Abdominal examination Flashcards
Preparation.
a) Patient position (4 things)
b) Ask the patient what?
c) And of course what things for all examinations?
a) - Patient should be adequately exposed (from xiphisternum to pubis)
- Patient should be lying comfortably with the head a little elevated - 10-15 degrees (one pillow).*
- The arms should be placed alongside the body.*
- The legs should be straight (not crossed).*
- These relax the abdominal muscles.
b) Are they in any pain?
c) - Wash hands
- Introduce self
- Ask patient’s name, DOB and age (and check against wristband)
- Explain the examination and obtain consent
General inspection (end-of-the-bed-o-gram).
a) General appearance - what may be noted?
b) Other features indicating GI/systemic disease
c) Paraphernalia around the bed
d) Paraphernalia attached to patient
a) - Do they look generally well or unwell?
- Are they obviously in pain, discomfort or distress?
- Do they appear confused?
- Are they very still (?peritonitis) or writhing around (?colic)?
- Note their observations if available
b) - Jaundice (best examined in natural light: most often found on the sclera, frenulum or abdomen)
- Bruising/ purpura
- Cachexia
c) - IV fluids
- TPN feeds
- Blood bags
- Oxygen
- ‘Nil by mouth’ sign
d) - Oxygen
- Cannulas, PICC lines, CVCs, etc.
- Catheters
- NG tubes
- Stomas - colostomy, ileostomy, urostomy, jejunostomy
Examination of the hands/arms.
a) General observations
b) GI-specific signs
c) Other marks on the hands/arms
a) - Cold, clammy, warm/well-perfused
- Take pulse and CRT
- Tar staining (?malignancy)
b) - Clubbing: IBD, PBC, coeliac disease, cystic fibrosis or other malabsorption syndromes
- Kolionychia: iron deficiency
- Leukonychia striata (Muehrcke’s lines): low albumin
- Chronic liver disease: palmar erythema, Dupuytren’s contracture
- Hepatic encephalopathy - ASTERIXIS
c) - Track marks - IVDU
- Scratch marks - pruritis (bilirubinaemia)
- Bruising
Examination of the face, neck and chest.
a) Eyes - possible signs
b) Mouth - possible signs
c) Neck - possible signs
d) Chest - possible signs
a) - Subconjunctival pallor
- Jaundiced sclera
- Xanthelasma around the eye (?PBC)
- Kayser-Fleischer rings (Wilson’s disease)
b) - Dry mucous membranes
- Jaundiced frenulum
- Stomatitis/ glossitis (iron/B12/folate deficiency)
- Aphthous ulcers (IBD)
c) - Lympadenopathy
- Especially Virchow’s node (usually upper GI cancer)
- Say “If the patient were at 45 degrees I would inspect the JVP”
d) - Spider naevi
- Gynaecomastia
Inspection of the abdomen.
a) Possible signs
b) Types of surgical incisions
c) How to examine scars
d) Types of “bags”
a) - Distension (fat, fluid, faeces, flatus, foetus), abdominal respiration, bruising, scars, stoma, hernias, visible peristalsis (?BO), distended veins (?liver disease)
- Classical bruising of retroperitoneal haemorrhage - Cullen sign and Grey-Turner’s sign
- Sister Mary Joseph nodule - malignant metastatic umbilical nodule (sign of advanced abdominal Ca)
- A mass may be apparent. To exaggerate the presence of a mass, inspect with the head raised from the bed to tense the abdominal muscles
b) - Laparotomy scars - eg. midline, paramedian, McBurney’s/gridiron, transverse, etc.
- Laparoscopy scars - including port sites
- Surgical drain scars
- Stoma sites
c) - Inspect the scar - determine length, site, orientation and consider possible operation (eg. “a 5 cm oblique scar in the right iliac fossa, indicating possible previous open appendicectomy”)
- Feel for healing/tenderness
- Cough impulse to assess for possible incisional/port site hernia
d) - Surgical drain
- Surgical wound bag
- Fistulae bag
- Ileostomy bag (may be end or loop)
- Colostomy bag (usually end)
- Urostomy bag (ileal conduit for urine)
General palpation of the abdomen.
a) Why must you palpate all abdominal scars?
b) If patient has pain, start palpating where?
c) Reason for superficial and deep palpation?
d) Signs of local peritonism
e) Signs of generalised peritonitis
f) Differentiating true peritonism from a wimp patient
a) To assess for hernia - examine for cough impulse. Also get patient to sit forward (if midline laparotomy - distinguish from divarication of the recti)
b) Start away from pain, work towards it
c) - Superficial - parietal peritoneum inflammation, tenderness, guarding
- Deep - visceral peritoneum inflammation, organomegaly, other masses
d) Signs.
- Involuntary guarding in specific area
- May have percussion tenderness or rebound tenderness
- Acute cholecystitis - Murphy’s sign
- Appendicitis - Rovsing’s, Obturator, Psoas and Pointing signs
e) - Board-like abdominal rigidity
- Involuntary guarding of entire abdomen
- Bowel sounds absent
f) Elicit true peritonism* by…
- distracting patient while palpating,
- asking them to cough or take a deep breath,
- pressing stethoscope firmly while auscultating
*Don’t be afraid of pressing firmly so that the patient jumps off the bed, as this is a good sign that they have true peritonism that will require active management
Palpation of organs and masses.
a) What are the borders for the renal angle?
b) Which organs may be felt in normal individual?
c) Features of a renal mass
d) Features of a liver mass
e) Features of gallbladder mass
f) Features of splenic mass
g) What else should be felt?
h) If no hepatosplenomegaly found on palpation, how should you save yourself some time?
a) Lower border of 12th rib and lateral borders of erector spinae muscles
- DON’T FORGET to examine the back for scars
b) - Liver, possibly kidney (if very thin), possibly gallbladder
- Note: spleen should NEVER be palpable
c) - Grow downwards from flanks to iliac fossae, palpable front and back, ballottable
d) - RUQ, extends downwards to RIF if large
- Moves with respiration
e) - Globular mass in RUQ
- Moves with respiration
f) - Extends from LUQ to (if very large) RIF across umbilicus
- Moves with respiration
g) - Abdominal aorta
- Bladder
- Any hernias or enlarged lymph nodes
h) Say to examiner - “I didn’t find any HSM, so I think it will be unnecessary percussing them if you agree?”
Palpation ?
?
Percussion.
a) Ascites
b) Organomegaly*
c) Other uses
*Note: you can omit percussion of liver and spleen if no organomegaly felt on palpation - say to examiner
a) - Detecting ascites vs. flatus - dull vs. resonant
- Confirm with shifting dullness
b) - Liver, gallbladder, spleen, kidneys and any other solid masses (eg. GI tumours) will be dull to percuss
c) - Full bladder from chronic retention
- Percussion tenderness
Auscultation.
a) Auscultation of BS useful in what 3 situations?
b) What else can be auscultated?
a) - Mechanical bowel obstruction - tinkling (high-pitched and frequent bowel sounds)
- Paralytic ileus - absent BS
- Peritonitis - absent BS
b) Bruits: aortic or renal
After auscultation, do what final examination?
Legs - any pitting oedema
(and remember lymph nodes here if forgotten)
To complete the abdominal examination.
I SHRUG.
- Examine the groin for any hernias or lymphadenopathy
- Perform a digital rectal examination and examination of the external genitalia
- Obtain a stool sample and urine sample for analysis
Signs of chronic liver disease.
a) List some signs from hands to chest to abdomen
b) Childs-Pugh score (5 criteria)
c) Clinical signs of ascites
a) Signs of CLD:
- Palmar erythema, asterixis, Dupuytren’s contracture
- Bruising
- Jaundice
- Spider naevi (differentiate from Campbell de Morgan spots/ senile angioma)
- Gynaecomastia (and testicular atrophy)
- Ascites (+ ankle oedema)
- Distended veins - abdomen (severe = caput medusae), rectal varices, parastomal varices, etc.
b) Calculates mortality risk in cirrhosis (5 criteria):
- Bilirubin level (jaundice)
- Encephalopathy grade 1 - 4 (eg. asterixis, confusion, ataxia, rigidity, hyper-reflexia, stupor, coma)
- Albumin
- Ascites
- INR (clotting dysfunction)
c) - Abdominal distension
- Dullness to percussion in the flanks when supine
- Shifting dullness when patient rotated onto side
- Fluid thrill
Hernias.
a) Longitudinal midline mass, expands on sitting up - likely diagnosis
b) Clinical signs - how to assess?
c) Visible/palpable types
d) Non-visible types
e) Define ‘hernia’
f) Strangulated hernia - characteristics?
g) Obstructed hernia - characteristics?
a) Divarication of the recti (not a hernia)
b) - Cough impulse, reducible (unless incarcerated = irreducible), expand on sitting up
- Often present in the groin/testes so these must be examined if suspected hernia
c) - Incisional - previous surgical site (including port site)
- Epigastric - upper abdomen in midline
- Umbilical - through umbilicus
- Parastomal - around stoma site
- Inguinal - above and medial to the pubic tubercle. May be direct (through defect in posterior wall of inguinal canal) or indirect (through deep ring of inguinal canal)
- Femoral - below and lateral to the pubic tubercle
d) - Spigelian hernia - between layers of the abdominal muscles
- Hiatus hernia - stomach pushed up into the thoracic cavity through a weakness in the diaphragm
e) Protrusion of a viscus through the wall of its cavity
f) - Compression of hernia to the extent that blood supply is compromised, causing ischaemia and pain
- More common in femoral > inguinal hernias
g) - Compression of hernia (bowel) to the extent that the bowel lumen contents become obstructed (emergency)
Surgical scars: differentials
a) Rooftop (bilateral subcostal incision)
b) Mercedes Benz (rooftop plus sternotomy)
c) Midline laparotomy
d) Gridiron/McBurney’s (oblique)
e) Lanz scar (transverse)
f) Hockey stick
g) Port scars: 2 most common
h) Pfannensteil
a) Upper GI (eg. Whipple’s procedure)
b) Liver transplant
c) Emergency abdominal surgery (may be upper or lower midline laparotomy)
d) Open appendicectomy
e) Open appendicectomy
f) Renal transplant (usually in RIF)
g) - Laparoscopic cholecystectomy: 3 or 4 port sites - umbilical, epigastric, R hypochondrium, R flank
- Laparoscopic appendicectomy: umbilical port, LIF or RIF port
h) Transverse suprapubic incision: pelvic surgery, including CS
