you!! • Any Questions???