Rashad Jurangpathy (4th year)

THE ABDOMINAL EXAMINATION

BASICS!!

1. INTRODUCTION & CONSENT

2. INSPECTION

3. PALPATION

4. PERCUSSION

5. AUSCULTATION

6. CLOSE

Introduction• Introduce yourself• Explain – what’s involved / how long• Consent• Exposure• Wash hands• Position• WIPE

• ‘Good morning/afternoon Mr/Mrs, my name is Rashad Jurangpathy and I am a 3rd year medical student. Is it ok if I quickly examine your tummy? This will involve me inspecting your tummy, having a quick feel and listen to it, as well as looking at your hands and your face. It will only take about 10 minutes of your time. Is that ok? For this examination, I’d like you to undress from waist upwards – you can do so behind the curtains whilst I go and wash my hands. Tell me when you’re ready. (Tell examiner, ideally I’d like the patient exposed from nipples to knee, but will not ask in this case, to preserve the dignity of the patient)’

BASICS!!

1. INTRODUCTION & CONSENT

2. INSPECTION

3. PALPATION

4. PERCUSSION

5. AUSCULTATION

6. CLOSE

End of bed examination / ‘outside-in’

Around the bed

• Medication / lines / PCA• Monitors• Fluids• Catheter bags

Patient itself

• Comfortable?• Well?• Nutritional state / unfinished food• Quick inspection of abdomen

• Distension• Stoma bags• Obvious masses• Pulsatile masses• Scars

• Any obvious signs?

Hands

Hands

• Warmth & perfusion• Clubbing• Leuconychia• Koilonychia

• Palmo Palmar erythemao Dupuytren’s contracture – ‘thickening + shortening of

palmar fascia, resulting in flexion deformities of 4 and 5

• Pulse• Asterixis (30 seconds)

• BP

Causes of clubbing

GI Causes (4 C’s):1. IBD (esp. Crohn’s)

2. Cirrhosis

3. GI lymphoma

4. Malabsorption disease, e.g. coeliac

Resp Causes:1. Lung cancer2. Chronic lung suppurative disease:

a) CFb) Empyemac) Bronchiectasis

3. Fibrosing alveolitis4. Mesothelioma

Cardiac Causes:1. Congenital cyanotic heart disease2. Endocarditis3. Atrial myxoma

Signs of chronic liver diseaseCOMPENSATED SYMPTOMS• Parotid enlargement• Spider naevi• Gynaecomastia• Clubbing, dupuytren’s contracture, xanthomas• Scratch marks• Testicular atrophy• Purpura

GENERAL SYMPTOMS• Jaundice• Loss of body hair

DECOMPENSATED SYMPTOMS• Encephalopathy, asterixis, fetor hepaticus, drowsy• Ascites• Capud medusae• Oedema

Causes of palmar erythema

Hyperdynamic states:• Pregnancy• Polycythaemia• Cirrhosis• Thyrotoxicosis

Face• Eyes

– Jaundice– Conjunctival pallor– Kayser-fleischer rings

• Face– Malar flush

• Mouth– STICK TONGUE OUT: Hydration status / Glossitis (smooth, red, sore tongue) –

iron, folate or b12 def.– TONGUE TO ROOF OF MOUTH: jaundice / central cyanosis– SHOW TEETH: dental caries / irregular dentition– GUMS: gingivitis / scurvy (soft & haemorrhagic)– Ulcers– Angular stomatitis (cheilitis) – iron def.– Abnormal pigmentation:

• Peutz-Jeghers• Telangiectasia

– Hallitosis / Fetor

Face

Neck, Chest & Abdomen• Palpate for Virchow’s node• Inspect chest for:

– Spider Naevi: >6 = abnormal; along course of SVC; can be blanched when pressed in middle and will then refill

– Gynaecomastia– Loss of hair

• Inspect abdomen more closely now – make sure to check flanks closely:• Distension – size/shape/symmetry – 5F’S: fluid (ascites), foetus, faeces, fat, flatus• Stoma bags• Obvious masses• Pulsatile masses• Scars• Spider naevi• Purpura• Caput medusae• Grey Turner’s & Cullen’s signs• Scratch marks• Striae• Bruising• Hernias – including umbilical, incisional & para-stomal

Neck, Chest & Abdomen

Spider naevi

Caput medusae

Cullen’s sign

Grey-turner’s sign

A- Ileostomy – End ileostomy – UC sufferers who have a

proctocolectomy

B – Loop colostomy – Colon Ca palliation

C – End colostomy – Hartmann’s procedure for

diverticular disease – sigmoid region excised, proximal region brought to surface with rectum

conserved

R hemicolectomy – Crohn’s (removal of affected ileum + proximal colon) – Crohn’s predominantly affects terminal ileum leading to stricturing + episodic SBO

Lanz scar (appendicectomy)

McBurney’s scar (appendicectomy)

Liver transplant

Open cholecystectomy

Rarely used – R hemicolectomy

Hysterectomy / cystectomy

L loin/lumbar incision – nephrectomy / renal transplant (hockey stick scar)

Midline scars – laparotomy / AAA repair / bowel resection

Vertical groin incision – embolectomy in femoral artery

Rooftop + thoracotomy - oesophagectomy

Rooftop incision (mercedes benz scar without the top

vertical line) – liver transplant / upper GI /

pancreas

BASICS!!

1. INTRODUCTION & CONSENT

2. INSPECTION

3. PALPATION

4. PERCUSSION

5. AUSCULTATION

6. CLOSE

Palpation• Always start off by asking: ‘Where is the pain?’• Always start palpation away from site of pain• Get to level of abdomen – either kneel down or raise bed• Always look at patient’s face whilst palpating• Start with LIGHT palpation (1 hand), and then DEEP palpation (2 hands)• Palpate all the 9 segments• LIGHT palpation:

– Check for tenderness (+ rebound tenderness) / guarding / rigidity– If tender on light palpation, ask pt. it ok to press deeper– Rebound tenderness indicates if parietal peritoneum is inflamed (peritonitis) – in exam, say

that you would test for rebound tenderness

• DEEP palpation:– Feel for any masses: site, size, shape, mobility, consistency, pulsation, bruit

• For any mass/lump/bump, try and assess the following:– Site– Size– Shape– Colour– Consistency– Surface– Temperature– Tenderness– Translucency– Mobility– Pulsation– Fluctuation– Reducibility– Edge– Regional lymph nodes– Perhaps auscultate as well

Palpation for organomegalyPalpation of liver:• RIF & upwards to RUQ; move up 2cm at a time• Push in on inspiration to feel lower border• Normal liver size – M: 10-12cm / F: 8-10cm• To assess accurately for hepatomegaly, need to percuss for upper and lower borders

(liver is dull, lung is resonant)– Normal upper border: 5th ICS

• If can feel liver border, need to assess:– Size, surface, edge, consistency (craggy – hepatocellular cancer), tender, pulsatile (tricuspid

regurgitation)– Is it smooth generalised enlargement? Knobbly generalised enlargement? Localised swellings?

Palpation of spleen:• RIF & upwards diagonally to LUQ• Spleen situated against diaphragm, in area of rib IX-X - Can only feel spleen if

enlarged• Ways to differentiate it from enlarged kidney:

– Cannot get above it (ribs in the way)– Moves on inspiration (towards RIF)– Overlying percussion note is dull– May have a palpable notch on medial side

Palpation for organomegaly

Palpation of kidneys:• Bimanual (balloting) – keep top hand steady on abdomen, and use bottom

hand to push up• Left higher than right

– Lt superior pole: rib XI– Rt superior pole: rib XII– Lower poles around level of disc between LIII and LIV

• Check for any difference in the kidneys; if palpable, check for size, surface, consistency

Palpation cont.

Palpate for AAA:• AAA = pulsatile & expansile• If present, don’t press too hard

Check for ascites if distension visible1. Shifting dullness2. Fluid thrill

Check hernial orifices- Ask them to cough

BASICS!!

1. INTRODUCTION & CONSENT

2. INSPECTION

3. PALPATION

4. PERCUSSION

5. AUSCULTATION

6. CLOSE

Percussion

Percussion of liver and spleen – do after palpating each organ

BASICS!!

1. INTRODUCTION & CONSENT

2. INSPECTION

3. PALPATION

4. PERCUSSION

5. AUSCULTATION

6. CLOSE

Auscultation

Listen for bowel sounds:• Active, absent, tinkling• Listen for 2 minutes at one area before concluding absence• Listen at 3 areas• Absent BS = paralytic ileus or peritonitis• Tinkling BS = bowel obstruction (BS are also more frequent)

Listen for bruits:• Aortic bruits (atheroma or aneurysm) – above umbilicus• Renal artery bruits (renal artery stenosis) - 2.5cm above and lateral to umbilicus

BASICS!!

1. INTRODUCTION & CONSENT

2. INSPECTION

3. PALPATION

4. PERCUSSION

5. AUSCULTATION

6. CLOSE

Conclusion

Thank patient, ask if he has any questions, tell him he can redress now and then WASH HANDS

Present the examination

To complete my examination, I would:1. Check the external genitalia

2. Perform a DRE

3. Dipstick the urine

4. Check the hernial orifices (if not done already)

EXAMPLE ABDOMINAL EXAMINATION

Next week

‘ECG & Abdo X-rays’With

Isma Qureshi (4th year) &

Adeel Iqbal (5th year)

Wednesday 28th October, Drewe LT, 2pm

Final Reminders

• Remember to purchase MM membership for priority for MM OSCE

• All slides are available online