Abdominal Examination

Question 1

What is the structure of the abdominal exam?

Answer 1

• Identify key components of the patient
• Exclude red flags
• Justify vital signs and abdominal exam and potential areas of focus
• Informed consent
• Patient supine with knees up and draping
• Stand on RHS of patient
• OBS
• Auscultation: general & abdominal aorta, renal arteries and femoral arteries
• Percussion: general & possible specific depending on case
• Palpation: general & specific (liver, kidney), also AA and kidneys
• Additional tests

Question 2

What are the 4 additional tests?

Answer 2

• McBurney’s: rebound tenderness of the appendix (2/3rds the way toward ASIS from umbilicus)
• Murphy’s: mid-clavicular line at subcostal margin. Pt breathe in and identify if there is an increase in pain (gall bladder)
• rebound tenderness: assessing for potential peritonitis
• Fluid movement test: testing for acites and shifting of dullness

Question 3

Ascites?

Answer 3

Build up of fluid in the peritoneal cavity

Question 4

Caput Medusae

Answer 4

Caput medusae is the appearance of distended and engorged superficial epigastric veins, which are seen radiating from the umbilicus across the abdomen
It is also a sign/cause of portal hypertension

Question 5

Palpation?

Answer 5

Palpate lightly first, then deeper
Observe the patients’ face throughout
Coordinate patient’s inhalation with your palpation
Palpate the 4 quadrants
Liver edge palpation (not usually palpable)
Spleen palpation (not normally palpable)
Kidneys (not normally palpable)
Abdominal aorta: note the rate, rhythm, amplitude & diameter (normal = 2-3 cm)

Question 6

Percussion?

Answer 6

Percuss multiple sites within each quadrant for patterns of tympany and dullness
Percuss the spleen (outline the borders to establish size)
Percuss the liver (outline the border to establish size)

Potentially here you could discuss that excessive flank dullness could be a sign of ascites, and conduct the fluid movement test

Question 7

Shifting dullness?

Answer 7

Shifting Dullness
This maneuver is performed with the patient supine.
Percuss across the abdomen as for flank dullness, with the point of transition from tympany to dullness noted.
The patient then is rolled on his/her side away from the examiner, and percussion from the umbilicus to flank area is repeated.
Positive test: When ascites is present, the area of dullness will shift to the dependent site. The area of tympany will shift toward the top.
Note: The shift in zone of tympany with position change will usually be at least 3 cm when ascites is present

Question 8

Auscultation?

Answer 8

Listen for bowel sounds (normal is 5-30 per minute)
Listen for bruits
Abdominal aorta
Renal arteries
Femoral arteries
Listen for friction rubs (over the liver and spleen)

Question 9

Observation?

Answer 9

Examine the fingernails (e.g. cyanosis, clubbing)
Inspect the arms for obvious scars, lumps, scars, bruising, swelling
Inspect the conjunctiva (e.g. jaundice, pallor)
Observe the mouth and lips (e.g. Cyanosis)
Assess the abdominal contour
Inspect the skin over the abdomen
Inspect the umbilicus (e.g. herniation)
Inspect the abdominal region for peristalsis/ascites, pulsations and obvious veins

Question 10

Cyanosis

Answer 10

blueness: suggests lack of oxygen supply to the tissue, and if present with abdominal pain/symptoms anemia could be considered