Abdominal

Question 1

What are the steps in examining an abdominal swelling?

Answer 1

Inspection:

1. Site
2. Number of swellings
3. Shape: spherical, ovoid, kidney shaped or irregular
4. Size
5. Surface colour
6. Surface smooth/irregular
7. Skin normal, inflamed or ulcerated
8. Movements of swelling: pulsatile
9. Cough impulse
10. Movement tests

Palpation:
1. Temperature - compared to normal skin
2. Tenderness
3. Smooth surface or lobular surface
4. Edge:
well defined and regular; benign swelling
well defined and irregular; malignancy
diffuse and ill defined; swelling/abscess - inflammation
Slipping edge - can get under a lipoma
5. Paget’s test: hold skin taut, press edge then press centre (solid = firmer in centre than at edge, liquid/cystic = softer at centre than at edge)
6. Sign of moulding - holds shape after being pressed; sign of cyst

If swelling is soft:

1. Fluctuation - propagation of impulse in multiple directions; (hold one finger on one side and press the other end, impulse is felt in other finger, repeat at 90 degrees) indicates fluid is present
2. Transillumination - implies presence of clear fluid, blood and pus will not transilluminate
3. Cough impulse - if the swelling is communicating with the peritoneal/pleural/cranial cavities or spinal canal, the swelling will tense or expand on straining/coughing/on force of gravity
4. Reducibility - compression of the swelling will reduce the size, if the swelling is communicative (as above) it will increase in size upon straining/coughing/ force of gravity
5. Compressibility - after compression, the swelling immediately expands to it’s original size = vascular
6. Pulsatility - is a finger lifted up only (transmitted through lump; non-pulsatile) or two fingers on either side are lifted in different directions (expansile lump)

Relationship to skin; fixity:

1. Fixity to skin - skin cannot be pinched over it
2. Tethering to subcutaneous material - skin can be pinched but on moving the skin it becomes puckered
3. Tethering to muscle - ask patient to flex underlying muscle; becomes fixed and immobile