Contents
Summary of Abdominal Examination
- Introduce yourself, check right patient (name DOB, wrist-band) explain that you are going to perform an abdominal examination and what this will involve, and ask the patient’s permission
- Get patient to lie flat, and expose between costal margin and pubic bone
- Assessment order: 1. Inspection 2. Auscultation 3. Percussion 4. Palpation (1st superficial then deep) [see Detailed Abdominal Examination below]
[Auscultation precedes percussion and palpation to prevent guarding or change in bowel sounds].
Start your physical examination assessing without touching!
Facial expression & body posture
For evidence of distress
Hands
- Polished nails
- Tattoos
- Clubbing
- Crohn’s disease
- Ulcerative colitis
- Coeliac disease
- Koilonychia – iron deficiency
- Leukonychia – hypoalbuminaemia – liver failure, malnutrition (e.g. coeliac)
- Beau’s lines – acute illness
- Terry’s nails – liver/renal failure
- Dupuytren’s contracture – alcoholic liver disease / spontaneous
- Asterixis (30 seconds) – quite slow frequency, whole hand tilts forwards – a results of encephalopathy caused by urea.
- Palmar erythema – chronic liver disease (also pregnancy and skin conditions!)
- Tar staining in fingers – may indicate cigarette smoking
Arms
- Spider naevi – blanch, caused by excess oestrogen (pregnancy, cirrhosis). Can have several of these in a normal ‘healthy’ individual.
- Bruising – chronic liver disease (2,7,9&10)
Eyes
- Conjunctiva
- Sclera
- Kayser-Fleisher rings
- Xanthelasma
Mouth
- Use a torch! Tongue depressor is also useful
- Angular stomatitis – iron deficiency
- Gums – scurvy if inflamed, leukaemia if hypertrophied.
- Teeth – general hygiene. Can lose enamel if lots of reflux.
- Tongue
- Candida – cannot be scraped off
- Glossitis – big smooth red tongue – sign of iron deficiency anaemia
- Ulceration (ill fitting dentures – think of nutrition consequences)
- Leukoplakia – white furry plaque on the tongue – possible sign of malignancy
Neck
- No need to do a full neck exam, but perhaps worth checking Virchow’s node (Trosier’s Sign)
Chest
- Spider naevi
- Gynecomastia (can be caused by spironolactone) and also liver failure (hair loss)
Overview of Abdominal Examination
Inspect
- Skin colour & condition (incl. moles), skin integrity intact?
- Contour & symmetry (flat / rounded?), bulges, deformities
- Umbilicus (inverted / everted), in midline? herniation? discoloration? discharge?
- Visible pulsations/movements, varicosities?
Auscultate
- Normal gurgling sounds
- High pitched and tinkling in obstruction
- Absent in peritonitis and ileus (ileus is a non-mechanical obstruction (i.e. has a neurological cause – there are two main types: post-operative and paralytic)
- Listen just next to umbilicus for renal bruit. Listen 2 inches above umbilicus for everything else.
Percuss
- Liver
- Shifting dullness – remember keep fingers orientated in same direction as possible fluid.
Palpate
- All 9 regions / all 4 quadrants
- Ask for tenderness
- Palpate gently for superficial lumps (hernias? lymph nodes? tenderness? other masses?)
- Deep palpation – checking for same things
- Feel for liver – it is normal to feel the bottom edge if you are high up. Also normal to feel nothing at all. Causes of hepatomegaly: CCCi
- Congestive – right sided heart failure
- Cirrhosis – alcoholic, autoimmune
- Carcinoma – (primary, secondary)
- Infection – HBV, HIV, EBV, CMV (cytomegalovirus)
- Feel for spleen – this cannot be felt in a normal individual. Causes of splenomegaly:
- Feel for kidneys – remember when differentiating spleen and kidney, you cannot ballot the spleen! Causes of large kidneys:
- Polycystic kidney disease
- Tumours
- Amyloidosis
- Aorta – feel just either side of midline around umbilicus – in thin people should be able to feel it pulsating – should be less than 4.5cm diameter. If aneurysm then it would be pulsating and expanding.
Extra areas to assess:
- Examine external genitalia
- Urine dipstick
- Hernial orifices
- PR exam
- Ankle oedema
- Erythema nodosum – red, symmetrical lesions on shins, painful
Detailed Abdominal Examination
General Instructions
The patient should lie completely flat. If the patient is particularly uncomfortable, then they may use 1 or 2 pillows under the head. Only in unusual circumstances would you perform an abdominal examination when the patient is not lying completely flat.
You should ask the patient to expose themselves as far down as the pubic bone and as far up as the costal margin.
1. Inspection
Stand at the end of the bed, and assess the patient without touching them. Tell them what you are doing so they will feel more relaxed. Look for general patient comfort, symmetry, colour, and obvious masses and scars. Also have a look at the patient’s sides, and at the patients back. Don’t get them to sit up and down too much though!
Look for the 5 F’s of abdominal swelling (fat, flatus, fluid, faeces, foetus). Hernias can be more easily noticed if you ask the patient to sit up without using their hands to help them.
Smoking – are there any obvious signs the patient does it? It is a large cause of bladder, oesophageal and colorectal cancer.
Is there…
- a drip?
- tube feeding? (nasogastric or intravenous)
- cartons of food around?
- any medicine lying around?
Does the patient look generally sick!? This ‘gut’ instinct is actually a good thing!
Hands
- Polished nails can be a sign of scratching. If there are rashes present as well you can be pretty sure they have been scratching!
- Little tattoos on the hands. These can often be DIY jobs, and as a result the patient may have contracted hepatitis (B or C)
- Clubbing. In relation to abdominal diseases this can be a sign of:
- Ulcerative colitis
- Crohn’s disease
- Coeliac disease
- Koilonychia – spoon shaped nails. This is a sign of iron deficiency anaemia.
- Leuconychia – white nails – a sign of hypoalbuminaemia – and thus liver failure
- Any words ending in -onychia mean: in relation to the nails
- Beau’s lines – these are a sign of an acute illness. They are white lines across the nails (not raised). The nails grow out in about 12 weeks, so you can tell by how far the line is down the nail, when this person had acute illness.
- Terry’s nails – these have a ‘ground glass’ appearance, and there is no lunula. They can be a sign of liver or renal failure.
- Dupuytren’s contracture – this is where a finger is bent towards the palm of the hand. It can be a spontaneous condition, but it is also associated with alcoholic liver disease. As well as looking for the contracture, you should feel the palmar aponeurosis – it may feel hard and tight. Most commonly affects the ring and little fingers.
Dupuytren’s Contracture. Image from Wikimedia Commons. Author: Frank C. Müller - Flap (asterixis) – this can be a result of encephalopathy – a failure of the liver to detoxify toxic substances. The main toxin involved is urea. For the flap to appear the patient has to hold their hands out in front of them for at least 30 seconds.
- This is different to the flap seen in CO2 retention. The CO2 retention flap will appear before 30 seconds.
Spider naevi – these are little vascular raised things on the skin. If you press on them they will blanch, but then re-appear when the pressure is lifted. They are found on the face, hands, forearms and trunk – anywhere that is drained by the superior vena cava. They are associated with any condition that causes increased circulating oestrogen – e.g. cirrhosis (as the liver is unable to remove circulating oestrogen – particularly in alcohol related disease), pregnancy. If you press on them, you can see the blood refilling them from the middle, then spreading out. It is normal for an individual (most commonly women) to have up to 5 of these without a pathological cause.
- Bruising – could possibly be a sign of chronic liver disease – reduced platelets. Clotting factors 2, 7, 9 &10 are the liver dependent clotting factors.
- Oedema
- Jaundice
- Campbell De Morgan Spots – aka Cherry Angioma – these are red/purple spots that are non-blanching (and thus can be differentiated from spider naevi). They appear commonly in middle to late age, and often there is no underlying cause. They are the result of proliferation of blood vessels. They can be as small as a pin prick, and rarely grow larger than 6mm diameter. They most commonly appear on the chest. It is possible that when they appear suddenly they are associated with underlying disease (such as liver disease)
Mouth
When examining the mouth, make sure you use a torch! You will miss loads if you don’t. A tongue depressor is also an advantage. There are 6 things to check in the mouth:
- Lips – angular stomatitis – sign of severe iron deficiency anaemia This is also seen in dehydration!
- Gums – can show scurvy (Vit C deficiency) if they are inflamed / bleeding / damaged at all. May also show hypertrophy in leukaemia. Gums can also show hypertrophy in rare instances:
- When being treated with cyclosporin (immunosuppressant)
- When being treated with some epilepsy drugs
- Teeth – check general oral hygiene. Teeth may lose their enamel from chronic gastric reflux / vomiting.
- Tongue:
- Candida – cannot be scraped off with a tongue depressor. This id not the same as the normal covering on the tongue that many people have; which can be scraped off, so try to differentiate these two
- Glossitis – inflammation of the tongue. A symptom of iron-deficiency anaemia. The tongue will appear smooth, shiny and red.
- Ulceration – often from ill-fitting dentures.
- Leukoplachia – a white, hairy plaque on the tongue and a sign of pre-malignancy.
- Geographical tongue – looks a bit like a map – halfway between glossitis and normal tongue.
- Anaphylaxis – this can cause a rapid (within minutes or hours) swelling of the tongue that makes it very large.
- Cheeks – may show signs of ulceration and leukoplachia
- Fauces (back part of the mouth near the tonsils)
- Pigmentation around the lips – Peutz–Jeghers syndrome – a hereditary condition which leads to massive numbers of polyps forming in the digestive tract. Also causes a freckling like pigmentation around the mouth. The polyps from this condition can bleed and cause obstruction, and these patients have an extremely high cancer risk.
Eyes
- Jaundice – ask the patient to look to the floor, and lift up their top eyelids. Look for signs of yellowing.
- Anemia – ask the patient to look to the ceiling and pull down their bottom eyelids. Look in the conjunctiva.
- Kayser–Fleischer ring – these are rings that encircle the iris. They are the result of copper deposition, seen in Wilson’s Disease.
- Hyperlipidemia:
- Xanthelasma – lipid deposits around the eyes. can be a sign of diabetes or high cholesterol.
- Corneal arcus – lipid deposits in the cornea – naturally occur in old age, but can be pathological at younger ages.
Neck / Chest
- Lymph nodes – learn all the names and places of these!!
- Spider naevi again
- Ask patient to take a big breath in and out and check the symmetry of the chest and abdomen as it rises and falls.
2. Auscultation
- You should listen about 2 inches above the umbilicus, along the midline. This enables you to hear the kidneys, bowel sounds, heart sounds and pretty much everything!
- This is where you listen for bowel sounds. For example, an obstruction in the bowel will cause a high pitched ‘tinkling’ noise. Absent bowel sounds can be an indication of peritonitis. If at first you cannot hear bowel sounds you should keep trying for 2-3 minutes!
- Bruit – these are the noises that come from turbulent blood flow through abnormally rough arteries. You will hear them as a rhythmic ‘whooshing’ sound as the heart pumps. The most common type of bruit is renal bruit, although hepatic bruit can also sometimes be heard.
3. Percussion
- When percussing, the most important thing you are listening for is fluid in the abdomen. You should begin percussion in the middle of the chest, and then gradually move to the patient’s side. It is normal for there to be dullness at the sides (although it is not always present). If there is dullness, then you should get the patient to roll over, and leave them for 30 seconds or so to allow any fluid (if present) to follow gravity and move to the bottom of the patient. It is very important to ensure you keep your hand on the patient where the dullness is, so that when you have rolled them over, you are percussing in the same region. If after 30 seconds there is still dullness in the same region then there is nothing to worry about. If, however, a dull area has now become resonant, then we say the patient has shifting dullness due the presence of fluid in the abdomen. When percussing for shifting dullness you should have your fingers in line with the patient’s trunk (i.e. in line with any possible fluid level) so that you can easily detect the fluid level. When generally percussing the abdomen, the orientation of your fingers doesn’t particularly matter.
- Percuss for the liver – start on the patient’s chest well above where you would expect the liver to be, then gradually move down. When you reach the upper border of the liver, it will become dull. Do the same for the bottom of the liver. Usually the liver will be totally covered by the rib cage.
4. Palpation
- Learn the 9 sections of the abdomen. The 4 quadrants division is also often used.
- Approach the patient confidently! Tell them what you are going to do, and ask them if they have any tenderness. If they do, then leave this area till last, and palpate it more gently. Then first of all do a superficial palpation. This is quite gentle. Do it in all 4 quadrants. Use the whole of your hand at 90’ to the patient and sort of ‘do the worm’ with your hand. Generally the larger the patient, the more of these palpations you want to do. This is to check for masses, and for tenderness.
- ALWAYS look at the patients face as you palpate – to see if anywhere is tender.
- Deep palpation – the same thing again, but harder.
- Now you should attempt to feel individual organs. The stomach is well covered by the rib cage and so much too difficult to feel. Start with the…
- Liver. Place you hand on the patient’s right, quite low down in the right iliac fossa. Lead your hand with the outside edge of your index finger. So your hand is at 90º to the patient with index finger on top. Ask the patient to take a deep breath in. This will force the liver downwards. You may feel the bottom of the liver push against the top of your hand. Tell the patient to breathe out. If you don’t feel anything, then move your hand, then tell the patient to breathe in again. It is normal for you not to be able to feel the liver at all even after several attempts and gradually moving your hand upwards. It is also normal to feel the very bottom edge of the liver if you are reasonably far up.
- If you feel a mass in the right hypochondrium try to feel above it – if you can feel above it, then it is not the liver (except in VERY rare cases of emphysema)! The key features of the liver are:
- Cannot feel above it
- Descends on inspiration
- You use exactly the same technique for the spleen, but this time, start roughly in the same place, but go diagonally towards the left. If you cannot feel the spleen, ask the patient to lie on their side and face you and try again. Usually the spleen and gallbladder cannot be palpated, unless there is a pathological cause. You should never be able to feel the top edge of the spleen; if you can, then it’s probably not the spleen you are feeling!
- Tipping for the spleen – get the patient to roll onto their right hand side, with their left knee bent upwards. Ask the patient to rest their left arm on your left shoulder. Put your hand under the left costal margin, and ask the patient to take a deep breath. You may just feel the edge of the spleen. This is good for cases where the spleen is only slightly enlarged, and the normal method of feeling for the spleen revealed nothing or was inconclusive.
- Traube’s note – sometimes the spleen may be enlarged by not palpable. In which case, you may be able to detect its enlargement using percussion. You should percuss at the 9th intercostal space at the anterior axillary line. Normally this area is resonant, but as the spleen enlarges and occupies it, it becomes dull. The anterior axillary line is parallel to the mid-clavicular line; however is more lateral, roughly halfway between the mid-clavicular and mid-axillary lines.
- Features of the spleen:
- Expands diagonally across the abdomen in cases of enlargement
- Descends with inspiration
- You cannot feel above it
- You may be able to feel the splenic notch in a large palpable spleen
- Gallbladder – this is very rarely palpable. It is normally enlarged in the case of gallstones, but these lead to thickening and fibrosis of the gallbladder, and these characteristics mean it is not normally palpable. It is more likely to be felt in cases of carcinoma of the head of pancreas which leads to bile ducts obstruction, and gallbladder distension. It may also be palpable in cases of a gallstone obstructing the cystic duct; in which instance, there will be no jaundice.
- Courvoisier’s law – this states that a palpable gallbladder in the presence of jaundice is very unlikely to be due to gallstones due to the reasons described above.
- For the kidney, put your left hand on the patient’s back, underneath them, just about 2 cm away from the vertebrae, just under where the ribs meet the vertebrae. Put your right hand on the patient’s front, corresponding to where your back hand is. You should then try and jiggle the kidney up and down. This is known as balloting.
- For the aorta, you should feel just on either side of the midline on the patient’s front. In thin people, you should be able to feel the aorta pulsating. As long as it is less than 4.5cm in diameter, then this is normal.
Finally
Normally you wouldn’t have to do all these things, but in an OSCE, you have to say you would do them!
- Check the external genitalia. E.g. there is testicular atrophy in liver disease.
- Perform a rectal exam – sphincter tone, polyps, appendicitis (sensitive on right hand side)
- Check for ankle oedema – liver failure
- Do a urine dipstick test
- Check the hernial orifices
Finally, cover up the patient, and thank them!!
Palpating for AAA
You do this in the midline, in the centre of the abdomen. If you can feel a pulsatile mass here then you need to examine it further.
- Put your hands on either side of the mass. If it is expansile then it will push your hands upwards and outwards. This implies the structure is vascular – i.e. it is an AAA
- If it is pulsatile then it will just push your hands upwards but not outwards. This implies that the mass is overlying a vascular structure, but is not vascular itself; i.e. it could be the liver overlying the aorta.
Signs you may find on abdominal exam
Grey-Turner’s sign
A discolouration in the flanks, as a result of blood leaking into the subcutaneous tissues. Can be caused by haemorrhagic pancreatitis, ruptured aortic aneurysm, ruptured ectopic pregnancy.
Cullen’s sign
Similar to Grey-Turner’s sign; however, it is found around the umbilicus. The causes are the same as for Grey-Turner’s.
Murphy’s sign
Pain elicited when palpating in the region of the gallbladder. Worse on inspiration. Usually caused by inflammation of the gallbladder.
Rebound tenderness – this can be used to test for peritonitis. Press hard on the abdomen, then quickly release. If the pain is worse on releasing the pressure, then rebound tenderness is present.
Rovsing’s sign – test for peritonitis – when pressing on the left iliac fossa, pain may be felt on the right iliac fossa. The opposite may also occur (Reverse Rovsing’s).
Psoas sign – test for appendicitis – with the patient lying down, place your hand just above the patient’s right knee, and ask them to flex the right hip joint. If this causes severe pain, then this is a positive psoas sign, and appendicitis may be present.
Obturator sign – test for appendicitis – with the patient lying down, and their right knee flexed, raise and internally rotate the leg. If this causes pain, this is a positive obturator sign, and may be indicative of appendicitis.