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Abdominal Examination

From Mediwikis

The examination of a patients abdomen is important for any OSCE stations involving a gastrointestinal complaint.

Introduction

  1. Wash Hands
  2. Introduce self I've been asked to examine your abdomen today to find out how well things are working. Would that be okay?
  3. 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.

  1. Do you have any questions?
  2. Are you in any pain?
  3. Comment: I would begin with a full patient history, and then proceed with the physical examination.
  4. Would you mind removing your shirt, and laying back for me?

Inspection

From the end of the bed

  1. 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.
  • Smiles.

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.

  1. Inspect for jaundice, pallor or flushing
  2. Are there scars, wasting or abdominal masses?

Hands

  1. Can you hold out your hands for me please?
  2. Check nails for:
    Clubbing of fingers in Cystic Fibrosis
    1. clubbing
      Finger nail clubbing, courtesy of AllAccessMedicine.
      (There are 4 distinct features of clubbing; Increased fluctuance of the nail bed, loss of the angle of the nail bed, increased curvature of the nail and finally expansion of the terminal phalanx).
    2. koilonychia (spooning)
    3. leukonykia (white nails)
  3. Check palms for:
    1. Dupytrens contracture
    2. Palmary erythema (hyperdynamic circulation)
  4. Could you please turn your hands over, close your eyes and cock your wrists back?
    1. Asterixis (flapping tremor in hepatic encephalopathy, hypercapnia)

Eyes

  1. Could you look up? I'm going to pull down on your eyelids briefly. Please let me know if its uncomfortable.
  2. Are the conjunctivae of normal color, with no sign of anaemia or jaundice?

Mouth

  1. Could you please open your mouth and stick out your tongue? And touch it to the roof?
  2. Is the tongue a normal size and colour?
  3. Any angular stomatits or mouth ulcers?

Neck

  1. I'm just goint to press on your neck a bit now, let me know if you feel any discomfort
  2. Feel along neckline for lymphadonopathy
  3. Check Virchow's node - enlarged, hard left supraclavicular lymph node (abdominal malignancy), in left supraclavicular fossa

Chest

  1. Look for hair loss, spider naevi, gynaecomastia
  2. Look for distention or swelling of the abdomen

Legs

  1. Press on ankles for oedema

Palpation

  1. Maintain eye contact throughout
  2. Can you please lower your trousers and boxers just to the level of your hips please?
  3. 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.
Areas of the abdomen

Regional palpation

  1. Gently palpate over the 9 regions. Begin with left iliac. Superficial, then Deep palpation
  2. 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

Balloting the kidneys.
  • 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.

Percussion

  1. I'm now going to tap your abdomen. Just relax and breathe normally.
  2. Begin percussing in midline
  3. Percuss towards yourself laterally in epigastrum.
  4. Keep one finger in this position, have patient roll towards you
  5. Listen for shifting dullness - dull would become resonant upon rollover.
  6. No evidence of fluid in peritoneal cavity.
  7. Percuss margins of liver.
  8. Percuss margins of spleen.

Auscultation

  1. Now I'm going to listen to your stomach, just relax and breath normally.
  2. 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.
  3. Renal bruits: 3 cm lateral, 3 cm above umbilicus.
  4. Aortic bruits: audible in midline, pressing stethoscope firmly into abdomen.

Summary

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