James Wight

Examination of the Abdomen

• Wash your hands.• Introduce yourself to the patient, and ask permission to examine them.• Expose the patient, and lie them flat.

Inspection

Look around the bed Oxygen mask/nasal prongs, drips, cigarettes, special foods, diabetic diet

Look at the patient Comfortable at rest, wound drain, catheter, NG tube, jaundice, scratch marks, spider naevi, gynaecomastia, striae, bruising, anaemia, pigmentation, cachexia, dehydration, abdominal distension, abdominal masses, scars (rooftop, L-shape, Mercedes-Benz, subcostal, midline, Lanz, Hockeystick, inguinal), Sister Mary Joseph Nodule, Grey-Turner’s/Cullen’s sign, stomas, acanthosis nigricans, tattoos

Look at the hands Clubbing (cirrhosis, lymphoma, IBD, Coeliac disease), leukonychia (hypoalbuminaemia), koilonychias (iron deficiency), palmar erythema, Dupuytren’s contracture, anaemia, tendon xanthomata, liver flap

Look at the eyes Jaundice, anaemia, Kayser-Fleischer rings, xanthelasma

Look in the mouth Ulcers, pigmentation, telangiectasia, fetor hepaticus, Candida, angular stomatitis, gums, smooth tongue, leukoplakia, atrophic glossitis, macroglossia

Palpation

Feel the neck Supraclavicular lymph nodes, particularly Virchow’s node

→ Inspect the abdomen again, including asking the patient to raise their head or legs

Light palpation In all 9 segments of the abdomen (ask if there’s any pain first, and watch the patient’s face)

Deep palpation In all 9 segments of the abdomen, watching the face

Feel for the liver Starting in the right iliac fossa, asking the patient to breathe in each time you palpate

Feel for the spleen Starting in the right iliac fossa, asking the patient to breathe in each time you palpate

Ballot the kidneys Put one hand posteriorly in the flank, and flick the kidney onto a hand positioned anteriorly

Feel for a AAA Above the umbilicus (the aorta divides below this

point)

Percussion

Percuss the liver Starting in the right iliac fossa until dull, then percuss out the upper border

Percuss the spleen Starting in the right iliac fossaCheck for shifting dullness With finger in the midline, move down the

flank until percussion note becomes dull. Ask the patient to roll away from you – ascites is suggested if the note becomes resonant.

Check for fluid thrill Ask patient to position their hand in the midline, and flick the abdomen to test for transmitted thrill

Auscultation

Listen for bowel sounds Up to three minutes. Can be normal, absent or tinkling (in obstruction)

Listen for bruits Aortic, renal, iliac, femoral

Final manoeuvres

Examine the ankles for oedemaExamine the hernial orifices (or say you would, as below)

I would complete my examination by….

“I would like to examine the hernial orifices, examine the genitalia, perform a digital rectal examination, dipstick the urine and look at the observation chart (temperature, BP, sats)”

GlossarySpider naevi – telangiectasia with a central arteriole from which radiate numerous small vessels. Found in the distribution of the SVC, and due to hyperoestrogenic state in liver failure.Leukonychia – whitening of the nails due to hypoalbuminaemiaKoilonychia – “spoon-shaped” nails due to iron deficiencyDupuytren’s contracture – thickening of the palmar fascia, seen in relation to excess alcohol intake, DM, epilepsy and hereditary. Sister Mary-Joseph nodule – umbilical nodule due to metastatic cancerGrey-Turner’s/Cullen’s signs – flank/periumbilical bruising seen in pancreatitisKayser-Fleischer rings – green-brown rings seen in the iris in Wilson’s diseaseFetor hepaticus – a musty-sweet smell found in liver failureAngular stomatitis – cracks seen at the corner of the mouth, seen in iron deficiencyLeukoplakia – white tongue: smoke, spirits, sepsis, syphilis, sore teethAtrophic glossitis – a smooth tongue, seen in vit B12 and folate deficiency (amongst other things)Acanthosis nigricans – velvety pigmented plaques in the axilla and back of the neck, seen in GI malignancy (and several other conditions)