Abdominal Examination Flashcards
Describe the intro to the exam
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Briefly explain what the examination will involve using patient-friendly language.
Gain consent to proceed with the examination.
Adjust the head of the bed to a 45° angle and ask the patient to lay on the bed.
What needs to be exposed for the purpose of the abdomen exam
Wash your hands.
Adequately expose the patient’s abdomen for the examination from the waist up (offer a blanket to allow exposure only when required and if appropriate, inform patients they do not need to remove their bra). Exposure of the patient’s lower legs is also helpful to assess for peripheral oedema.
Ask the patient if they have any pain before proceeding with the clinical examination.
Which clinical signs should you look for upon general inspection
Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying pathology:
Age: the patient’s approximate age is helpful when considering the most likely underlying pathology, with younger patients more likely to have diagnoses such as inflammatory bowel disease (IBD) and older patients more likely to have chronic liver disease and malignancy.
Confusion: often a feature of end-stage liver disease, known as hepatic encephalopathy.
Pain: if the patient appears uncomfortable, ask where the pain is and whether they are still happy for you to examine them.
Obvious scars: may provide clues regarding previous abdominal surgery.
Abdominal distention: may suggest the presence of ascites or underlying bowel obstruction and/or organomegaly.
Pallor: a pale colour of the skin that can suggest underlying anaemia (e.g. gastrointestinal bleeding or malnutrition). It should be noted that healthy individuals may have a pale complexion that mimics pallor.
Jaundice: a yellowish or greenish pigmentation of the skin and whites of the eyes due to high bilirubin levels (e.g. acute hepatitis, liver cirrhosis, cholangitis, pancreatic cancer).
Hyperpigmentation: a bronzing of the skin associated with haemochromatosis.
Oedema: typically presents as swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites) and is often associated with liver cirrhosis in the context of an abdominal examination OSCE station.
Cachexia: ongoing muscle loss that is not entirely reversed with nutritional supplementation. Cachexia is commonly associated with underlying malignancy (e.g. pancreatic/bowel/stomach cancer) and advanced liver failure.
Hernias: may be visible from the end of the bed (e.g. umbilical/incisional hernia). Asking the patient to cough will usually cause hernias to become more pronounced.
Which medical paraphernalia should you look out for that are pertinent to the abdomen exam
Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current clinical status:
Stoma bag(s): note the location of the stoma bag(s) as this can provide clues as to the type of stoma (e.g. colostomies are typically located in the left iliac fossa, whereas ileostomies are usually located in the right iliac fossa). Surgical drains: note the location of the drain and the type/volume of the contents within the drain (e.g. blood, chyle, pus). Feeding tubes: note the presence of feeding tubes (e.g. nasogastric/nasojejunal) and whether the patient is currently being fed. Other medical equipment: ECG leads, medications, total parenteral nutrition, catheters (note volume/colour of urine) and intravenous access. Mobility aids: items such as wheelchairs and walking aids give an indication of the patient’s current mobility status. Vital signs: charts on which vital signs are recorded will give an indication of the patient’s current clinical status and how their physiological parameters have changed over time. Fluid balance: fluid balance charts will give an indication of the patient’s current fluid status which may be relevant if a patient appears fluid overloaded or dehydrated. Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications.
Describe inspection of the palms in the abdomen exam
Palms
Inspect the palms for any of the following signs:
Pallor: may suggest underlying anaemia (e.g. malignancy, gastrointestinal bleeding, malnutrition).
Palmar erythema: a redness involving the heel of the palm that can be associated with chronic liver disease (it can also be a normal finding in pregnancy).
Dupuytren’s contracture (see more details in the palpation section).
Describe inspection of the nails in the abdomen exam
Inspect the nails for any of the following signs:
Koilonychia: spoon-shaped nails, associated with iron deficiency anaemia (e.g. malabsorption in Crohn’s disease).
Leukonychia: whitening of the nail bed, associated with hypoalbuminaemia (e.g. end-stage liver disease, protein-losing enteropathy).
Describe finger clubbing in the abdomen exam
Finger clubbing
Finger clubbing involves uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed. Finger clubbing is associated with several underlying disease processes, but those most likely to appear in an abdominal OSCE station include inflammatory bowel disease, coeliac disease, liver cirrhosis and lymphoma of the gastrointestinal tract.
To assess for finger clubbing:
Ask the patient to place the nails of their index fingers back to back.
In a healthy individual, you should be able to observe a small diamond-shaped window (known as Schamroth’s window).
When finger clubbing develops, this window is lost.
Describe asterisks (flapping tremor) in the abdomen exam
Asterixis (also known as ‘flapping tremor’) is a type of negative myoclonus characterised by irregular lapses of posture causing a flapping motion of the hands. In the context of an abdominal examination, the most likely underlying cause is either hepatic encephalopathy (due to hyperammonaemia) or uraemia secondary to renal failure. CO2 retention secondary to type 2 respiratory failure is another possible cause of asterixis.
Ask the patient to stretch their arms out in front of them.
Then ask them to cock their hands backwards at the wrist joint and hold the position for 30 seconds.
Observe for evidence of asterixis during this time period.
Describe palpation of temperature in the abdomen exam
Temperature
Place the dorsal aspect of your hand onto the patient’s to assess temperature:
In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion.
Cool hands may suggest poor peripheral perfusion.
Describe palpation of the radial pulse
Radial pulse
Assess the patient’s radial pulse:
Palpate the patient’s radial pulse, located at the radial side of the wrist, with the tips of your index and middle fingers aligned longitudinally over the course of the artery.
Once you have located the radial pulse, assess the rate and rhythm.
Describe palpation of dupuytren’s contracture
Dupuytren’s contracture involves thickening of the palmar fascia, resulting in the development of cords of palmar fascia which eventually cause contracture deformities of the fingers and thumb. There are a number of factors that have been associated with the development of Dupuytren’s contracture including genetics, excessive alcohol use, increasing age, male gender and diabetes.
To assess for Dupuytren’s contracture:
Support the patient’s hand and palpate the palm to detect bands of thickened palmar fascia that feel cord-like.
Describe inspection of the arms
Arms
Inspect the patient’s arms for the following:
Bruising: may suggest underlying clotting abnormalities secondary to liver disease (e.g. cirrhosis).
Excoriations: scratch marks that may be caused by the patient trying to relieve pruritis. In the context of an abdominal examination, this may suggest underlying cholestasis.
Needle track marks: important to note as intravenous drug use can be associated with an increased risk of viral hepatitis.
Describe inspection of the axillae
Whilst supporting the patient’s arm, inspect each axilla for the following:
Acanthosis nigricans: darkening (hyperpigmentation) and thickening (hyperkeratosis) of the axillary skin which can be benign (most commonly in dark-skinned individuals) or associated with insulin resistance (e.g. type 2 diabetes mellitus) or gastrointestinal malignancy (most commonly stomach cancer).
Hair loss: loss of axillary hair associated with iron-deficiency anaemia and malnutrition.
Describe the eye signs
Conjunctival pallor: suggestive of underlying anaemia.
Jaundice: most evident in the superior portion of the sclera (ask the patient to look downwards as you lift their upper eyelid).
Corneal arcus: a hazy white, grey or blue opaque ring located in the peripheral cornea, typically occurring in patients over the age of 60. In older patients, the condition is considered benign, however, its presence in patients under the age of 50 suggests underlying hypercholesterolaemia.
Xanthelasma: yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia.
Kayser-Fleischer rings: dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues (including the liver causing cirrhosis).
Perilimbal injection: inflammation of the area of conjunctiva adjacent to the iris. Perilimbal injection is a sign of anterior uveitis, which can be associated with inflammatory bowel disease. Other clinical features of anterior uveitis include photophobia, ocular pain and reduced visual acuity.
Describe the mouth signs pertinent to G.I pathology
Angular stomatitis: a common inflammatory condition affecting the corners of the mouth. It has a wide range of causes including iron deficiency (e.g. gastrointestinal malignancy, malabsorption).
Glossitis: smooth erythematous enlargement of the tongue associated with iron, B12 and folate deficiency (e.g. malabsorption secondary to inflammatory bowel disease).
Oral candidiasis: a fungal infection commonly associated with immunosuppression. It is characterised by pseudomembranous white slough which can be easily wiped away to reveal underlying erythematous mucosa.
Aphthous ulceration: round or oval ulcers occurring on the mucous membranes inside the mouth. Aphthous ulcers are typically benign (e.g. due to stress or mechanical trauma), however, they can be associated with iron, B12 and folate deficiency as well as Crohn’s disease.
Hyperpigmented macules: pathognomonic for Peutz-Jeghers syndrome, an autosomal dominant genetic disorder that results in the development of polyps in the gastrointestinal tract.
Where are apthous ulcers located
Top of mouth, at the back of the palate.
What is pout-jegheurs syndrome
Peutz–Jeghers syndrome (often abbreviated PJS) is an autosomal dominant genetic disorder characterized by the development of benign hamartomatous polyps in the gastrointestinal tract and hyperpigmented macules on the lips and oral mucosa (melanosis)
Describe the importance of lymph nodes in the neck
The left supraclavicular lymph node (known as Virchow’s node) receives lymphatic drainage from the abdominal cavity and therefore enlargement of Virchow’s node can be one of the first clinical signs of metastatic intrabdominal malignancy (most commonly gastric cancer). The right supraclavicular lymph node receives lymphatic drainage from the thorax and therefore lymphadenopathy in this region can be associated with metastatic oesophageal cancer (as well as malignancy from other thoracic viscera).
How do we palpate for lymphadenopathy in the neck
Palpate the supraclavicular fossa on each side, paying particular attention to Virchow’s node on the left for evidence of lymphadenopathy.
