Abdominal examination

General look
Is he in pain or cachectic or obese?
Hands for clubbing, koilonychia (spoon-shaped nails) and signs of
liver disease, including leukonychia and palmar erythema.
Look at the mouth and throat for aphthous ulcers, which are
common in gluten enteropathy and inflammatory bowel disease
Ask the patient to look down and retract the upper eyelid to expose the
sclera; look to see if it is yellow in natural light
Look for anemia by exposing conjunctiva
Examine the cervical, axillary and inguinal lymph nodes; gastric
and pancreatic cancer may spread to cause enlargement of the
left supraclavicular lymph nodes
Nutritional state
Record the height, weight, waist circumference and the patient’s body
mass index
Look for abdominal striae, which indicate rapid weight gain, previous
pregnancy or, rarely, Cushing’s syndrome. Loose skin folds signify recent
weight loss.
Features of chronic liver
disease
Inspection
■ Examine the patient in good light and warm surroundings.
■ Position the patient comfortably supine with the head resting
on only one or two pillows to relax the abdominal wall muscles. ■
Look at the teeth, tongue and buccal mucosa
■ Note any smell, e.g. alcohol, fetor hepaticus

Expose the abdomen from the xiphisternum to the symphysis

pubis, leaving the chest and legs covered.?? Nipple to mid thigh ??
 Inspection- from the foot of the
bed

Start inspection from the foot of the bed

◦ Obvious abdominal findings
◦ Abdominal symmetry
◦ Shape of abdomen: flat, distended
◦ umbilicus
◦ Stoma bags
◦ Drains – wound drains, abdominal drains
Inspection- from the right side
of the patient
Stand to the right side of the patient
◦ Movement of abdominal wall with respiration
◦ Visible peristalsis,
◦ Visible pulsation
◦ Dilated vein, discoloration, pigmentation
◦ Presence of scar : site , shape: neat, ugly, wide, bulge
◦ Examine for divaricated recti
◦ Ask patient raises the head off the bed or coughs.
Abdominal scars and stomas
Palpation
■ Ensure that your hands are warm.
■ If the bed is low, kneel beside it.
■ Ask the patient to show you where any pain is and to report
any tenderness elicited during palpation.
■ Ask the patient to place the arms by the sides to help relax
the abdominal wall.
■ Use your right hand, keeping it flat and in contact with the
abdominal wall.
■ Observe the patient’s face for any sign of discomfort
throughout the examination.
 Begin with light superficial palpation away from any site of
pain.
Palpate each region in turn, looking for
◦ Abdominal muscle tone
◦ Superficial tenderness
◦ Superficial masses
◦ Palpable cough impulse

Repeat with deeper palpation.

Palpation
Describe any mass using the basic principles: its site, size, surface,
shape and consistency, and note whether it moves on respiration.
Is the mass fixed or mobile?
■ To determine if a mass is superficial and in the abdominal wall
rather than within the abdominal cavity, ask the patient to tense
the abdominal muscles by lifting his head.
■ An abdominal wall mass will still be palpable, whereas an
intra-abdominal mass will not.
Muscle tone : guarding and rigidity
Tenderness Discomfort during palpation may vary and be accompanied
by resistance to palpation.
Organs : describe size, surface: smooth or irregular, edge: smooth or
irregular, consistency: soft or hard, tenderness and whether it is
pulsatile.
Hepatomegaly
Splenomegaly
■ Place your hand over the umbilicus. Keep your hand stationary
and ask the patient to breathe in deeply through the mouth.
■ Feel for the splenic edge as it descends on inspiration
■ Move your hand diagonally upwards towards the left
hypochondrium 1 cm at a time between each breath the patient
takes.
■ Feel the costal margin along its length, as the position of the
spleen tip is variable.
■ If you cannot feel the splenic edge, ask the patient to roll
towards you and on to his right side and repeat the above. Palpate
with your right hand, placing your left hand behind the patient’s
left lower ribs, pulling the ribcage forward
■ Feel along the left costal margin and percuss over the lateral
chest wall to confirm or exclude the presence of splenic dullness.
Percussion
Ask the patient to hold his breath in full expiration.
■ Percuss downwards from the ??right fifth intercostal space?? in
the mid-clavicular line, listening for the dullness that indicates the
upper border of the liver.
■ Measure the distance in centimeters below the costal margin
in the mid-clavicular line or from the upper border of dullness to
the palpable liver edge.
■ Ask the patient to breathe in deeply and gently palpate the
right upper quadrant of the abdomen in the mid-clavicular line.
As the liver descends, the inflamed gallbladder contacts the
fingertips, causing pain and the sudden arrest of inspiration
(Murphy’s sign)
Ascites
Shifting dullness
■ With the patient supine, percuss from the midline out to the
flanks. Note any change from resonant to dull, along with areas
of dullness and resonance.
■ Keep your finger on the site of dullness in the flank and ask
the patient to turn on to his opposite side.
■ Pause for ??10??seconds to allow any ascites to gravitate, then
percuss again. If the area of dullness is now resonant, shifting
dullness is present.
Auscultation
■ With the patient supine, place your stethoscope diaphragm to
the right of the umbilicus and do not move it.
■ Listen for up to 2 minutes?? before concluding that bowel
sounds are absent. Bowel sounds are gurgling noises from the normal
peristaltic activity of the gut. They normally occur every 5–10 seconds,
but the frequency varies.
■ Listen above the umbilicus over the aorta for arterial bruits.
■ Now listen 2–3 cm above and lateral to the umbilicus for
bruits from renal artery stenosis.
Auscultation
Listen over the liver for bruits. A friction rub, which sounds like
rubbing your dry fingers together, may be heard over the liver
(perihepatitis) or spleen (perisplenitis).
A succussion splash sounds like a half-filled water bottle being
shaken. Explain the procedure to the patient, then shake the
patient’s abdomen by lifting him with both hands under his
pelvis. An audible splash more than 4 hours after the patient has
eaten or drunk anything indicates delayed gastric emptying, e.g.
pyloric stenosis.
 Hernias
■ Examine the groin with the patient standing upright.
■ Inspect the inguinal and femoral canals and the scrotum for any lumps or bulges.
■ Ask the patient to cough; look for an impulse over the femoral or inguinal canals and
scrotum.
■ Identify the anatomical relationships between the bulge, the pubic tubercle and the inguinal
ligament to distinguish a femoral from an inguinal hernia.
■ Palpate the external inguinal ring and along the inguinal canal for possible muscle defects.
Ask the patient to cough and feel for a cough impulse.
■ Now ask the patient to lie down and establish whether the hernia reduces spontaneously.
If so, press two fingers over the internal inguinal ring at the mid-inguinal point and ask the
patient to cough or stand up while you maintain pressure over the internal inguinal ring. If
the hernia reappears, it is a direct hernia. If it can be prevented from reappearing, it is an
indirect inguinal hernia.
■ Examine the opposite side to exclude the possibility of asymptomatic hernias.
Digital Rectal
Examination(DRE)
Explain what you are going to do, why it is necessary and ask for
permission to proceed. Tell the patient that the examination may be
uncomfortable but should not be painful.
■ Offer a chaperone; record if this is refused. Record the name of
the chaperone.
■ Position the patient in the left lateral position with his buttocks at
the edge of the couch, his knees drawn up to his chest and his
heels clear of his perineum
■ Put on gloves and examine the perianal skin, using an effective
light source.
■ Look for skin lesions, external haemorrhoids and fistulae.
■ Lubricate your index finger with water-based gel.
■ Place the pulp of your forefinger on the anal margin and apply steady pressure on the
sphincter to push your finger gently through the anal canal into the rectum
■ If anal spasm occurs, ask the patient to breathe in deeply and relax. If necessary insert a
local anesthetic suppository before trying again. If pain persists, examination under general
anesthesia may be necessary.
■ Ask the patient to squeeze your finger with his anal muscles and note any weakness of
sphincter contraction.
■ Palpate systematically around the entire rectum; note any abnormality and examine any
mass. Record the percentage of the rectal circumference involved by disease and its distance
from the anus
■ Identify the uterine cervix in women and the prostate in men; assess the size, shape and
consistency of the prostate and note any tenderness.
■ If the rectum contains feces and you are in doubt about palpable masses, repeat the
examination after the patient has defecated.
■ Slowly withdraw your finger. Examine it for stool color and the presence of blood or mucus
Thank you