Abdominal Examination Flashcards
What 5 stages should be involved in the introduction prior to starting the abdominal exam?
- wash your hands and don PPE if appropriate
- introduce yourself 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
How should the patient be positioned and exposed prior to starting an abdominal examination?
- the head of the bed should be adjusted to a 45o angle and the patient lies down
- adequately expose the patient’s abdomen for the examination from the waist up
- offer a blanket to allow exposure only when required and inform patients that they do not need to remove their bra
- exposing the patient’s lower legs is helpful to assess for peripheral oedema
What question is important to ask before starting the abdominal examination?
ensure to ask the patient if they are in any pain before starting the examination
What clinical signs, not related to the physical appearance of the patient, are observed from the end of the bed?
- age
- confusion
- pain
- if the patient appears uncomforthable, ask where the pain is and whether they are still happy for you to examine them
Why is it important to take note of the patient’s age before starting examination?
the approximate age is helpful when considering the most likely underlying pathology
younger patients are more likely to have diagnoses such as inflammatory bowel disease (IBD)
older patients are more likely to have diagnoses such as malignancy and chronic liver disease
What can confusion be a sign of?
hepatic encephalopathy
this is a feature of end-stage liver disease
What types of skin discolouration / changes should be looked for from the end of the bed?
- any obvious scars
- pallor
- jaundice
- hyperpigmentation
What is pallor?
What can it be a clinical sign of?
a pale colour of the skin that can suggest underlying anaemia
(e.g. due to gastrointestinal bleeding or malnutrition)
healthy individuals may have a pale complexion that mimics pallor
What is jaundice?
What causes it and what conditions is it commonly seen in?
a yellowish or greenish pigmentation of the skin and whites of the eyes due to hyperbilirubinaemia
this occurs in:
- acute hepatitis
- liver cirrhosis
- cholangitis
- pancreatic cancer
What is hyperpigmentation of the skin and what is it associated with?
a bronzing of the skin associated with haemochromatosis
What other clinical signs should be looked for from the end of the bed?
- abdominal distension
- oedema
- cachexia
- hernias
What might the presence of abdominal distension suggest?
it may suggest the presence of ascites or underlying bowel obstruction and / or organomegaly
In the context of abdominal examination, what does oedema suggest?
How does it present?
oedema typically presents as swelling of the limbs (pedal oedema) or abdomen (ascites)
it is often associated with liver cirrhosis
What types of hernias may be visible from the end of the bed?
How can they be made more pronounced?
umbilical or incisional hernias may be visible from the end of the bed
asking the patient to cough usually causes hernias to become more pronounced
What is cachexia?
What is it commonly associated with?
ongoing muscle loss that is not entirely reversed with nutritional supplementation
associated with underlying malignancy (e.g. pancreatic / bowel / stomach cancer) and advanced liver failure
What objects and equipments around the bed should be looked for before starting the examination?
- stoma bag (s)
- surgical drains
- feeding tubes
- other medical equipment
- mobility aids
- vital signs charts (and how these have changed over time)
- fluid balance
- prescriptions
What should be noted about stoma bag(s)?
note the location of the stoma bag(s) as this can provide clues as to the type of stoma
colostomies are typically located in the left iliac fossa
ileostomies are usually located in the right iliac fossa
What should be noted about surgical drains?
the location of the drain and the type / volume of contents within the drain
(e.g. blood, chyle, pus)
What other medical equipment around the bed should be looked for?
- ECG leads
- any medications
- total parenteral nutrition
- catheters (note volume / colour of urine)
- intravenous access
What are the 4 stages involved in inspection of the hands?
- inspect the palms
- look for nail signs
- assess for finger clubbing
- assess for asterixis (flapping tremor)
What 3 signs are looked for when inspecting the palms?
- pallor
- palmar erythema
- Dupuytren’s contracture
What does pallor of the palms suggest?
it may suggest underlying anaemia
(e.g. malignancy, gastrointestinal bleeding, malnutrition)
What is palmar erythema and what does it suggest when inspecting the palms?
a redness involving the heel of the palm
it can be associated with chronic liver disease
(it is also a normal finding in pregnancy)
What 2 signs should the nails be inspected for?
- koilonychia
- leukonychia
What is koilonychia and what is it associated with?
spoon-shaped nails
associated with iron deficiency anaemia (e.g. malabsorption in Crohn’s disease)
What is leukonychia and what is it associated with?
whitening of the nail bed
this is associated with hypoalbuminaemia
(e.g. end-stage liver disease , protein-losing enteropathy)
What is 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
What abdominal conditions are associated with finger clubbing?
- inflammatory bowel disease
- coeliac disease
- liver cirrhosis
- lymphoma of the gastrointestinal tract
How is finger clubbing assessed?
- ask 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 (Schamroth’s window)
- Schamroth’s window is lost when finger clubbing develops
What are the possible abdominal causes of asterixis?
- hepatic encephalopathy (due to hyperammoniaemia)
- uraemia secondary to renal failure
How is asterixis assessed for?
- ask the patient to stretch their arms out in front of them
- 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
What are the 3 stages involved in palpation of the hands?
- assess the temperature
- assess the radial pulse
- assess Dupuytren’s contracture
How is temperature of the hands assessed?
What should they feel like?
the dorsal aspect of the hand is placed onto the patient’s hands
in healthy individuals, hands should be symmetrically warm, suggesting adequate perfusion
cool hands suggest poor peripheral perfusion
How is the radial pulse assessed?
- palpate the radial pulse using the tips of your index and middle fingers aligned longitudinally over the course of the artery
- assess the rate and rhythm of the radial pulse
What is Dupuytren’s contracture?
What factors are associated with the development of this condition?
Dupuytren’s contracture involves thickening of the palmar fascia
this results in cords of palmar fascia that eventually cause contracture deformities of the fingers and thumb
factors associated with the development of this include:
- genetics
- excessive alcohol consumption
- increasing age
- male gender
- diabetes
How is Dupuytren’s contracture assessed for?
the patient’s hand is supported and palpate the palm to detect bands of thickened palmar fascia that feel cord-like
What 3 things must the patient’s arms be inspected for?
- bruising
- excoriations
- needle track marks
What might bruising of the arms suggest?
underlying clotting abnormalities secondary to liver disease (e.g. cirrhosis)
What are excoriations and what may this suggest?
scratch marks that may be caused by the patient trying to relieve pruritis
this may suggest underlying cholestasis
Why are needle track marks important to note?
intravenous drug use can be associated with increased risk of viral hepatitis
What 2 things must the patient’s axillae be inspected for?
- acanthosis nigricans
- hair loss
What is acanthosis nigricans?
What is it associated with?
darkening (hyperpigmentation) and thickening (hyperkeratosis) of the axillary skin
this can be benign or associated with insulin resistance (e.g. type 2 diabetes) or gastrointestinal malignancy (most commonly stomach cancer)
What can hair loss in the axilla suggest?
loss of axillary hair is associated with iron-deficiency anaemia and malnutrition
What 6 things should the patient’s eyes be inspected for?
- conjunctival pallor
- jaundice
- corneal arcus
- xanthelasma
- kayser-fleischer rings
- perilimbal injection
What is conjunctival pallor suggestive of?
underlying anaemia
Where is jaundice most evident in the eye?
it is most evident in the superior portion of the sclera
(ask patient to look downwards as you lift their upper eyelid)
What is corneal arcus?
What does it suggest?
a hazy white, grey or blue opaque ring located in the peripheral cornea
it typically occurs in patients over the age of 60
in older patients, it is considered benign
in patients under the age of 50, it suggests underlying hypercholesterolaemia
What are xanthelasma?
yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia
What are Kayser-Fleischer rings?
What are they associated with?
dark rings that encircle the iris that are associated with Wilson’s disease
this involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues
(including the lvier causing cirrhosis)
What is perilimbal injection?
What is it associated with?
inflammation of the area of conjunctiva adjacent to the iris
it is a sign of anterior uveitis, which can be associated with inflammatory bowel disease
What 5 things should the patient’s mouth be inspected for?
- angular stomatitis
- glossitis
- oral candidiasis
- aphthous ulceration
- hyperpigmented macules
What is angular stomatitis and what can cause it?
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)
What is glossitis and what is it associated with?
smooth erythematous enlargement of the tongue
associated with iron, B12 and folate deficiency
(e.g. malabsorption secondary to inflammatory bowel disease)
What is oral candidiasis and what does it look like?
a fungal infection commonly associated with immunosuppression
characterised by pseudomembranous white slough which can be easily wiped away to reveal underlying erythematous mucosa
What is aphthous ulceration?
What do they tend to be associated with?
round or oval ulcers occurring on the mucous membranes inside the mouth
they are typically benign (due to stress or mechanical trauma)
they can be associated with iron, B12 and folate deficiency, as well as Crohns disease
What are hyperpigmented macules and what are they associated with?
these are pathognomonic for Peutz-Jeghers syndrome
this is an autosomal dominant genetic disorder that results in the development of polyps in the GI tract
How is the neck inspected during abdominal examination?
the neck is palpated for lymphadenopathy
palpate the supraclavicular fossa on each side, paying particular attention to Virchow’s node on the left for evidence of lymphadenopathy
What is Virchow’s node and why is it important to pay particular attention to this area?
it is the left supraclavicular lymph node
it receives lymphatic drainage from the abdominal cavity
enlargement of Virchow’s node can be one of the first clinical signs of metastatic intra-abdominal malignancy
(most commonly gastric cancer)
What might enlargement of the right supraclavicular lymph node suggest?
this receives drainage from the thorax
lymphadenopathy in this region can be associated with metastatic oesophageal cancer
(as well as malignancy from other thoracic viscera)
What 3 signs should the patient’s chest be inspected for?
- spider naevi
- gynaecomastia
- hair loss
What are spider naevi?
What are they commonly associated with and why should they be counted?
skin lesions that have a central red papule with fine red lines extending radially
they are caused by increased levels of circulating oestrogen
they are associated with liver cirrhosis
they can be a normal finding in pregnancy or women taking the combined oral contraceptive pill
if more than 5 are present, they are more likely to be associated with pathology such as liver cirrhosis
What is gynaecomastia?
What is it caused by?
enlargement of male breast tissue caused by increased levels of circulating oestrogen
(e.g. in liver cirrhosis)
other causes include medications such as digoxin and spironolactone
What can hair loss on the chest suggest?
this is caused by increased levels of circulating oestrogen
it can also be caused by general malnourishment
How should the patient be positioned for abdominal inspection and palpation?
the patient should be lying flat on the bed with their arms by their sides and their legs uncrossed
What 7 signs should be looked for when inspecting the patient’s abdomen?
- scars
- abdominal distension
- caput medusae
- striae (stretch marks)
- hernias
- Cullen’s sign
- Grey Turner’s sign
What are the 6Fs that describe the causes of abdominal distension?
- fat
- fluid
- flatus
- faeces
- fetus
- fulminant mass
What are caput medusae and what are they associated with?
engorged paraumbilical veins associated with portal hypertension
(e.g. liver cirrhosis)
What causes striae (stretch marks)?
What conditions are these associated with?
caused by tearing during the rapid growth or overstretching of skin
(e.g. ascites, intrabdominal malignancy, Cushing’s syndrome, obesity, pregnancy)
What is Cullen’s sign?
bruising of the tissue surrounding the umbilicus associated with haemorrhagic pancreatitis (a late sign)
What is Grey Turner’s sign?
bruising in the flanks associated with haemorrhagic pancreatitis
(a late sign)
If a stoma is present, what 4 characteristics need to be assessed?
Location:
- provides clues as to the type of stoma
Contents:
- can be stool (colostomy / ileostomy) or urine (urostomy)
Consistency of stool:
- note if it is liquid (ileostomy) or solid (colostomy)
Spout:
- colostomies are flush to the skin with no spout
- ileostomies and urostomies have a spout
What is the difference in location of colostomies and ileostomies?
- colostomies are typically located in the left iliac fossa
- ileostomies (and urostomies) are typically located in the right iliac fossa
Before beginning abdominal palpation, what should you ask the patient?
how should you be positioned?
ask the patient if they are aware of any areas of abdominal pain
if present, these areas should be examined last
kneel beside the patient to carry out palpation and observe their face throughout the examination for signs of discomfort
How should the abdomen be palpated?
- light palpation of each of the 9 abdominal regions should be done initially
- deep palpation of each of the 9 regions is then performed, applying greater pressure to identify any deeper masses
What are the 9 regions of the abdomen?
What 5 signs suggestive of GI pathology should be looked for during light palpation of the abdomen?
- tenderness
- rebound tenderness
- guarding
- Rovsing’s sign
- masses
How should tenderness be recorded?
note the abdominal region (s) involved and the severity of the pain
What is rebound tenderness?
What can it be associated with?
it is said to be present when the abdominal wall, having been compressed slowly, is released rapidly and results in sudden sharp abdominal pain
this is a non-specific, unreliable clinical sign
it can, in some cases, be associated with peritonitis (e.g. appendicitis)
What is guarding and what is it associated with?
involuntary tension in the abdominal muscles that occurs on palpation
it is associated with peritonitis
(e.g. appendicitis, diverticulitis)
What is Rovsing’s sign and what does it indicate?
palpation of the left iliac fossa causes pain to be experienced in the right iliac fossa
it was historically indicative of appendicitis
it is not reliable and indicates peritoneal inflammation of any cause affecting the left and/or right iliac fossa
If any masses are located during deep palpation, what 5 characteristics should be assessed?
- location
- size and shape
- consistency
- mobility
- pulsatility
How is the location of an abdominal mass recorded?
note which of the 9 abdominal regions the mass is located within
How is the mobility of an abdominal mass assessed?
assess if the mass appears to be attached to superficial or underlying structures
What is a pulsatile abdominal mass suggestive of?
a pulsatile abdominal mass is suggestive of vascular aetiology
(e.g. abdominal aortic aneurysm)
How is the liver palpated?
- begin palpation in the right iliac fossa, starting at the edge of the superior iliac spine, using the flat edge of your hand (radial side of right index finger)
- ask patient to take a deep breath and as they begin to do this palpate the abdomen
feel for a step as the liver edge passes below your hand during inspiration
- repeat this process of palpation moving 1-2cm superiorly from the right iliac fossa each time towards the right costal margin
- as you get close to the costal margin (1-2cm below it) the liver edge may become palpable in healthy individuals
If the liver edge is palpable, what 4 characteristics should be assessed?
- degree of extension below the costal margin
- consistency of the liver edge
- tenderness
- pulsatility
Why is the degree of extension of the liver below the costal margin assessed?
if it is greater than 2cm then this suggests hepatomegaly
Why is consistency of the liver edge recorded?
a nodular consistency suggests cirrhosis
What might hepatic tenderness suggest?
hepatitis or cholecystitis (as you may be palpating the gallbladder)
Why is the pulsatility of the liver’s edge assessed?
pulsatile hepatomegaly is associated with tricuspid regurgitation
Is the gallbladder usually palpable?
What does it suggest if it is?
the gallbladder is not usually palpable in healthy individuals
if the gallbladder is palpable, this suggests enlargement secondary to biliary flow obstruction
(e.g. pancreatic malignancy / gallstones)
and/or infection
How is the gallbladder palpated?
What does it feel like?
palpation of the gallbladder is attempted at the right costal margin, in the mid-clavicular line (tip of the 9th rib)
if it is enlarged, a well-defined round mass that moves with respiration may be noted
What does tenderness of the gallbladder on palpation suggest?
What if the gallbladder is not tender?
tenderness suggests a diagnosis of cholecystitis
a distended painless gallbladder indicates underlying pancreatic cancer
(particularly if also associated with jaundice)
What is Murphy’s sign and how is it assessed?
- position fingers at the right costal margin in the mid-clavicular line at the liver’s edge
- ask the patient to take a deep breath
- if the patient suddenly stops mid-breath due to pain, this suggests the presence of cholecystitis
How is the spleen palpated?
- palpation begins in the right iliac fossa, starting at the edge of the superior iliac spine, using the flat edge of your hand (radial side of right index finger)
- ask patient to take a deep breath and as they begin to do this palpate the abdomen with you fingers aligned with the left costal margin
feel for a step as the splenic edge passes below your hand during inspiration (splenic notch may be noted)
- repeat process of palpation moving 1-2cm superiorly from the right iliac fossa each time towards the left costal margin
What would a palpable spleen suggest?
How large would the spleen have to be for it to be able to be felt?
- in healthy individuals, you should not be able to palpate the spleen
- a palpable spleen at the edge of the left costal margin suggests splenomegaly
- for the spleen to be palpable at this location it would need to be 3 times its normal size
What are the 5 causes of splenomegaly?
- portal hypertension secondary to liver cirrhosis
- haemolytic anaemia
- congestive heart failure
- splenic metastases
- glandular fever
How are the kidneys balloted?
- place left hand behind the patient’s back, below the ribs and underneath the right flank
- place right hand on the anterior abdominal wall just below the right costal margin in the right flank
- push your fingers together, pressing upwards with your left hand and downwards with your right hand
- ask patient to take a deep breath and as they do this feel for the lower pole of the kidney moving down between your fingers
- if a kidney is ballotable, describe its size and consistency
- repeat this process on the opposite side to ballot the left kidney
In what types of healthy patients are the kidneys sometimes ballotable?
the kidneys are not usually ballotable
in patients with a low body mass index, the inferior pole can sometimes be palpated during inspiration
What are the causes of bilateral and unilaterally enlarged kidneys?
- bilaterally enlarged, ballotable kidneys occur in polycystic kidney disease or amyloidosis
- a unilaterally enlarged, ballotable kidney can be caused by a renal tumour
How is the aorta palpated?
- using both hands, deep palpation is performed just superior to the umbilicus in the midline
- note the movement of your fingers
