Abdomen

History & Examination

Important history Dyspepsia- heartburn Dysphagia- difficulty swallowing Altered bowel habit- diarrhea/constipation Pain- colicky, stretch, radiation, referred Bleeding- UGI/LGI Jaundice Urinary symptoms- hematuria, dysuria, frequency,

urgency, hesitancy, retention Appetite Dietary history

Examination Oral cavity

Abdomen Male genitalia

Anus/rectum

Oral cavity Angular stomatitis, cheilitis Teeth- number, color, ridges, caries Gums- swelling, bleeding, pyorrhea Buccal mucosa- ulcer, pigmentation Tongue- size, color, papillae Palate, tonsils, pharynx

Abdomen- regions 4- vertical & horizontal planes thru umbilicus-

RUQ, RLQ, LUQ, LLQ 9- vertical planes thru 9th costal cartilage & femoral

artery; horizontal planes are subcostal & interiliac- R & L hypochondrium, lumbar, iliac and epigastrium, umbilical, hypogastrium

Abdomen- regions

Quadrants & organs RUQ- liver, GB, upper pole of R kidney,

hepatic flexure of colon LUQ- stomach, spleen, pancreas, upper

pole of L kidney, splenic flexure of colon RLQ- lower pole of R kidney, appendix,

terminal ileum, R colon, R ovary LLQ- lower pole L kidney, L colon,

L ovary

Pre-examination Comfortable room & couch Adequate light Patient lying supine Adequate exposure Examiner’s hand at the level of patient’s

abdomen

Examination- components Inspection- see, don’t touch

Palpation- touch

Percussion- tap

Auscultation- use stethoscope

Inspection Shape- scaphoid, normal, distended Umbilicus- shape, inverted/everted Movements- normal or restricted,

pulsation, visible peristalsis Striae or scars Prominent veins Genitalia & groin

Palpation Relaxed patient & abdominal wall Start from the point farthest from

possible area of involvement e.g. for liver start from LLQ & for spleen from RLQ

Palpate whole abdomen in an order

Special techniques Deep palpation- in obese, muscular or

poorly relaxed Dipping- tense ascites Bimanual- for kidney & spleen Ballotable- kidney Shifting dullness & fluid thrill- for ascitis

It helps Spleen L hypochondrium Grows towards RLQ Upper border not

reached Moves with respiration Medial notch Not ballotable Dull on percussion

L kidney Renal angle posteriorly Grows towards LLQ Upper border reachable Restricted mobility No notch Ballotable Colon overlying on

percussion

Liver RUQ Moves with respiration Tender or not? Edge- soft, firm, hard Surface- smooth, nodular Pulsatile in TR Confirm span by percussion

Gall bladder Underlies liver in RUQ Moves with respiration Usually not palpable Tender- Murphy’s sign- +ve in acute

cholecystitis Palpable GB- mucocoele, cancer,

CBD obstruction

Urinary bladder Midline, suprapubic Usually not palpable When palpable- smooth, symmetrical,

lower border not reached, Urge to micturate on palpation Dull on percussion

Percussion Only light percussion required

Resonant note allover, except over liver where it is dull

Used to confirm liver or spleen or bladder enlargement & ascitis

Auscultation Paraumbilical For bowel sounds or bruit Normal BS- intermittent gurgles

interspersed with tinkles Increased- intestinal obstruction Decreased- paralytic ileus Bruit- over aorta, iliac/renal arteries

Don’t forget Groin- LNE, hernia

Male genitalia

PR examination- for local pathology, prostate examination in males

Stigmata of CLD Muscle wasting Pallor, jaundice Clubbing Palmar erythema Dupuytren’s contracture Spider nevi Gynecomastia Testicular atrophy Caput medusae Ascites

Supported by

X-ray, US/CT, Endoscopy