Abdominal Examination

TO START

W2I2P4E

  • Wash your hands

  • Wear appropriate PPE

  • Introduce yourself and check patient’s Identity (full name, DOB)

  • Permission: “May I examine your abdomen?”

  • Privacy: Ensure curtains to the bay are closed

  • Pain: “Are you in any pain at all?” - if so where?

  • Position: Start with the patient on the bed at 45o, then lie the patient flat to examine the abdomen

  • Exposure: From the xiphisternum to the pubic symphysis (bra left on)

INSPECTION

Surroundings

  • Monitoring – fluid balance

  • Treatments – O2, IV infusions (note what and how much), total parenteral nutrition (TPN), NG tubes, surgical drains (note volume and colour of liquid draining), catheter (note volume), patient-controlled analgesia

  • Paraphernalia – food and drink, Ensure, Creon (pancreatic insufficiency), nil by mouth signs, vomit bowl, stoma kit, cigarettes

Patient

  • Appearance - alert, confused (hepatic encephalopathy)

  • Behaviour - writhing (colicky pain) very still (peritonism)

  • Body habitus - obese, cachectic, abdominal distension (ascites)

  • Colour - pallor (anaemia), jaundice, hyperpigmentation (haemochromatosis, Addison’s)

UPPER PERIPHERIES 

Nails

  • Clubbing (4Cs: Cirrhosis, Crohn’s, ulcerative Colitis, Coeliac) - look for Schamroth’s window

  • Koilonychia - spoon-shaped nails (iron deficiency anaemia)

  • Leukonychia - whitening of nail bed (low albumin: coeliac, cirrhosis, nephrosis)

Hands

  • Palmar erythema - redness of heel of the palm (chronic liver disease)

  • Dupuytren’s contracture (associated with excess alcohol use)

  • Tar stains (smoking increases risk of oesophageal and colon Ca, Crohn’s and peptic ulcers)

Arms

  • Asterixis - coarse flapping tremor when arms held out straight and wrists dorsiflexed for 15s (hepatic encephalopathy or ureaemia)

  • Radial pulse - assess rate and rhythm

  • Assess temperature

  • Inspect for bruising (deranged clotting 2o to liver disease), excoriations  (pruritis 2o to hyperbilirubinaemia), tattoos/track marks (risk factors for hepatitis)

  • Offer to measure BP

Face

  • Eyes - conjunctival pallor (anaemia), scleral icterus (yellowing of the sclera; jaundice), Kaiser-Fleisher rings (copper deposits in iris seen with slit lamp; Wilson’s disease), xanthelasma, corneal arcus (hypercholesterolaemia)

  • Mouth - oral candidiasis (immunosuppression), aphthous ulcers (Crohn’s, iron/B12/folate deficiency), angular stomatitis (fissuring of corners of mouth; iron/B12/folate deficiency), glossitis (beefy red tongue; iron/B12/folate deficiency)

  • Breath - alcohol, pear drops (DKA), foetor hepaticus (liver failure)

  • Bilateral parotid swelling (chronic alcohol abuse, recurrent vomiting eg. bulimia)

Neck

  • Lymphadenopathy - palpate for lymphadenopathy, esp in left supraclavicular fossa (Virchow’s node - drains lymph from abdomen, can be first sign of Ca, esp gastric, Troisier’s sign)

Chest

  • Inspect the chest for:

    • Spider naevi - central red papule with fine lines radiating, >5 pathological (liver cirrhosis)

    • Gynaecomastia - breast tissue in men, due to + oestrogen eg in liver cirrhosis

    • Hair loss - due to + oestrogen

ABDOMEN

Screening tests

  • Lie the patient flat

  • Ask the patient to take a deep breath - pain/reduced movement suggests peritonism 

  • Ask the patient to lift their head to their chest - inspect for divarication of recti or paraumbilical/incisional hernia

  • Ask the patient to cough while your hands are over the inguinal region - palpate for a hernia 

Inspect

  • Distension (6Fs: fat, fluid, flatus, faeces, foetus or f***ing big tumour)

  • Scars (see page 62): How old is the scar? Has it healed well?

  • PEG tube

  • Stomas - comment on position, spout, contents of bag

    • Ileostomy (Usually RIF, spouted, green liquid)

    • Colostomy (Usually LIF, flushed to skin, faeculent solid)

    • Urostomy (RIF, spouted, contains urine)

  • Striae - stretch marks (pregnancy, Cushing’s – purple)

  • Caput medusae - engorged paraumbilical veins (portal hypertension, liver cirrhosis)

  • Grey-Turner sign - bruising around flanks (haemorrhagic pancreatitis)

  • Cullen’s sign - bruising around the umbilical area (haemorrhagic pancreatitis)

  • Pulsations (AAA)

Palpate

  • Palpate the nine areas - first superficially, then deeply

    • Start away from any pain

    • Palpate at the level of the patient (kneel down)

    • Watch the patient’s face throughout for a reaction

  • Look specifically for:

    • Masses - see below

    • Tenderness - note the area, rebound tenderness (peritonitis), Rovsing’s sign (palpating LIF causing pain in RIF; appendicitis)

    • Guarding - abdominal muscle contraction on palpation, may be voluntary and distractible or involuntary (peritonism)

  • Palpate for organomegaly:

    • Liver - ask the patient to take slow deep breaths in and out and palpate upwards from the RIF to R hypochondrium with the edge of your hand, palpating on inspiration - if enlarged will feel tap on inspiration (1-2cm below costal margin is normal)

      • Hepatomegaly differential: chronic liver disease, cancers, R heart failure, lymphoma, leukaemia, sarcoid, amyloidosis

    • Spleen: Palpate from RIF to L hypochondrium as above (spleen should not be palpable in healthy individuals)

      • Splenomegaly differential: lymphoma, leukaemia, portal hypertension, infection, sarcoid, amyloidosis

  • Ballot the kidneys: 

    • Place one hand in the patient’s flank and one hand anteriorly on their abdomen

    • ‘Ballot’ the kidney from your hand on the patients back into your hand palpating their stomach - the kidneys are not usually palpable (unless low BMI)

      • Bilaterally enlarged: polycystic kidneys, amyloidosis  

      • Unilaterally enlarged: renal tumour

  • Feel for the aorta: 

    • Using both hands, deeply palpate just superiorly to the umbilicus

    • A normal aorta is palpable as a pulsatile mass

    • An expansile mass suggests an AAA

  • Consider assessing for Murphy’s signs - palpation in the R hypochondrium and the patient taking a deep breath in causes the patient to wince with a ‘catch’ in breath due to pain, suggests cholecystitis 

Percuss

  • Percuss:

    • Liver for organomegaly - from RIF to R hypochondrium

    • Spleen for organomegaly - from RIF to L hypochondrium

    • Bladder for distention - downwards from umbilicus to suprapubic region

    • Shifting dullness - to assess ++ ascites

      • Percuss from the patient’s umbilicus to their L side

      • If dull (suggesting fluid) ask the patient to roll towards you whilst keeping your hand on the area that was dull 

      • Percuss again after 30s - if resonant the dullness has shifted and suggests the presence of fluid in the abdomen 

Auscultate 

  • Bowel sounds - normal: gurgling, tinkling suggests obstruction, absent: suggests ileus

    • Listen for 30 seconds in each quadrant before concluding absent

  • Bruits - listen at renal arteries (superior and lateral to umbilicus) and aorta for bruits, suggestive of turbulent blood flow eg AAA, stenosis

LOWER PERIPHERIES

Legs

  • Assess for peripheral oedema - note the level

  • Erythema nodosum - red, tender nodules on shin, suggestive of Crohn’s

CLOSURE

Closure

  • Thank the patient, ensure they are comfortable and dressed

  • Remove PPE

  • Clean equipment and wash hands

To complete

(HIDE in the PUB)

  • Examine the Hernial orifices, Inguinal lymph nodes,  Digital rectal examination (DRE) and External genitalia

  • Pregnancy test (if female), Urine dip, Basic Obs (sats, BP, temp)

MASSES

  • Liver edge - comment on distance from costal margin (↑ early cirrhosis, ↓advanced cirrhosis), surface (smooth vs hard), tenderness, pulsatile (Tricuspid Regurgitation)

  • Epigastric mass - if expansile consider AAA, if not ?gastric, pancreatic Ca

  • LHC mass - spleen: unable to get above mass, dull to percuss, notched. Kidney: able to get above mass, resonant to percuss, ballotable

  • RIF mass - caecal cancer, Crohn’s, appendix mass

  • Suprapubic mass - bladder (retention, Ca)

  • LIF mass - constipation, sigmoid Ca, diverticular disease

  • Remember to consider gynaecological causes in women!

💡
In summary, I performed an abdominal examination on [name], a [age] year old [sex]. On inspect s/he had no peripheral stigmata of gastrointestinal disease. His abdomen was soft and tender, with no masses or organomegaly. On auscultation, he had normal bowel sounds. In conclusion, this was a normal abdominal examination.