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Abdominal Examination

 

The abdominal cavity hosts a variety of organs including the oesophagus, stomach, small intestine, large intestine, liver, gall bladder, pancreas, adrenal glands, spleen, kidneys, bladder and abdonminal aorta. Pathology of a huge number of body systems may therefore be detected on examination.

 

Check ID and obtain informed consent

Introduce yourself to the patient by clearly stating your name and role. Ask the patient their name and date of birth and check this information against their hospital wristband or equivalent. Explain why you need to examine them and what the examination will involve before obtaining verbal consent from the patient.

 

 

"Hello, my name is Henry Johnson. Can I ask you your name? I am a medical student and I have been asked examine your abdomen to assist with my learning. Is that okay with you?"

 

Wash your hands before and after touching a patient or equipment.

 

Before examining the patient, you should take a detailed history. Make sure you ask these important questions:

  • Have you had a change in bowel habit?
  • Have you lost any weight?
  • Have you noticed blood in your stools or phlegm?
  • Are you in any pain?
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    General examination

    The patient must be lying flat and should ideally have their whole torso exposed. It may be more acceptable to the patient if their chest is covered for most of the examination.

     

    Begin by looking at the patient for anything obvious:

    Does the patient have a fever or look unwell?
    Does the patient have any abdominal distension or ascities?
    Does the patient look yellow?
    Does the patient have muscle wasting?
    Does the patient appear anaemic?

    Does the patient look well hydrated?

    Is the patient over or underweight?

     

    Inspect the nails for:

    Clubbing

    Leukonychia

    Koilonychia

     

     

    clubbing

    Clubbing is a deformity of the nails and nail-beds which is associated with a number conditions. Abdominal causes of clubbing include malabsorption, inflammatory bowel disease and coeliac disease. To examine for clubbing, ask the patient to hold their fingertips together as above. Patients with clubbing lack Schamroth's window.

     

    koilonychia

    Leukonychia is a white discoloration of the nails. It may sometimes suggest hypoalbuminaemia.

    Koilonychia (spooning) is a deformity of the nails that is associated with iron deficiency anaemia.

     

    Inspect the hands for features of chronic liver disease:

    Palmar erythema (reddening)

    Dupuytren's contracture

    Asterixis (hepatic flap)

     

     

    Palmar erythema is a reddening over the thenar and hypothenar eminences of the palm. Dupuytren's contracture is a fixed flexion contracture where fingers are permanently bent towards the palm.

    hepatic flap examination

    Asterixis is an involuntary flapping movement of the hands. It is associated with encephalopathy due to hepatic failure. To examine for asterixis, ask the patient to outstretch their arms and dorsiflex (bend back) their hands at the wrist and hold for at least 15 seconds.

     

    Examine the cervical and supraclavicular lymph nodes. It is especially important to examine Virchow's node, located in the left supraclavicular fossa.

     

    Virchow's node is located in the left supraclavicular fossa. An enlarged node, known as Troisier's sign, is an indicator of malignancy in the abdominal cavity


    Inspect the patients eyes for:

    Icteric sclerae (jaundiced eyes)

    Kaiser-Fleischer rings

    Gently retract the patient's lower eyelid and examine the conjunctiva for:

    Conjunctival pallor (pale conjuntiva)

     

    jaundice
    Icteric sclerae are yellow tinted eyes. They are an obvious sign of jaundice (increased levels of billirubin in the blood). Kaiser-Fleischer rings are dark rings encircling the iris. They are linked to diseases which cause copper deposition. Conjunctival pallor is a sign of anaemia.

     

    Ask the patient to show you their teeth and open their mouth wide whilst you inspect for signs of oral hygiene:

    Angular stomatiasis (inflammation at the corners of the mouth)
    Inflammation of the oral cavity
    Dentition (the condition of the patient's teeth)
    Ulcers
    Glossitis (tongue inflammation)

    Leukoplakia (white furring of the tongue)

    Candidiasis (oral thrush)

    Finally, smell the patient's breath for signs of ketosis (smells like pear-drops) or uraemia (smells like fish).

     

    Inspect the abdomen

    Look at the abdomen and chest from the end of the bed before moving to the right side of the bed. Pay particular attention to:

    More than 5 spider angiomas (spider naevi)
    Gynaecomastia
    Scars, bruises, distention and anything else that looks out of place
    Caput medusa (distended blood vessels radiating from the umbilicus, suggestive of portal vein hypertension)

     

    Spider angiomas (spider naevi) are web-shaped arrangements of blood vessels close to the skin which are eliminated by pressure at the centre. 5 or more spider angiomas may be a sign of liver disease. Gynaecomastia is the development of large mammary glands in males. It may develop in males with alcohol liver disease as a result of increased oestrogen production.

     

    Palpation of the abdomen

    The patient must be lying supine. Ask the patient if they are in pain and begin palpation furthest away from the tender area:

    Place your hand flat against the patient's abdomen and apply pressure using your fingers
    Perform light palpation of the 9 zones of the abdomen
    Perform deep palpation of the 9 zones of the abdomen

     

    abdominal examination regions

    The 9 zones of the abdomen
    RH: Right hypochondrium, E: Epigastrium, LH: Left hypochondrium, RF: Right flank (lumbar), U: Umbilical, LF: Left flank (lumbar), RIF: Right iliac fossa (inguinal), SP: Suprapubic, LIF: Left iliac fossa (inguinal).

     

    Attempt to palpate the liver:

    Ask the patient to take a deep breath
    Push the radial border of your hand firmly into the right iliac fossa
    Repeat this process working up the abdomen to the right hypochondrium

     

    Attempt to palpate the liver:

    Ask the patient to take a deep breath
    Push the radial border of your hand firmly into the right iliac fossa
    Repeat this process working across the abdomen to the left hypochondrium

     

    Attempt to ballot the kidneys:

    Place one hand underneath the patient at the flank towards the midline
    Place the other hand over the flank towards the midline
    Attempt to 'bounce' the kidney between the two hands

     

    Attempt to palpate the bladder by pushing deep in the suprapubic area. It is not normally palpable when empty but can extend up as far a the umbilicus when full. Remember that pressure on the bladder may cause the patient to urinate!

     

    Attempt to palpate the abdominal aorta which is located in the midline above the umbilicus. If you are able to feel the aorta, measure the diameter of the aorta with your fingers. Normal size is around 2-3cm.


    Percuss the abdomen

    Percuss for the liver and spleen by tapping along the same route you took when palpating for each organ. Both organs will be dull to percussion.

     

    Percuss for the bladder by tapping over the suprapubic region. An enlarged bladder will be dull to percussion.

     

    Percuss for ascities (fluid in the peritoneal cavity):

    Percuss from the umbilicus laterally towards the left flank until dulness is heard
    Place a finger at the point of transition from resonant to dull percussion, or mark with a pen
    Ask the patient to roll onto thieir right side and hold this position for 30 seconds
    Tap the previosly marked spot which should now be resonant to percussion if there is free fluid in the peritoneal cavity

     

    Auscultate the abdomen

    Listen over the abdomen using the diaphragm of the stethoscope for bowel sounds:

    It is nomal to hear intermittent gurgling over the abdomen
    High pitched 'tinkling' sounds are suggestive of a bowel obstruction

     

    Listen for bruits using the diaphragm of the stethoscope:

    Above the umbilicus for an abdominal aortic aneurysm
    Each side of the midline above the umbilicus for renal artery stenosis

     

    Finishing up...

    Thank the patient for allowing you to examine them and invite them to make themselves comfortable; don't forget to wash your hands before completing any relevant documentation.

     

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