Abdominal examination Flashcards
What is the first part of any introduction to an examination?
Wash hands
Intro self
Pt details
Explain an abdo exam to a patient
I’ve been asked to examine your abdomen today, it’s going to involve me having a general inspection of your arms, face and chest before having a feel of your tummy in various areas, and listening with my stetho.
What else would you include in your intro?
Expose ok?
Chaperone?
Pain or discomfort?
What do you inspect in a abdo exam?
Bedside
General
Hands
Arms
Axillae
Face
Eyes
Mouth
Chest wall
Abdomen
When inspecting the bedside what are you looking for?
Feeding tubes
stoma bags
drains
When inspecting generally what are you looking for?
General appearance
body habitus
colour
What could the following indicate?
a) Obvious pallor
b) Jaundice
a) sig anaemia - ?GI bleed
b) Cirrhosis / hep / biliary issue
When inspecting the hands what are you looking for?
Clubbing;
Koilonychia (spooning of the nails);
Leukonychia (whitened nail bed);
Dupuytren’s contracture;
In a abdo exam what could clubbing indicate?
Hepatic cirrhosis.
Inflammatory bowel disease (ulcerative colitis/Crohn’s).
Coeliac disease.
In an abdo exam what could the following indicate?
a) Koilonychia
b) Leukonychia
c) Dupuytren’s contracture
a) Chronic iron deficiency
b) minor trauma / post chemo / hypoalbumaemia
c) ?alcoholism / liver failure
What are the different types of leukonychia?
What do they indicate?
Leukonychia partialis =
- white patches is normal in minor trauma but striae
affecting all nail beds can occur post chemotherapy.
Leukonychia totalis =
- hypoalbuminaemia caused by liver failure/nephrotic
syndrome/protein malabsorption/protein-losing
enteropathies.
What is Dupuytren’s contracture?
Fibrosis + shortening of the palmer aponeurosis
Before inspecting the arms in an abdo exam what else do you want to do?
Temp of hands + forearms
Radial pulse
Check for asterixis
When inspecting the arms in an abdo exam what are you looking for?
What may they suggest?
Bruising – abnormal coagulation (secondary to liver failure).
Petechiae – Low platelets (e.g. splenomegaly).
Scratch marks – Pruritus caused by cholestasis.
Track marks – IVDU (hepatitis).
When inspecting the axillae in an abdo exam what are you looking for?
What may they indicate?
Lymphadenopathy – Malignancy/infection.
Hair loss – Malnourishment/iron deficiency anaemia.
Acanthosis nigricans – Hyperpigmentation seen in GI
adenocarcinomas/obesity.
When inspecting the face in an abdo exam what are you looking for
Where else does it affect and cause?
Telangiectasia;
Affects the face, oral mucosa, GI tract, lungs, liver + brain
resulting in recurrent haemorrhage.
When inspecting the eyes in an abdo exam what are you looking for?
What does it indicate?
Xanthelasma (yellow raised lesions around the eyes);
- Hypercholesterolaemia.
Corneal arcus (yellowish/grey ring surrounding the iris);
- Hypercholesterolaemia.
Scleral jaundice;
- Haemolysis/hepatitis/cirrhosis/biliary obstruction.
Conjunctival pallor;
- Significant anaemia.
Kayser-Fleischer rings (brown rings that encircle the iris);
- Wilson’s disease due to copper deposition.
When inspecting the mouth in an abdo exam what are you looking for?
Pigmentation (freckles)
Angular stomatitis
Glossitis
Oral candidiasis (white slough on oral mucous membranes)
Dehydration
Halitosis (bad breath)
Dental caries
Ulcers
What do the following signs indicate?
a) Pigmentation (freckles);
b) Angular stomatitis;
c) Glossitis;
d) Oral candidiasis
e) Ulcers;
a) Peutz-Jegher syndrome, associated with small bowel
hamartomas.
b) Can be caused from vitamin B12, folate or iron
deficiency.
c) Painful = vitamin B12 or folate deficiency.
Painless = iron deficiency.
d) Iron deficiency/immunodeficiency.
e) Can be associated with vitamin B12/iron deficiency,
Crohn’s, Coeliac.
Before inspecting the chest and abdomen what else do you want to do?
JVP check
Palpate LN
When inspecting the chest wall in an abdo exam what are you looking for?
Spider naevi
Gynaecomastia
Hair loss;
What are the following?
a) Spider naevi
b) Gynaecomastia
a) Central red spot with red extensions
b) Male breast development
What number of spider naevi are considered significant?
> 5
What are the following associated / indications of?
a) spider naevi
b) gynaecomastia
c) hair loss
a) Associated with chronic liver disease.
b) Can be due to increased circulating oestrogens in liver
failure, digoxin or spironolactone.
c) Malnourishment/iron deficiency anaemia.
Before properly inspecting the abdomen what do you want to do and why?
Posterior abdominal wall to inspect skin for scars, swellings etc.
What do you need to do / make sure of before inspecting, palpating, percussing and auscultating the abdomen?
Ask the pt to lie flat on their back w/ arms by their side (if they can) - 1 pillow if they want
Lower bed
When inspecting the abdomen in an abdo exam what are you looking for?
Shape + symmetry.
Visible peristalsis.
Scars;
Stomas;
Movement during breathing;
Bruising from retroperitoneal bleed; = Cullen’s / Grey Turner’s
Visible swellings/masses.
Visible aortic pulsation;
Distended veins;
Abdominal distension
What types of scars / skin changes would you potentially see in a abdo exam?
Sudden weight loss = loose folds of skin.
Sudden weight gain = striae (pink new, silver old).
Any skin lesions?
Give 3 stoma examples and their position
LIF = colostomy.
RIF = ileostomy.
RIF + urine = urostomy
What does movement of the abdomen when breathing suggest?
Diaphragmatic ventilation usually ceases with acute peritonitis ventilation is then via movement of chest wall.
Where do you see the following and what do the following indicate?
a) Cullen’s
b) Grey Turner’s
a) umbilical
?pancreatitis/ruptured AAA.
b) flanks
?pancreatitis/ruptured AAA.
When inspecting any visible swellings / masses what do you want to assess?
What might they indicate?
Size/position/consistency/mobility
?organomegaly/malignancy
What might a visible aortic pulsation look like?
What could it indicate?
Central pulsatile + expansile mass
?AAA
What might engorged abdominal veins indicate?
What is the name for engorged paraumbilical veins?
Portal HTN
Caput medusae
What are the 5Fs of abdominal distension?
Fluid (ascites).
Faeces (constipation).
Flatus (subacute intestinal obstruction).
Foetus (pregnancy).
Fat (obesity).
When palpating an abdomen what do you want to do?
Ask about any areas of pain + examine these last.
Kneel so you are level with the patient.
Palpate the 9 regions
Observe the patient’s face throughout for signs of discomfort.
During light palpation what are you assessing for?
Tenderness (note the areas involved and the severity).
Rebound tenderness (pain is worsened on releasing pressure) = peritonitis.
Guarding (involuntary tension in the abdominal muscles) either localised or generalised.
Masses (large/superficial masses may be noted on light palpation).
During deep palpation what are you assessing for?
Masses -
- Location
- Size
- Shape
- Consistency (smooth/soft/hard/irregular)
- Mobility (attached superficially/deeply)
- Pulsatility (vascular).
If a mass is identified what should you do and why?
If identified then ask patient to raise head + shoulders off the pillow
Masses within the abdominal wall become more prominent when the recti are contracted whereas intra-abdominal masses become less prominent.
If the stomach is distended what should you do and what is it called?
Shake stomach briskly side-to-side + listen for sloshing.
Succession splash
How do you palpate for the liver?
Start the palpation in the RIF, patient to take deep breaths.
On exhalation, the examining hand palpates deeply to feel for a ‘step’ as the liver edge passes under the hand.
Repeat 1–2cm closer to the right hypochondrium if nothing felt.
Where can the liver normally be palpated?
Up to 1cm below the right costal margin on deep inspiration.
If the liver edge is felt what should you note?
Degree of extension below the costal margin.
Consistency of liver edge (smooth/irregular).
Tenderness = ?hepatitis.
Pulsatility = pulsatile enlarged liver can be caused by tricuspid regurgitation.
How do you check Murphy’s sign
What is a positive sign?
What does a positive sign indicate?
Ask patient to breathe out then gently place hand below the right costal margin in the mid-clavicular line.
If inspiration is prevented by the inflamed gallbladder coming into contact with fingers = POSITIVE.
Positive sign requires no pain when performed on the left side.
Positive Murphy’s sign = acute cholecystitis.
How do you palpate the spleen?
Start the palpation in the RIF, patient to take deep breaths.
On exhalation, the examining hand palpates deeply to feel for a ‘step/notch’ as the splenic edge passes under the hand.
Repeat 1–2cm closer to the left hypochondrium if nothing felt.
When is the spleen palpable?
Only when enlarged (3x normal size).
How do you ballot the kidneys?
Place left hand behind the patient’s back at the right flank.
Place right hand just below right costal margin at the right flank.
Press your right hand’s fingers deep into the abdomen whilst pressing upwards with your left hand.
Repeat on left kidney.
When are the kidneys palpable?
Right kidney lower pole may be palpable in thin, normal people.
Left kidney rarely palpable.
Where do you palpate to feel the bladder?
Suprapubic region
When is the bladder palpable?
Empty bladder is not palpable.
Enlarged full bladder can be felt arising from behind the pubic symphysis + will make patient want to urinate
?urinary retention.
How do you palpate the abdominal aorta?
Palpate using fingers from both hands.
Palpate just above the umbilicus at the border of the aortic pulsation.
Note movement of fingers;
Where do you percuss in an abdo exam?
nine regions
liver
spleen
bladder
How do you percuss the liver?
Percuss up from the RIF from resonant to dull.
Percuss down from right chest to determine size of liver.
Where does the normal liver start?
Normal liver is just below nipple line.
How do you percuss for the following?
a) Spleen
b) Bladder
a) Percuss up from the RIF moving towards the left
hypochondrium.
b) Percuss suprapubic region, dull = bladder.
When do you test for shifting dullness?
If ascites is suspected
How do you assess for shifting dullness?
Percuss from centre towards the left flank.
If dull note is heard, keep finger in position + ask patient to roll onto their right side, wait a 10 seconds and percuss,
if the note becomes resonant percuss back towards the umbilicus until the note becomes dull as the dullness has shifted.
In an abdominal exam what do auscultate?
What are you listening for?
Where do you listen?
Bowel sounds
- Present + normal = gurgling.
- Abnormal = tinkling (bowel obstruction).
- Absent = ileus/peritonitis.
Suprapubic region
Aorta -> Bruits
Just above the umbilicus;
Renal arteries -> Bruits
Just above the umbilicus, laterally.
Upon completing the exam what do you want to do first?
Thank pt
Wash hands
To complete my exam….
ISHRUG
I’d like to check inguinal lymph nodes, a stool sample, examine the femoral and inguinal hernial orifices, perform a rectal examination, urinalysis and examine the external genitalia
