Medicine Bedside: Abdominal Examination

Question 1

Inspection

Answer 1

End of bed

1. Shape
   - Normal / Scaphoid / Distended (屎肥仔汽水)
2. Symmetry
3. Mass / Swelling
4. Dilated veins
   - IVC obstruction
   - Portal hypertension (i.e. Caput medusae) (由肚臍散出去)
   —> observe direction of flow below umbilicus
5. Scars
6. Striae
   - acute abdominal distension with SC bleeding e.g. Ascites, Pregnancy
7. Pigmentation
   - pregnancy
   - Addison’s disease
8. Movement
   - Thoraco-abdominal respiration
   - Epigastric pulsation e.g. thin patients, transmitted pulsation
   - Visible peristalsis in intestinal obstruction
9. Umbilicus
   - normal, depressed in fat abdomen
   - bulging / everted with increased ***intraabdominal pressure e.g. Ascites (horizontal slit vs pregnancy: vertical slit)
10. Visible peristalsis
    - Intestinal obstruction
11. Visible pulsation
    - Aneurysm
12. Hernia
    - Incisional (diastasis recti)
    - Groin (cough impulse: cough / left head up / standing)
13. Ecchymosis / Bruising
    - Cullen’s sign —> Umbilical
    - Grey-Turner’s sign —> Flank

Question 2

Palpation

Answer 2

Sit down
Ask for pain

1. 9 areas
   - feel for tenderness
   - feel for mass
   - ***Peritoneal signs
   —> Tenderness
   —> Guarding (involuntary contraction against pressure)
   —> Rigidity (generalised contraction)
   —> Rebound tenderness
   —> Absent bowel sound (ileus due to diffuse peritonitis)
2. Liver
3. Spleen
4. Kidneys

Question 3

Liver

Answer 3

• upper border: 5th ICS
• lower border: Costal margin, Mid Clavicular Line
• span: 10cm

1. Palpation
   - hand avoid rectus muscle
   - hand parallel to liver lower border
   - extend hand to cover left lobe (normally cannot feel due to rectus muscle)
   - deep breath
   - normal liver maybe palpable on inspiration or it can be pushed down by thoracic abnormalities e.g. emphysema
2. Percussion
   - finger parallel to liver dullness
   - resonant to dull
   - move perpendicularly
   - percuss above costal margin
   - epigastrium for ***left lobe
   - upper border: from above downwards
3. Liver span
4. Character of edge
   - sharp / rounded
5. Character of surface
   - smooth / nodular (small nodules usually cannot feel, only large nodule: HCC)
   - **Smooth: Fatty liver, alcoholic cirrhosis, primary biliary cholangitis
   - **Nodular: Polycystic kidney and liver disease
6. Consistency
   - soft / firm / hard
   - ***Hard: Cancer
7. Tenderness
8. Bruit
   - vascular tumour (e.g. HCC) —> heard all over
   - alcoholic hepatitis —> heard all over
   - compression of aorta —> turn patient to right side and bruit less prominent

Question 4

Spleen

Answer 4

1. Palpation
   - deep breath
   - fingers parallel to Gardner’s line (umbilicus to left anterior axillary fold)
2. Hooking
   - right lateral position
   - renal angle (lateral border of erector spinae + lowermost rib)
3. Percussion
   - finger perpendicular to Gardner’s line
   - percuss above costal margin
   - spleen is dull (∵ anterior structure)
4. Dipping (for Ascites)
   - dip hand to push down spleen and then allow it to float upwards again
   - dip on lateral side also

Question 5

Kidneys

Answer 5

1. Palpation
   - Renal angle
   - deep breath
   - feel something —> bimanual palpation
   - right kidney lower than left
2. Percussion
   - partially resonant (∵ overlaid by small intestines + colon)

Question 6

Distinguish between enlarged spleen vs left kidney

Answer 6

1.
Spleen: Anterior
Kidney: Retroperitoneal (∴ bimanually palpable)

2.
Spleen: No subcostal gap
Kidney: Subcostal gap present

3.
Spleen: Dull
Kidney: Always partially resonant (∵ overlaid by intestine)

4.
Spleen (>10cm): Notches along medial border
Kidney: No notches

5.
Both move up and down with respiration

Question 7

Ascites

Answer 7

1. From resonant to dull
2. Fingers: **parallel but **move perpendicularly to line of dullness
3. Right lateral position —> new line of dullness —> shifting dullness (previously dull area now resonant)
   - not sensitive, require >=1L of fluid
4. Fluid thrill
   - flick on one side and feel for transmitted thrill on other side
   - much less sensitive

Question 8

Auscultation

Answer 8

1. Bowel sounds
   - Hyperactive:
   —> after meal
   —> intestinal obstruction

• Hypoactive:
  —> peritonitis
  —> after surgical operation —> adynamic ileus

2. Liver bruit
3. Splenic rub
4. Renal bruit (Renal artery stenosis):
   - midway between xiphisternum and umbilicus
   - lateral to rectus muscle
5. Succussion splash of stomach
   - pyloric stenosis

Question 9

Other mass

Answer 9

1. Site
2. Size
3. Shape
4. Localisation
   - abdominal wall: lift head to make mass more prominent
   - intraperitoneal vs retroperitoneal: less prominent, turn patient to right side, intraperitoneal organ drops and easier to feel
5. Movement (with respiration / by itself)
6. Tenderness
7. Consistency
8. Pulsation