Abdominal Examination

Introduction

• Wash hands
• Introduce self
• Ask Patient’s name, DOB and what they like to be called
• Explain examination and obtain consent
• Expose and lie patient flat

General inspection

• Stand at the foot of the patient’s bed and look at the patient, and then around the bed
• Does the patient look well/unwell? Are they in any pain/discomfort?
• Look for jaundice, pallor, muscle wasting and cachexia
• Look around the bed for paraphernalia, e.g. vomit bowls, intravenous infusions, nutrition, catheter etc.

Hands

• Examine for asterixis (flapping tremor) by asking the patient to hold their arms out straight, with their wrists ‘cocked back’ and observe for a flap (flap = hepatic encephalopathy)
• Nails
  • Look for clubbing by asking the patient to place their two index finger nails together – Schamroth window test (cirrhosis, IBD, coeliac disease)
  • Leukonychia – pale/white nails (hypoalbuminaemia in liver cirrhosis/enteropathy)
  • Koilonychia – spoon shaped/flattened nails (iron deficiency)
• Palms
  • Look for palmar erythema (hyperdynamic circulation due to ↑oestrogen levels in liver disease/pregnancy)
  • Look and feel for Dupuytren’s contracture – thickened palmar fascia (can be related to alcoholism/liver disease)
  • You may also see fingertip capillary glucose monitoring marks (in diabetes)

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Face

• Eyes
  • Look at the sclera for jaundice (liver disease)
  • Ask permission from the patient then pull down the lower eyelid to look for conjunctival pallor (anaemia, e.g. due to GI bleeding, malabsorption)
  • And lastly periorbital xanthelasma – yellowish deposit of cholesterol around the eyes (hyperlipidaemia in cholestasis)
• Mouth: ask the patient to open their mouth, look for:
  • Glossitis – inflammation and depapillation of the dorsal surface of the tongue (iron/B₁₂ deficiency)
  • Stomatitis – mucosal inflammation, including ‘angular stomatitis/chelitis’ at the corners of the mouth (iron/B₁₂ deficiency)
  • Aphthous ulcers (IBD)

Neck and torso

Ask patient to sit forwards:

• Neck: briefly examine for cervical lymphadenopathy from posteriorly – especially Virchow’s node in left supraclavicular fossa (classically gastric malignancy)     
• Back inspection: look at the back for spider naevi (significant if >5) and any skin lesions (immunosuppression)

Ask patient to sit back:

• Chest inspection, look for:
  • Spider naevi – central red capillary spot with deep red extensions that, when pressure is applied, refill from the centre (significant if >5)
  • Gynaecomastia – male breast swelling
  • Loss of axillary hair (all due to ↑oestrogen levels in liver disease/pregnancy)

Abdomen

Inspection

Closely look at the patient’s abdomen for:

• Scars
• Distension (5Fs: Fluid, Flatus, Fat, Fetus, Faeces)
• Striae (pregnancy, Cushing’s syndrome)
• Spider naevi
• Hernias (ask patient to cough)
• Movement with respiration (absent in peritonitis)
• Obvious pulsations, and distended abdominal wall veins/‘caput medusae’ (portal hypertension)
• Stomas

Palpation

Percussion

• Note general percussion quality (tympanic = flatus; percussion tenderness = peritoneal irritation)
• Liver: percuss upwards from the RIF to find the lower border of the liver (normally beneath right costal margin). The percussion note should become dull over the liver. Next, percuss the chest downwards in the right mid-clavicular line to find the upper border of the liver (normally beneath 5^th costal cartilage). Ideally, percuss with the patient in expiration.
• Spleen: percuss diagonally from the RIF towards the spleen. The dull percussion note of the spleen is only heard when it is enlarged. Also percuss in Traube’s space, which is just above the left costal margin in the mid-clavicular line (if resonant, there is no splenomegaly).
• Flank: percuss all the way across abdomen in each direction laterally from the midline. The flank should be resonant. If a dull percussion note is heard, go on to demonstrate shifting dullness (have patient roll to other side and percuss again – it should become resonant if the cause is ascites). You could also demonstrate fluid thrill (have patient press hand firmly on abdominal midline while you tap one side and feel the other; fluid wave = ascites).

Auscultation

• Use diaphragm to listen for bowel sounds at ileocaecal valve in RLQ until heard, up to 1 minute (tinkling = obstruction; absent = paralytic ileus/peritonitis)
• Use bell to listen for aortic bruit (midline between xiphisternum and umbilicus; may indicate AAA); and renal bruits (5cm superior and lateral to umbilicus bilaterally; renal artery stenosis)

Finally

• Check for pitting oedema by pushing over the tibia for 10 seconds, then run finger over feeling for indent (hypoalbuminaemia)

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To complete

• Thank patient and restore clothing
• ‘To complete my examination, I would examine the external hernial orifices, the external genitalia, and perform a digital rectal examination.’ 
• Summarise and suggest further investigations you would consider after a full history

Why don’t you test your knowledge on some examination findings?

How about some questions around some of the conditions you may see?

Now try some OSCE stations!

1. Normal abdominal exam
2. Chronic liver disease
3. Hepatosplenomegaly
4. Renal transplant
5. And there’s even more!