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Abdominal Examination

 

The abdominal examination is a fundamental examination that all doctors and medical students should have a sound grasp of. An effective examination always follows a detailed history and is based on the following four underlying key principles:

  1. Inspection
  2. Palpation
  3. Percussion
  4. Auscultation

Always ensure the patient is lying comfortably with adequate exposure. The environment should ideally be warm and quiet and hands should be washed prior to examination.

 

Inspection

 

The first part of any examination is inspection, which can be divided into the following phases:

 

General Inspection

  • Patient supine
  • Observe patient from the end of the bed
      1. Note if comfortable at rest
      2. Medication around the bed or patient controlled analgesia

       

      Hands

      • Koilonychia (consider iron-deficiency anaemia)
      • Leukonychia (consider causes of hypoalbuminaemia e.g. nephrotic syndrome, liver failure)
      • Clubbing (abdominal causes include cirrhosis, ulcerative colitis & Crohn’s disease)
      • Tar staining (from smoking)
      • Palmar erythema  (due to liver disease or increased levels of circulating oestrogens)
      • Dupuytren’s contracture (often seen in patients with liver cirrhosis and diabetes)
      • Ask patient to stretch out arms in front of them with wrist and fingers extended. Note if there is a liver flap present (seen in liver disease)
      • Radial pulse (to consider thyroid status or sepsis)

       

      Face

      • Conjunctival pallor
      • Jaundice of the sclera
      • Kayser-Fleisher rings (Wilsons disease)
      • Buccal mucosa for any ulceration (Crohn’s disease)
      • Tongue: angular stomatitis (anaemia), glossitis (anaemia, infection), leukoplakia (tobacco use)
      • Left supraclavicular lymph node (Virchow’s node/Troisier’s Sign) – enlargement may indicate metastatic deposits due to abdominal malignancy

       

      Abdominal wall

        • Expose entire abdominal wall and chest with the patient’s arms at their side
        • Look for symmetry of abdominal wall movement during respiration (absent if abdominal wall rigid due to peritonitis)
        • Note any distension
        • Note any gynaecomastia (in men)
        • Chest: Spider naevi (liver cirrhosis, pregnancy)
        • Skin for striae & surgical scars (Figure 1)
        • Bluish discolouration of umbilicus is positive Cullen’s sign (acute pancreatitis)
        • Bluish discolouration of flanks is positive Grey Turner’s sign (acute pancreatitis)
        • Engorged veins (note direction of blood flow: ABOVE umbilicus blood flows normally UPWARDS, BELOW umbilicus blood flows usually DOWNWARDS – reverses if IVC obstruction)
        • Spider angiomas

         

        Masses (inspect from several angles)

        • Abdominal wall mass is more prominent on tensing of abdominal wall muscles – ask patient to raise head or feet off bed
        • Intra-abdominal mass is less prominent on tensing of abdominal wall muscles
        • Masses are commonly:
          • Hernias: umbilical, epigastric, incisional, or spigelian
          • Neoplasms: benign & malignant
          • Haematomas
          • Infections
        • Inspect mass for movement, pulsation and peristalsis
        • Describe all masses in relation to the abdominal quadrants & consider relationship of intra-abdominal organs to determine cause
        • Stomas

         

          Causes of clubbing

          Palpation

           

          Following inspection, palpation and then percussion are performed. The abdomen can be divided into nine regions (Figure 2a) or four quadrants: right and left upper quadrants and right and left lower quadrants (Figure 2b). All regions should be identified during palpation and percussion.

           

          • Palpation is divided into superficial and deep
          • Ask patient to point to area of greatest pain and palpate this region last
          • Superficial: using the fingertips, gently examine the abdominal wall and gauge the level of tenderness. Note any feeling of crepitus (subcutaneous gas or fluid) and any irregularities (lipomas or hernias of abdominal wall)
            • Deep: two-handed palpation using the lower hand to feel and the upper hand to exert pressure. Palpate each quadrant with the most painful region last.
            • Have patient inspire deeply and palpate up towards the right costal margin (liver, gallbladder) and left costal margin (spleen)

               

              Rigidity: involuntary abdominal muscle contracture (peritoneal inflammation)

              Guarding: voluntary abdominal muscle contracture

              Rebound tenderness: tenderness elicited following rapid removal of examining hand

              Rovsing’s sign: palpation of left lower quadrant causes tenderness in right lower quadrant (appendicitis)

              Pulsating mass: structure above aorta

              Expansile mass: aorta 

              Mcburney’s point: 1/3 distance along a line from the anterior superior iliac spine to the umbilicus. Tenderness suggests appendicitis.

              Murphy’s sign: positive in acute cholecystitis. Elicit by placing hand below costal margin in RUQ and patient to breathe deeply. Painful if gallbladder is inflamed.

              Cullen’s sign: yellow/blue discolouration around the umbilicus (acute pancreatitis)

              Grey Turner’s sign: bruising of the flanks (acute pancreatitis)

              Organomegaly: enlarged liver, spleen or kidney (Table 1) 

               

              Percussion

               

              • Dullness in flanks or shifting dullness suggests fluid (ascites)
                • Asses for shifting dullness. Use whenever dullness is detected in the flanks during routine percussion

                 

                  1. Percuss outwards towards patient’s left flank
                  2. Note point where percussion note changes from resonant to dull
                  3. Roll patient on to his or her right (45 degrees)
                  4. After 30-60 seconds (allows fluid in abdomen to move), repeat percussion over noted area
                  5. The area that was originally dull to percussion should now be resonant (as moving the patient will have caused the fluid to shift under gravity)

                   

                    Auscultation

                     

                    Auscultation should be performed to help further indicate any intra-abdominal pathology.

                    • Listen for bowel sounds for one minute
                    • Normal bowel sounds are low-pitched and intermittent
                    • Absent/diminished bowel sounds indicate an ileus
                    • High pitched and “tinkling” sounds indicate bowel obstruction
                    • Vascular bruits

                     

                       

                      TO COMPLETE THE EXAMINATION:

                      The exam should be completed with a rectal examination, examination of the hernial orifices and an examination of the external genitalia. The patient’s vital signs (BP, temperature and pulse rate) should also be measured.

                       

                      References

                       

                      • Oxford Concise Medical Dictionary. 6th Ed. Oxford; Oxford University Press 2002
                      • Goldberg A, Stansby G. Surgical Talk. 2nd Ed. London; Imperial College Press 2005
                      • Talley NJ, O’Connor S. Clinical Examination. 5th Ed. Australia; Elsevier 2006
                      • GP Notebook (www.gpnotebook.co.uk)

                       

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