Abdominal Exam Flashcards
General inspection from the end of the bed of the patient
- comfortable and calm
- jaundice
- pallor
- muscle wasting/ cachexia
- confused
- obese
- abdominal distension
- dressings
- needle track marks (hepatitis/HIV)
- excoriation (pruritus in Cholestasis)
General inspection from around the bed
- vomit bowels
- feeding tubes
- stoma bags
- drains
- dialysis filter
What do you inspect nails for?
- clubbing (cirrhosis, IBD, coeliac)
- Leukonychia (hypoalbuminaemia in liver cirrhosis)
- koilonychia (IDA)
- Beau’s lubes (transverse ridges across nail)
- Cap refill time
What do you inspect the palms for?
- palmar erythema (hyperdynamic circulation due to inc oestrogen levels in liver disease and pregnancy)
- palmar crease pigmentation (Addison’s)
- Dupuytren’s contracture (familial, liver disease)
What do you inspect for in the arms?
- flapping tremor (hepatic encephalopathy, kidney failure)
- pulse (tachy and low volume of blood loss)
- take BP
- inspect arms for bruising (coagulation due to liver failure)
- tattoos (risk factor for infections)
- petechiae (low platelets in splenomegaly)
- AV fistula (dialysis)
- excoriation marks (skin becomes itchy in jaundice)
What do you look for in the eyes?
- conjunctival pallor
- sclerosing icterus (liver disease, biliary obstruction)
- periorbital xanthelasma (hyperlipidaemia in cholestasis)
- Kaiser-Fleischer rings (Wilson’s)
- corneal arcus
What do you look for in the mouth?
- Lips: angular stomatitis/chromosomes (iron/B12 def), localised pigmentation in Peru’s Jeghers syndrome
- gums: gingivitis, bleeding, hypertrophy, pigmentation, mouth ulcers (Chron’s and coeliac)
- tongue: glossitis (B12, folate, iron def), Oral candidiasis (iron def, immunodeficiency), leukoplakia (smoking, HIV)
- breath odour (ketotic in ketoacidosis, alcohol)
What do you look for in the neck?
- Virchow’s node of L: supraclavicular lymphadenopathy
- JVP: raised in portal HTN
What do you inspect the abdomen for?
- distension
- incisional hernias (ask pt to cough)
- scars/ striae (pregnancy, Cushing’s)
- spider naevi
- movement with respiration (absent in peritonitis)
- distended portal systemic anastomoses (portal HTN)
- scars (laparotomy)
- caput Medusa (engorged umbilical vein from portal HTN)
- stones (colostomy in RIF, ileostomy in LIF)
Which signs should you look for?
Cullen’s sign: bruising near umbilicus (retroperitoneal bleed from pancreatitis or ruptured AAA)
Grey-Turner’s sign: bruising in the flanks (retroperitoneal bleed from pancreatitis or ruptured AAA)
How do you do general palpate on of abdomen?
- ask if pt is in any pain
Superficial palpation: - start away from pain and kneel to pt level
- lightly palpate all 9 areas whilst watching pt face
- check for tenderness, guarding, rebound tenderness
Deep palpation: - masses, deep toner was
- Rosving’s sign (appendicitis), Murphy’s sigh (cholecystitis) morning
How do you palpate the liver?
- push in on inspiration
- move your L side of abdomen
- hepatomegaly: metastasis, cirrhosis, leukaemia, CCF
- tenderness in hepatitis
- pulsatile enlarged liver in tricuspid regurgitation
How do you palpate the spleen?
- push in on inspiration
- move across abdomen towards top right corner
- huge splenomegaly: lymphoma, CML, myelofibrosis, kala-azar
- moderate splenomegaly: portal HTN, storage disease e.g. Gauchers
- small splenomegaly: IE, typhoid
How do you palpate the kidney?
- L hand always underneath
- press firmly on abdomen and flick bottom hand up
- unilateral: carcinoma, hydronephrosis, cyst, hypertrophy
- bilateral: PCKD, bilateral hydronephrosis, amyloidosis
What else should you palpate for?
AAA
Press down in horizontal plane of umbilicus
Pulsatile not expansive
What are the different percussion qualities?
Percussion tenderness is peritonitis
Tympanic is flatus
How do you percuss for liver, spleen and bladder?
Liver: find upper and lower borders
Spleen: dull percussion only heard when spleen is enlarged
Bladder: tap from umbilicus towards pubic symphysis
What else should you percuss for?
Shifting dullness:
- ask pr to roll onto their side whilst keeping finger on side of abdomen
- ideally wait for 30 sec then percuss again on side
- if was dull, then becomes resonant = shifting dullness
Where should you auscultate?
- listen for normal bowel sounds in RIF for up to 1 min
- tinkling = obstruction
- absent = paralytic ole is or peritonitis
- listen for aortic and renal bruits with BELL
How would you like to complete the exam?
- full history and exam
- examine hernial orifices, external genitalia and perform DRE
- basic obs
- dipstick urine
- urinalysis (bilirubin)
- faeces exam (FOB, MCS)
- AMTS if suspect confusion
