W3 clinical skills: Abdomenal examination Flashcards
what is the purpose of abdominal examination?
- Assessing Abdominal Organs
- Detecting Abnormalities
- Diagnosing Conditions
- Evaluating Pain
- Assessing Bowel Sounds
- Detecting Fluid
- Monitoring Disease Progression
- Guiding Further Tests
how would you start the examination?
Introduction:
1. Your name and role
2. Patients details (name and age). How can you address them?
3. Explain procedure and consent
e.g. “First I’m going to be doing a general inspection which will involve me looking and feeling your face,
arms, hands and legs/ And then ill be doing the abdominal/stomach exam which will involve me
touching and listening to your stomach. It shouldn’t be painful but let me know if you are feeling
uncomfortable. Is that okay with you? Please could you take off your shirt”
how do you do general inspection
General inspection (as they walk in)
* Crouching, holding their stomach – abd pain
* Distended abdomen
* Wasting – chronic illness
* Confusion – hepatic encephalopathy
* Paraphernalia
vital signs
- I want to look at vital signs now (just state, might stop and ask to continue)
- BP, pulse, RR, temp and O2 stat
general exam. of the eyes?
Eyes
1. Conjunctiva: Pink, pallor (pull lower lids down and ask pt to look up)
2. Sclera: white, jaundiced (Lift upper lids and ask to look down)
3. Drooping eyelids
4. Arcus cornealis (grey ring in eye, high chol)
5 Xanthelasma (yellow nodules around eye, high chol)
general exam. of the mouth?
- Iips
- Peripheral cynanosis, angular stomatitis or chelitis - Mucosa
- Dry/moist - Halitosis (sweet - liver failure; acetone – DM, OH or smoke)
- Ulcers
- Candida (immunocompro)
5.Tongue
-Central cyanosis
- Frenulum – pink or pallor
6.Dentition
-Dental caries (IE)
-Healthy, bleeding or infected gums
general exam. of neck?
- Parotidomegaly
* Ask to clench. If large parotid gland = chronic OH abuse
how do we examine hands?
- Palmar and dorsal surface
- Pink/pale
-Warm, dry, sweaty
-Palmar erythema – chronic liver disease
- Hepatic flap/ Asterixis: Hands flexed in front – if flap then hepatic encephalopathy
- Duputytrens contractures: Ring finger contracts – chronic alcoholism - Nails
-Shape
* Normal
* Spoon
* Clubbing (check shamroth sign, nail angle laterally and squeeze for
sponginess)
- Liver cirrhosis, inflame bowel disease
- Leukonychia (white lines – hypoalbuminemia d/t chronic liver disease) - Colour – pink, pale or peripheral cyanosis (check cap refill time (<2s = good peripheral
perfusion) - Skin turgor
- Slight pinch – hydration status
- Lower limbs
- Pedal oedema – start close to toes and go up – if oedema continue until it stops to find extent
- Kidney disease or chronic liver disease (low albumin)
- Look for: Skin changes, bruising, puritis, clubbing - Upper limbs
- Entire lymph node exam
- Look for: skin changes, bruising, puritis (scratches) – obstructive jaundice
3.Thorax
- Gyno or hairless = chronic OH abuse - liver disease
- Spider nevi = central arterioles radiate = liver cirrhosis - Arms
- 3. Bruising – clot abnormality
Focused abdominal exam (lying down, expose from nipple to pubic symphysis)
* Inspection
- Skin changes
- Lesions
- Bruising
- Pruritis
- Surgical scars - Masses
- Pulsating abdominal aortic aneurysm (triple A)
- Distended veins – portal hypertension or SVC obstruction - Shape
- Fullness on flanks – ascites
- Protruding masses – organomegaly or non-benign lesions
- Distended – Fluid, fat, flatulence, faeces and foetus (Five F’s)
4.“ No abnormalities of shape and colour noted”
palpation
- “Bend your knees for me and open your mouth a bit. Let me know if there any pain on your stomach
when I do this” - Superficially
- Over 9 regions. Looks at face and see if tender or if there is any superficial masses.
- Start top away from you and move down and towards you.
- Pt reports: pain or tenderness. Look at pt face to see if its tender, and superficially feel for
masses.
Deep
-Do on same regions and look at pt faces. Palpate for deeper masses that you could have
missed. - “On palpation my patient’s abdomen was soft and non-tender”
percussion
- Expect resonant throughout. If dull then organomegaly or non- benign lesion.
- Go over 9 regions. Will notice dullness at liver region – comment if enlarged.
- Put hand flat on abdomen and use two middle phalanges for dullness or resonance.
- Do all 9 regions
- “I’m expecting resonance in my patient”.
- If dull then clarify if stoney dull (fluid in peritoneal cavity); dull (organomegaly or nonbenign
lesion)
- “My pts abdomen was resonate”
auscultations
- Below umbilicus just to the left to hear for bowel sounds.
- If absent: when was the last time they ate, constipation, vomiting, if you have any loud
bowel sound (ballbarikme? – means active bowel, just can’t hear the sounds)
liver
- Located in right upper quadrant. Enlarges from the right costal margin to the right iliac fossa.
- COPD can push down the liver t/f measure
Palpate:
o When palpate move your hand during expiration (diaphragm is contracted and the liver is moved up)
and hand is still when inspire (liver moves down).
o “Maxwell can you take normal breaths in and out”
o Start at bottom and slowly move hand to right costal margin, feeling for the liver edge. Hand only
move during expiration to catch liver edge during inspiration. Pt must breathe normally. From r iliac
fossa to r costal margin.
o “No noted liver edge” OR “liver edge is smooth, non-tender and non-pulsatile”
-Could be notched or tender
* If positive liver edge - Measure span of the liver – either enlarged or pushed down from COPD
o Percussion of upper and lower border. Look at measurement in cm. Must not be larger than 13cm.
-Start at upper border. Look at sternal angle at midclavicular line 2nd intercoastal space.
Look for change from resonance to dullness. Expected at 5th or 6th intercostal space. This
will be the upper border.
- Now start from R iliac fossa (midclavicular line) to the R costal margin.
-Now measure liver space from 6th intercostal space to where you stopped.
- Must be below 13cm otherwise enlarged.
spleen
Palpate
o Located behind stomach in L upper quadrant. Enlarged inferior medially. The R iliac fossa to the L
costal margin.
o Remain on right side of patient
Put L hand posterior to abdominal wall and push up. When they expire you move your hand up in a
diagonal manner moving closer to the spleen each time they exhale.
§ If cannot feel the spleen edge and you suspect splenomegaly then “maxwell can you
move closer to me” – moves slightly onto his side (t/f facing you)
§ Move from R iliac fossa to L costal margin
* Lastly you can percuss if you still suspect splenomegaly.
o Intercostal space btw 11th anterior axillary line. If hear resonance on inspirate and expiration then
not enlarged. If resonance during exp, and dull in inspiration then enlarged spleen and palpate
again to check for enlarged spleen.
* No measurement done
* If spleen is felt could comment on surface, consistency, tenderness and length – not our notes
* If liver or spleen enlarged then suggest abdominal TB if asked
