ABDOMINAL EXAM

Question 1

Name 4 signs you might notice in the patient from the end of the bed which would be a clue to some abdominal pathology.

Answer 1

Overweight
Cachexic
Scars on abdomen
Jaundice
Dry skin
Uraemic frost
Calciphylaxis

Question 2

Name 4 things you might notice around the patient’s bed or on the patient which would be a clue to some abdominal pathology.

Answer 2

Vomit bowl
Nil-by-mouth sign
Stoma bag
Drain
NG-tube
Catheter

Question 3

Name 4 signs you would look for in a patient’s hands as part of an abdominal examination.

Answer 3

Clubbing
Koilonychia
Leukonychia
Muehrcke's lines
Palmar erythema
Dupuytren's contracture
Pigmentation of the palmar creases

Question 4

What could koilonychia be a sign of?

Answer 4

Hypochromic anaemia especially as a result of iron deficiency

Question 5

What could leukonychia be a sign of?

Answer 5

Hypoalbuminemia.
This could be a sign of chronic liver disease or cirrhosis as albumin is synthesised in the liver, or nephrotic syndrome where too much protein is lost from the kidney.

NB leukonychia is quite a common sign in normal individuals. The most common cause of leukonychia is minor nail damage.

Question 6

What are Muehrcke’s lines?

Answer 6

Muehrcke’s lines are simply widespread leukonychia. They are white lines that extend across the nail bed in parallel to the lunula (half moon). They are also a sign of hypoalbuminemia.

Question 7

What is palmar erythema and what can it be a sign of? (Name 3)

Answer 7

Reddening of the skin over the thenar and the hypothenar eminences.

Portal hypertension
Chronic liver disease (including hepatitis)
Pregnancy
Polycythemia
Thyrotoxicity
Rheumatoid arthritis
Eczema

Question 8

What is Dupuytren’s contracture and why might it be useful to look for as part of an abdominal exam?

Answer 8

In Dupuytren’s contracture, the palmar fascia within the hand becomes abnormally thick, which causes the fingers to curl and prevents full extension.

Liver cirrhosis is a recognised risk factor for Dupuytren’s contracture.

Question 9

What is the medical term for ‘liver flap’?

Answer 9

Asterixis

Question 10

Why is the presence of asterixis important to look for in an abdominal exam?

Answer 10

Asterixis is thought to be a sign of hepatic encephalopathy. Brain cells become damaged due to inability of liver to metabolise ammonia into urea.

Question 11

What might you be looking for in the arm during an abdominal examination and what would this be an indication of?

Answer 11

An arteriovenous fistulae - Indicate patient has chronic kidney disease and requires dialysis.

Bruising - may suggest abnormal coagulation (↑PT) due to liver failure

Question 12

Despite the fact that the abdominal exam is done with the patient lying flat, why might it be a good idea to check JVP in patient with possible abdominal pathology?

Answer 12

Check for fluid overload, which is possible in liver and renal dysfunction

Question 13

Name 3 signs you would look for in a patient’s eyes as part of an abdominal examination.

Answer 13

Jaundice
Conjunctival pallor
Xanthelasma

Question 14

What is jaundice and what can it be a sign of?

Answer 14

Yellowing of the skin and sclera due to build up of bilirubin in the blood.

Caused by: haemolysis, hepatitis, decompensated cirrhosis, biliary obstruction (gallstone, malignancy)

Question 15

Name 3 signs you would look for in and around a patient’s mouth as part of an abdominal examination.

Answer 15

Angular stomatitis
Oral candidiasis
Mouth ulcers
Tongue (glossitis)

Question 16

What is angular stomatitis and what can it be a sign of?

Answer 16

Inflamed red areas at the corners of the mouth.

Can be a sign of iron/B12 deficiency

Question 17

What is oral candidiasis and what can it be a sign of?

Answer 17

White slough noted on oral mucous membranes

Can be a sign of iron deficiency or immunodeficiency

Question 18

What can mouth ulcers it be a sign of, if found in a patient when doing an abdominal examination?

Answer 18

Crohn’s disease / coeliac disease

Question 19

What is glossitis and what can it be a sign of?

Answer 19

Smooth swelling of the tongue with associated erythema

Can be a sign of iron, B12 or folate deficiency

Question 20

What is the lymph node in the neck that you should check as part of an abdominal examination?

Answer 20

Virchow’s node – left supraclavicular fossa – suggestive of gastric malignancy

Question 21

Name 3 signs you would look for on a patient’s chest as part of an abdominal examination.

Answer 21

Spider naevi
Gynaecomastia
Hair loss

Question 22

What are spider naevi and what can they be a sign of? How many must there be to be considered a significant finding?

Answer 22

Central red spot with reddish extensions (>5 significant) – chronic liver disease

Question 23

What is gynaecomastia and what can it be a sign of?

Answer 23

Overdevelopment of male mammary glands (pseudofeminisation)

Can be a sign of liver cirrhosis, digoxin toxicity or spironolactone toxicity.

Question 24

What can hair loss it be a sign of, when found in a patient when doing an abdominal examination?

Answer 24

Malnourishment / iron deficiency anaemia

Question 25

What might you look on closer inspection of the patient’s abdomen during an examination?

Answer 25

Scars - previous surgery, transplant, stoma
Visible masses - tumours, hernias
Visible pulsation of AAA
Distension

Question 26

What are the five F’s denoting causes of distension that might be seen in an abdominal examination?

Answer 26

Fluid (ascites) 
Fat (obesity) 
Faeces (constipation)
Flatus 
Fetus (pregnancy)

Question 27

What is Cullen’s sign, something possibly seen during closer inspection of the abdomen during an examination?

Answer 27

Bruising surrounding umbilicus which signifies a retroperitoneal bleed. This is therefore a sign of pancreatitis/ruptured AAA.

Question 28

What is Grey-Turner’s sign, something possibly seen during closer inspection of the abdomen during an examination?

Answer 28

Bruising in the flanks which signifies a retroperitoneal bleed. This is therefore a sign of pancreatitis/ruptured AAA.

Question 29

Before palpating the abdomen, what must you do? How will this affect the manner in which you palpate the abdomen?

Answer 29

Ask about any painful sites. If there is a painful area, palpate it last.

Question 30

How should you be positioned when palpating the abdomen, during the abdominal exam?

Answer 30

Crouch down and palpate the abdomen with your eye line at the same level as the patient’s. This will enable you to assess for tenderness.

Question 31

How many segments of the abdomen should be individually palpated in the abdominal exam? Can you name them?

Answer 31

9

From right to left and top to bottom:

Right hypochondriac region
Epigastric region
Left hypochondriac region

Right lumbar region
Umbilical region
Left lumbar region

Right iliac region
Hypogastric region
Left iliac region

Question 32

How many times do you palpate the abdomen in an abdominal examination?

Answer 32

Twice. Once lightly and then once deeper.

Question 33

What are you looking for as you lightly palpate the abdomen during an abdominal examination?

Answer 33

Tenderness
Rebound tenderness
Guarding
Masses

Question 34

What is rebound tenderness and what is it often a sign of?

Answer 34

Pain is worsened on releasing the pressure during palpation.

Often a sign of peritonitis.

Question 35

Having palpated the 9 abdominal regions, what 4 parts of the abdomen should you palpate next in the abdominal exam?

Answer 35

Palpate liver
Palpate spleen
Ballot kidneys
Palpate for AAA - comment on whether it is expansile

Question 36

What 4 areas do you percuss during the abdominal exam?

Answer 36

Percuss liver
Percuss spleen
Percuss bladder - remember to ask about going to loo recently
Percuss for shifting dullness

Question 37

What do you auscultate for during the abdominal exam?

Answer 37

Bowel sounds - comment whether they are normal (gurgling), abnormal (e.g. “tinkling” - bowel obstruction) or absent (ileus / peritonitis)

Aortic bruits – auscultate just above the umbilicus – AAA
Renal bruits – auscultate just above the umbilicus, slightly lateral to the midline

Question 38

What could you say that you would do at the end of an abdominal examination?

Answer 38

Look for ankle oedema
Examine external orifices
Examine external genitalia
Take a stool/urine sample
Perform a PR exam