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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, NGtube, jaundice, scratch marks, spider naevi,gynaecomastia, striae, bruising, anaemia,pigmentation, cachexia, dehydration, abdominaldistension, abdominal masses, scars (rooftop, L-shape, Mercedes-Benz, subcostal, midline, Lanz,

Hockeystick, inguinal), Sister Mary JosephNodule, Grey-Turners/Cullens sign, stomas,acanthosis nigricans, tattoos

Look at the hands Clubbing (cirrhosis, lymphoma, IBD, Coeliacdisease), leukonychia (hypoalbuminaemia),koilonychias (iron deficiency), palmar erythema,Dupuytrens contracture, anaemia, tendonxanthomata, liver flap

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

Look in the mouth Ulcers, pigmentation, telangiectasia, fetorhepaticus, Candida, angular stomatitis, gums,

smooth tongue, leukoplakia, atrophic glossitis,macroglossia

Palpation

Feel the neck Supraclavicular lymph nodes, particularlyVirchows 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 theresany pain first, and watch the patients face)

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

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

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

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

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

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point)

Percussion

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

Percuss the spleen Starting in the right iliac fossa

Check for shifting dullness With finger in the midline, move down theflank until percussion note becomes dull. Askthe patient to roll away from you ascites issuggested if the note becomes resonant.

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

Auscultation

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

Listen for bruits Aortic, renal, iliac, femoral

Final manoeuvres

Examine the ankles for oedema

Examine the hernial orifices (or say youwould, as below)

I would complete my examination by.

I would like to examine the hernial orifices, examine the genitalia, perform a digital rectalexamination, 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 thedistribution 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 deficiency

Dupuytrens 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-Turners/Cullens signs flank/periumbilical bruising seen in pancreatitisKayser-Fleischer rings green-brown rings seen in the iris in Wilsons diseaseFetor hepaticus a musty-sweet smell found in liver failureAngular stomatitis cracks seen at the corner of the mouth, seen in iron deficiency Leukoplakia 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)