Abdominal Examination Flashcards
1
Q
What 5 stages should be involved in the introduction prior to starting the abdominal exam?
A
- 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
2
Q
How should the patient be positioned and exposed prior to starting an abdominal examination?
A
- 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
3
Q
What question is important to ask before starting the abdominal examination?
A
ensure to ask the patient if they are in any pain before starting the examination
4
Q
What clinical signs, not related to the physical appearance of the patient, are observed from the end of the bed?
A
- age
- confusion
- pain
- if the patient appears uncomforthable, ask where the pain is and whether they are still happy for you to examine them
5
Q
Why is it important to take note of the patient’s age before starting examination?
A
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
6
Q
What can confusion be a sign of?
A
hepatic encephalopathy
this is a feature of end-stage liver disease
7
Q
What types of skin discolouration / changes should be looked for from the end of the bed?
A
- any obvious scars
- pallor
- jaundice
- hyperpigmentation
8
Q
What is pallor?
What can it be a clinical sign of?
A
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
9
Q
What is jaundice?
What causes it and what conditions is it commonly seen in?
A
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
10
Q
What is hyperpigmentation of the skin and what is it associated with?
A
a bronzing of the skin associated with haemochromatosis
11
Q
What other clinical signs should be looked for from the end of the bed?
A
- abdominal distension
- oedema
- cachexia
- hernias
12
Q
What might the presence of abdominal distension suggest?
A
it may suggest the presence of ascites or underlying bowel obstruction and / or organomegaly
13
Q
In the context of abdominal examination, what does oedema suggest?
How does it present?
A
oedema typically presents as swelling of the limbs (pedal oedema) or abdomen (ascites)
it is often associated with liver cirrhosis
14
Q
What types of hernias may be visible from the end of the bed?
How can they be made more pronounced?
A
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
15
Q
What is cachexia?
What is it commonly associated with?
A
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
16
Q
What objects and equipments around the bed should be looked for before starting the examination?
A
- 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
17
Q
What should be noted about stoma bag(s)?
A
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
18
Q
What should be noted about surgical drains?
A
the location of the drain and the type / volume of contents within the drain
(e.g. blood, chyle, pus)
19
Q
What other medical equipment around the bed should be looked for?
A
- ECG leads
- any medications
- total parenteral nutrition
- catheters (note volume / colour of urine)
- intravenous access
20
Q
What are the 4 stages involved in inspection of the hands?
A
- inspect the palms
- look for nail signs
- assess for finger clubbing
- assess for asterixis (flapping tremor)
21
Q
What 3 signs are looked for when inspecting the palms?
A
- pallor
- palmar erythema
- Dupuytren’s contracture
22
Q
What does pallor of the palms suggest?
A
it may suggest underlying anaemia
(e.g. malignancy, gastrointestinal bleeding, malnutrition)
23
Q
What is palmar erythema and what does it suggest when inspecting the palms?
A
a redness involving the heel of the palm
it can be associated with chronic liver disease
(it is also a normal finding in pregnancy)
24
Q
What 2 signs should the nails be inspected for?
A
- koilonychia
- leukonychia
25
What is koilonychia and what is it associated with?
**_spoon-shaped nails_**
associated with **iron deficiency anaemia** (e.g. malabsorption in Crohn's disease)
26
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)
27
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**
28
What abdominal conditions are associated with finger clubbing?
* inflammatory bowel disease
* coeliac disease
* liver cirrhosis
* lymphoma of the gastrointestinal tract
29
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
30
What are the possible abdominal causes of asterixis?
* **hepatic encephalopathy** (due to hyperammoniaemia)
* **uraemia** secondary to renal failure
31
How is asterixis assessed for?
* ask the patient to **stretch their arms out i**n 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
32
What are the 3 stages involved in palpation of the hands?
* assess the temperature
* assess the radial pulse
* assess Dupuytren's contracture
33
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_**
34
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
35
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
36
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_**
37
What 3 things must the patient's arms be inspected for?
* bruising
* excoriations
* needle track marks
38
What might bruising of the arms suggest?
underlying **clotting abnormalities** secondary to liver disease (e.g. cirrhosis)
39
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_**
40
Why are needle track marks important to note?
**intravenous drug use** can be associated with increased risk of **_viral hepatitis_**
41
What 2 things must the patient's axillae be inspected for?
* acanthosis nigricans
* hair loss
42
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**)
43
What can hair loss in the axilla suggest?
loss of axillary hair is associated with **iron-deficiency anaemia** and **malnutrition**
44
What 6 things should the patient's eyes be inspected for?
* conjunctival pallor
* jaundice
* corneal arcus
* xanthelasma
* kayser-fleischer rings
* perilimbal injection
45
What is conjunctival pallor suggestive of?
underlying anaemia
46
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)
47
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_**
48
What are xanthelasma?
**yellow, raised cholesterol-rich deposits** around the eyes associated with **_hypercholesterolaemia_**
49
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_**)
50
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
51
What 5 things should the patient's mouth be inspected for?
* angular stomatitis
* glossitis
* oral candidiasis
* aphthous ulceration
* hyperpigmented macules
52
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**)
53
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)
54
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
55
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**
56
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_**
57
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
58
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**)
59
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)
60
What 3 signs should the patient's chest be inspected for?
* spider naevi
* gynaecomastia
* hair loss
61
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
62
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**
63
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**
64
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**
65
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
66
What are the 6Fs that describe the causes of abdominal distension?
* fat
* fluid
* flatus
* faeces
* fetus
* fulminant mass
67
What are caput medusae and what are they associated with?
**engorged paraumbilical veins** associated with **portal hypertension**
(e.g. **liver cirrhosis**)
68
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)
69
What is Cullen's sign?
**_bruising_** of the tissue **surrounding the umbilicus** associated with **_haemorrhagic pancreatitis_** (a late sign)
70
What is Grey Turner's sign?
**bruising in the flanks** associated with **_haemorrhagic pancreatitis_**
(a late sign)
71
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
72
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
73
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**
74
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
75
What are the 9 regions of the abdomen?
76
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
77
How should tenderness be recorded?
note the abdominal region (s) involved and the severity of the pain
78
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)
79
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)
80
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
81
If any masses are located during deep palpation, what 5 characteristics should be assessed?
* location
* size and shape
* consistency
* mobility
* pulsatility
82
How is the location of an abdominal mass recorded?
note which of the 9 abdominal regions the mass is located within
83
How is the mobility of an abdominal mass assessed?
assess if the mass appears to be attached to superficial or underlying structures
84
What is a pulsatile abdominal mass suggestive of?
a pulsatile abdominal mass is suggestive of **vascular aetiology**
(e.g. abdominal aortic aneurysm)
85
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
86
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
87
Why is the degree of extension of the liver below the costal margin assessed?
if it is **greater than 2cm** then this suggests **_hepatomegaly_**
88
Why is consistency of the liver edge recorded?
a **nodular** consistency suggests **cirrhosis**
89
What might hepatic tenderness suggest?
**hepatitis** or **cholecystitis** (as you may be palpating the gallbladder)
90
Why is the pulsatility of the liver's edge assessed?
**pulsatile hepatomegaly** is associated with **_tricuspid regurgitation_**
91
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**
92
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
93
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)
94
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_**
95
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**
96
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**
97
What are the 5 causes of splenomegaly?
* portal hypertension secondary to liver cirrhosis
* haemolytic anaemia
* congestive heart failure
* splenic metastases
* glandular fever
98
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
99
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
100
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**
101
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
