The examination of a patients abdomen is important for any OSCE stations involving a gastrointestinal complaint.
- Wash Hands
- Introduce self I've been asked to examine your abdomen today to find out how well things are working. Would that be okay?
- Confirm Name, Age, Date of birth
Always work out the patient's age, because this is one of the most important factors in making a diagnosis.
- Do you have any questions?
- Are you in any pain?
- Comment: I would begin with a full patient history, and then proceed with the physical examination.
- Would you mind removing your shirt, and laying back for me?
From the end of the bed
- Upon general inspection, does the patient appear generally well and comfortable at rest?
To be more precise, look at the components of a patient's appearance. A well patient has the following features:
- Sitting up in bed.
- Eye contact.
An unwell patient has the following:
- Lies with head on the pillow.
- Upper eyelids lowered.
- Mouth turned downwards.
- No eye contact.
- Pale face.
NB Tears are not of diagnostic value.
- Inspect for jaundice, pallor or flushing
- Are there scars, wasting or abdominal masses?
- Can you hold out your hands for me please?
- Check nails for:
- koilonychia (spooning)
- leukonykia (white nails)
- Check palms for:
- Dupytrens contracture
- Palmary erythema (hyperdynamic circulation)
- Could you please turn your hands over, close your eyes and cock your wrists back?
- Asterixis (flapping tremor in hepatic encephalopathy, hypercapnia)
- Could you look up? I'm going to pull down on your eyelids briefly. Please let me know if its uncomfortable.
- Are the conjunctivae of normal color, with no sign of anaemia or jaundice?
- Could you please open your mouth and stick out your tongue? And touch it to the roof?
- Is the tongue a normal size and colour?
- Any angular stomatits or mouth ulcers?
- I'm just goint to press on your neck a bit now, let me know if you feel any discomfort
- Feel along neckline for lymphadonopathy
- Check Virchow's node - enlarged, hard left supraclavicular lymph node (abdominal malignancy), in left supraclavicular fossa
- Look for hair loss, spider naevi, gynaecomastia
- Look for distention or swelling of the abdomen
- Press on ankles for oedema
- Maintain eye contact throughout
- Can you please lower your trousers and boxers just to the level of your hips please?
- I'm going to press on your stomach, lightly at first and then with increasing pressure. It's important that your let me know if you feel any pain or tenderness.
- Gently palpate over the 9 regions. Begin with left iliac. Superficial, then Deep palpation
- Observe the patient's face for signs of sensitivity or guarding.
Screwing up eyes. Indrawing of breath. Grunting. A glance towards the examiner.
Organ specific palpation
- Liver: under right costal margin, using edge of index finger, upon inspiration. Move up from right iliac.
- Spleen: Enlarges from left hypochondrium to right ileac, again during inspiration.
- Kidney: Ballotting action. Transpyloric line. Push firmly with left hand on top of stomach, flex fingers of right hand over back at kidney.
- Try to tip edge of kidney, same hand on top for either side.
- Aorta: Sits in midline down as far as the umbilicus. Enlarges laterally. Place hands laterally, moving towards midline. Feeling for pulsatile, expansile mass, indicating Aortic Abdominal Aneurysm.
- Palpate bladder: from epigastric region down.
- I'm now going to tap your abdomen. Just relax and breathe normally.
- Begin percussing in midline
- Percuss towards yourself laterally in epigastrum.
- Keep one finger in this position, have patient roll towards you
- Listen for shifting dullness - dull would become resonant upon rollover.
- No evidence of fluid in peritoneal cavity.
- Percuss margins of liver.
- Percuss margins of spleen.
- Now I'm going to listen to your stomach, just relax and breath normally.
- Listen for bowel sounds around umbilicus. If not heard, move to 3 other sites. Listen until first bowel sound heard, or for 2 minutes of silence.
- Renal bruits: 3 cm lateral, 3 cm above umbilicus.
- Aortic bruits: audible in midline, pressing stethoscope firmly into abdomen.
We have John, a 35 year old patient, he appears generally well, no signs of anaemia or jaundice
- No distention or abdominal masses.
- No pain or gaurding elicited.
- No signs of organomegaly.
To complete the abdominal examination, I would also attain:
- Hernial Orifices
- Digital rectal exam
- A urine dipstick test
- Abdominal x-ray