Abdominal Examination

Question 1

What would you do in terms of preparations and introductions?

Answer 1

• Professionalism, as before.
• Introduce yourself, as before.
• Ask permission, as before.
• Wash hands, as before.

Question 2

What general exam might you do at the beginning of the consultation?

Answer 2

-	It would include “general demeanour”: 
o	Do they look well?
o	Are they alert & oriented?
o	Are they in obvious pain?
o	Are they attached to any medical equipment?
o	Is there any evident disability?
-	Hands: pulse (shock), & various signs.
-	Mouth: ulcers etc
-	Eyes: pallor, and other signs. This is all 2nd year!

Question 3

How should you begin the examination and what would you look for?

Answer 3

• The patient should be lying flat, with one pillow for comfort.
• Is the patient in obvious pain? Is the patient lying completely still? Is the patient writhing around? Ask about pain.
• Inspect, & this includes inspect chest.
• Nutritional status: wasting or obesity.
• Telangectasia on chest & abdomen. Gynaecomastia
• Scars etc. Bruising, wounds, drains, fistulae.
• Distension.
• Visible pulsation.
• Prominent veins on abdominal wall. Caput Medusae.
• Visible peristalsis
• Visible masses

Question 4

What is a spider nevus (spider angioma) and what is it associated with?

Answer 4

Spider nevus (spider angioma), a form of acquired telangectasia

• Found in distribution of superior vena cava (face, neck, chest (front & back) & arms.
• Associated with high oestrogen levels: they are normal in pregnant women, sometimes women on contraceptive pill.
• Abnormal: they are found in liver disease due to inability to metabolise oestrogens.

Question 5

How should you palpate the abdomen?

Answer 5

• The patient should be lying flat, and you should be sitting or kneeling for the gentle & firm palpation.
• Ask “are you in any pain” or some such.
• Quickly gently palpate the 9 areas of abdomen, to elicit tenderness, detect rigidity (guarding) & rebound tenderness.
• Palpate the 9 areas again, more firmly, feeling for masses & pulsation.
• If you feel pulsation, try put hands on each side & feel it pressing outwards laterally.

Question 6

How do you palpate and percuss for the liver?

Answer 6

• Place hand on abdomen in R iliac fossa. Ask patient to breathe in. Push hand upwards to meet descending liver. Feel either with finger tips upwards, or with lateral side of index finger upwards. About four advancing positions of the hand will be needed.
• ## Percuss either downwards or upwards. Upper border is approximately in 5th ic space.

Question 7

How do you palpate and percuss for the spleen?

Answer 7

• Place hand in RIF. Push gently diagonally to meet spleen during inspiration. At least 4 advancing placements of the hand will be needed, finishing under L costal margin. Some people would advocate starting in L iliac fossa, & advancing upwards.
• You can roll the patient onto their R side, & palpate under costal margin: more sensitive.
• Percuss for splenic dullness. Normal spleen is lateral to anterior axillary line, & bisected by midaxillary line. Traub’s space (9th intercostal space) anterior to anterior axillary line should be resonant.

Question 8

How can you look/palpate for the kidneys?

Answer 8

Ballott for each kidney with one hand in loin, & the other on anterior abdominal wall.
Kidneys do move with respiration, but not significantly on palpation.

Question 9

Where can you auscultate for bowel sounds?

Answer 9

• We are not doing this in first year. This is where it will fit in when you come to second year.
• Auscultate for bowel sounds. Just to right of umbilicus is usual place, but doesn’t really matter
• (Auscultate for aortic & renal artery bruits: This is second year: we are not doing this).
• Discuss examination of groins, genitalia & per rectum.

Question 10

How do you end the consultation?

Answer 10

• Thank the patient.
• Offer to help them on with their clothes, get comfortable etc
• Wash hands again!

Question 11

Which liver pathologies may be present?

Answer 11

• Liver disease: many causes, infections (mostly viruses), neoplasia primary & secondary, chemicals (alcohol!), “autoimmune”, congenital, idiopathic.
• Cirrhosis is a frequent endpoint.
• Initially hepatomegaly, often ending as small shrunken liver.
• Portal hypertension leading to splenomegaly, ascites, caput Medusae. Bleeding oesophageal varices.
• Liver failure leading to bleeding, hypoalbuminaemia (leukonychia, ascites, oedema), jaundice, liver flap.

Question 12

What may be causes and signs of bleeding from the bowel?

Answer 12

• Many causes: peptic ulcer of stomach & duodenum, inflammatory bowel disease which may be idiopathic (“autoimmune”) or infective, neoplasia especially carcinoma of the stomach, & adenocarcinoma of the colon/rectum.
• Many of these will cause abdominal pain, tenderness, etc.
• A mass may be present with some.
• There may be obstruction.
• Bleeding high up in bowel presents as melaena (foul-smelling tarry faeces. Bleeding low in bowel will manifest as red blood in faeces.
• Vomiting of blood may be bright red, or dark “coffee grounds”.
• In inflammatory bowel disease there may be lesions in mouth & round anus.

Question 13

What may be the causes and signs of bowel obstruction?

Answer 13

• Causes : within lumen, within wall, outside wall.
• Include impacted faeces, neoplasia, volvulus, bowel twisting round adhesions from old operations, hernias.
• Abdominal pain, vomiting, distension, absolute constipation.
• Abdomen will usually be tender, loud tinkling bowel sounds unless ileus has set in.

Question 14

What may be the causes and characteristics of abdominal pain?

Answer 14

• Many causes! Acute & chronic. The “acute abdomen” is a subject in itself.
• Note appendicitis, typically 2-3 day history of pain moving from central abdo to RIF, may feel sick, may have diarrhoea &/or constipation, tenderness & guarding in RIF
• Note peritonitis: inflammation in peritoneal cavity, usually as a consequence of perforation of hollow viscus, or ascending infection up Fallopian tubes. Guarding, rigidity ++. Obvious pain, patient keeps very still. Absent bowel sounds.
• Note pancreatitis: acute abdo, upper abdo pain. Shock. Serum amylase very high.
• Also: full bladder, gynaecological & obstetric causes.

Question 15

What may be the causes and characteristics of a mass in the abdomen?

Answer 15

• Actually presenting as mass: most likely neoplasm of stomach, spleen, obstetric or gynaecological causes, full bladder, or aneurism if pulsatile.
• Big spleen may be due to portal hypertension, but many other causes: infections (malaria, kala-azar may cause enormous spleen) neoplasms (CGL & myelofibrosis may cause enormous spleen), haemolysis etc.
• Aneurism is typically of abdominal aorta: presents as pulsatile mass +/- pain.