Examination of the abdomen

General points
Approach from right hand side
Ask if patient can lie flat
Lie patient flat on one pillow
Exposure - ideally nipple to knee but realistically only lower garments to about halfway between iliac crest and synthesis pubis

1 - Visual survey
Look for
Pallor
Pigmentation
Jaundice
Spider naevi
Xanthelasma
Parotid swelling
Gynaecomastia
Scratch marks
Tattoos
Abdominal distension
Distended abdominal veins
An abdominal swelling or herniae
Surgical scars
Decreased body hair

2 - Comment on pigmentation

3 - Examine the hands
Dupuytren’s contracture
Clubbing
Leuconychia - white discolouration of the nails
Palmar erythema
Flapping tremor

4 - Pull down lower eyelid
Anaemia
Icterus in sclerae
Xanthelasma
Guttering between eyeball & lower lid is best place to look for pallor or discolouration

5 - inspect mouth
Cyanosis of lips - cirrhosis of liver
Swollen lips - Crohn’s
Telengiectasis - Osler-Weber-Rendu
Patches of pigmentation - Peutz-Jeghers
Mouth ulcers - Crohn’s disease

6 - Lymph nodes & JVP
Palpate neck & supraclavicular fossae for Cervical lymph nodes
If you find lymph nodes palpate axillae & groin for evidence of generalised lymphadenopathy - lymphoma, chronic lymphocytic leukemia
JVP may be enlarged in portal hypertension

7 - gynaecomastua
Palpate for glandular tissue in obese patients

8 - Spider naevi
Distribution of superior vena cava
May be seen on hands, arms, face & back

9 - Scratch marks
Anywhere on body - may be sign of hyperbilirubinaemia or uraemia

10 - Body hair distribution
More in men
Reduced chest hair and axillae hair
Think about facial hair
Examine pubic hair later

11 - Observe the abdomen
Three sections - epigastric, suprapubic & umbilical
Pulsations
Generalised distension - ascities
Swelling in one particular area
Scars or fistulae - ?previous surgery for Crohn’s
Distended abdominal veins - flowing away from umbilicus in portal hypertension. Upwards from groin in IVC obstruction

12 - Palpation
Ensure hands are flat at side of patient
Talk to patient to encourage them to relax
Ask patient if he has any tenderness & tell him to tell you if you hurt him.
1. Systematically examine whole abdomen with light palpation. Use pulps of fingers & gentle flexion of MCP joints with hand flat on abdominal wall
2. Deeper palpation
3. Internal organs. For liver & spleen start in right iliac fossa. Work up to right hypochondrium for liver. Work diagonally across abdomen to left hypochondrium for spleen. Organs felt best against radial border of index finger & pulps of index & middle finger. Organs descend on inspiration so gently press & move hand up to meet them at this time.
4. Kidneys are found by bimanual palpation in each lateral region
Palpation of internal organs is difficult if ascities is present. In such cases press quickly, flexing at wrist joint to displace fluid & palpate the enlarged organ.
Mass in left hypochondrium - spleen or kidney. Kidney - can get above it, can separate it form the costal edge, can bimanually palpate & it has resonant percussion note.
Deep palpation in flanks for ascending & descending colon.
Gentle palpation for aortic aneurysm in midline of abdomen.
Palpate for inguinal lymph nodes
Check hernial orifices
Note pubic hair thickness/distribution

Causes of an enlarged liver - 3C’s
· Cancer
· C2H5OH - alcohol
· Congestive cardiac failure


13 - percussion
Start at nipple moving down
Locate upper edge of liver & spleen
Left lower lateral chest wall may become dull to percussion before enlarged spleen is palpable
Lower palpable edges of both organs. Start percussing in right iliac fossa moving towards appropriate area moving from resonant to dull areas

14 - Shifting dullness
Check flanks for stony dullness - no need to continue with procedure of demonstrating shifting dullness if this is not present
Ask patient with ascities to turn on side - this shifts dullness from upper to lower flank

15 - Auscultation
Of little use in exam situation
Very important as part of full routine
Bowel sounds
Renal artery bruits
Listen for other sounds such as rub over spleen or kidney or a venous hum

16 - External genitalia
Not usually requires in exam but state that you would
Small testes - chronic liver disease

17 - Rectal examination
Abdominal examination is incomplete without rectal exam

I would also like to…
Rigid sigmoidoscopy
Dipstick urine for protein, blood, etc