Abdominal examination

From Ganfyd

If you feel: Hepatomegaly, check that its not pulsatile (tricuspid regurgitation) Midline abdominal mass, check that its not pulsatile (AAA) as it is all to easy to not rest your fingers still for the few seconds that makes the diagnosis obvious

For any clinical examination you should be guided by the history of the patient. On performing an abdominal examination you should be able to detect and should look for:

• Enlarged/tender Gall bladder
• Hepatomegaly
• Splenomegaly
• Signs of liver disease
• Upper Abdominal Mass
• Ascites

Procedure

General

• Hands
  • Nails (Leuconychia of protein deficiency, spoon shaped nails of iron deficiency)
  • palms (palmar erythema)
  • Asterixis ('liver flap' of hepatic encephalopathy)
• Eyes
  • Sclera (Jaundice, or strictly speaking, icterus)
  • Conjunctiva (Pallor)
• Mouth
  • Telangiectasia (Hereditary haemorrhagic telangectasia)
  • Peri-oral pigmentation (Peutz-Jeghers syndrome)
• Tongue
  • Dehydration
  • Coated
• Breath
  • Ketosis (starvation, diabetic ketoacidosis)
  • Halitosis
• Lymph nodes
  • Cervical
  • Left supraclavicular fossa (Virchow's node = Troisier's sign = likely metastatic GI malignancy]]
• Chest
  • Spider naevi (portal hypertension)
  • Purpura
  • Gynaecomastia

Inspection

• Routine
  1. Patient comfortably supine, one or two pillows to relax abdomen, arms by sides
  2. Expose between xiphisternum and pubis
  3. Deep breath and cough
• Shape and symmetry of abdomen
  • abdominal distension
  • movement with respiration
• Scars
• Note any other abnormalities
  • Abdominal herniae
  • Tangentially look for peristalsis

Palpation

1. Warm hands
2. Patient places arms alongside body
3. Ask to report any tenderness
4. Observe face for grimace
5. Light Palpation
   • muscle tone
   • rebound tenderness
   • guarding
6. Deep palpation
   • palm of hand
   • dipping
7. Liver
   • edge sharp, rounded, firm, irregular, tender
   • normal 1-2cm below costal margin
8. Gallbladder
   • Murphy's sign
9. Spleen
10. Kidneys
    • Bimanual technique 'balloting'
    • hands in loin and just above anterior superior iliac spine
11. Abdominal aortic aneurysm
12. Examine hernial orifices

Percussion

• Kinder way to elicit rebound tenderness
• Always percuss from resonant to dull
• Upper and lower borders of liver
• Ascites
  • Shifting dullness
  • Fluid thrill

Auscultation

• Bowel sounds x3
• Bruits
  • aortic
  • iliac
  • renal
• Succussion splash

For Completeness

1. • Rectal Examination
   • Examine Male/Female genitalia
   • Urine dipstick