Abdominal Examination

Abdominal examination and questions for medical student exams, finals, OSCEs and MRCP PACES

 

Intro (WIIPPPPE)

• Wash your hands
• Introduce yourself
• Identity of patient –confirm
• Permission (consent and explain examination)
• Pain?
• Position
  • Initially at 45⁰ but must be lying flat to palpate abdomen.  A pillow under the head or raising knees slightly might help this.
• Privacy
• Expose fully (nipples to knees).  Important to see hernial orifices.

 

General Inspection

• Surroundings
  • Monitoring:
    • Catheter +/- urometer (inspect for quantity and colour)
    • Pulse oximeter
    • Surgical drains
  • Treatments
    • Oxygen specs/mask (method of delivery, rate, SATs)
    • NG tube, IV fluids/ antibiotics
    • TPN lines
    • Central lines
    • PCA pump
    • Ensure drinks
    • Bottles of Creon
  • Paraphernalia:
    • Food and drink
    • Nil by mouth (NBM) signs
    • Vomit bowels
• Patient
  • Well/ unwell
  • Alert/ drowsy
  • Orientated/ confused
  • Comfortable at rest/ writhing around in pain/ peritonitic
  • Cachexia (look for temporalis wasting or skin fold thickness)/ obesity
  • Tachypnoea
  • Skin colour
    • Jaundice (seen when bilirubin >40)
    • Anaemic
    • Bronze diabetes (hereditary haemochromatosis)
  • Obvious scars

 

Hands

• Inspect
  • Clubbing ( 4 C’s)
    • Cirrhosis, Crohn’s disease, Coeliac disease, ulcerative Colitis
    • Koilonychia (iron deficiency)
  • Leuconychia
    • Hypoalbuminaemia secondary to liver disease, nephrotic syndrome, malnutrition or protein-losing enteropathy
  • Palmar erythema
    • Chronic liver disease, thyrotoxicosis, pregnancy
  • Dupuytren’s contracture (idiopathic, alcoholic liver disease)
• Palpate
  • Capillary refill
  • Pulse
  • Check for asterixis
    • Sign of hepatic encephalopathy, or any other type of encephalopathy.  Usually bilateral unless due to a neurological lesion.

 

Arms

• Bruises – coagulopathy (liver disease)
• Excoriations – pruritus (↑bilirubin / uraemia/ anaemia)
• Tattoos
• Needle track marks
• Cannulae
• PIC lines
• AV fistula scars
  • In use?  Look for needle marks.
  • Patent? Feel for a thrill, auscultate for bruit.
  • Kidney transplant?  Pay attention when palpating abdomen!

 

Eyes

• Scleral icterus
• Conjunctival pallor (anaemia)
• Kayser-Fleischer rings
  • Sign of Wilson’s disease – these can only be seen with a slit lamp.

 

Mouth

• Angular stomatitis (B12 or iron deficiency)
• Macroglossia (B12 or folate deficiency)
• Dry mucous membranes
• Oral candidiasis (immunosuppression)
• Gingival hypertrophy (immunosuppression)
• Aphthous mouth ulcers (IBD , coeliac)
• Patient’s breath
  • Alcohol
  • Pear drops in DKA
  • Fetor hepaticus in liver failure

 

Neck

• JVP
  • Raised in RHF leading to liver failure
• Cervical lymphadenopathy
  • The GI tract begins in the mouth!
• Virchow’s node
  • Left supraclavicular fossa – if palpable this is Troisier’s sign.

 

Chest

• Central lines
• Scars
• Gynaecomastia (chronic liver disease)
• Spider naevi in SVC distribution
  • >5 is pathological and suggests chronic liver disease

 

Abdomen

• Position
  • Ensure the patient is lying flat at this point
• Screening
  • Ask patient to take a deep breath in (peritonism)
  • Ask the patient to lift their head off the bed looking for divarication of rectus abdominis
  • Ask the patient to turn their head and cough whilst palpating hernial orifices
• Inspection
  • Distension (6Fs):
    • Fat
    • Foetus
    • Fluid
    • Flatus
    • Faeces
    • Fulminant tumour
  • Scars
    • Take some time over this, particularly when looking for small paracentesis or biopsy scars.
  • Striae
    • Pregnancy, rapid growth during puberty, medications e.g. steroids
  • Stoma + stoma bag
    • Position
    • Flush/ spouted
    • Contents of bag
  • Caput medusae
    • = Umbilical recanalisation due to portal HTN.  Flow is away from umbilicus.
  • Grey-Turner’s sign
    • = Bruising of the flanks.  Signs of retroperitoneal haemorrhage e.g. due to severe pancreatitis.
  • Cullen’s sign
    • = Periumbilical bruising.  Also a sign of retroperitoneal haemorrhage.
• Palpation
  • Same level as patient
    • 9 areas to palpate
    • Least painful → most painful area
    • Watching the patient’s face
    • Lightly then more deeply
      • Lightly – guarding, rigidity?
      • Deeply for organomegaly
        • Liver – start in RIF, towards RUQ
        • Spleen – start in RIF, towards LUQ
      • Ballot kidneys (upper hands still, bottom hand moves)
    • AAA – gently (above umbilicus!)
• Percussion
  • Liver (from RIF to RUQ and from clavicle down)
  • Spleen
  • Bladder
  • Shifting dullness if distended and suspect ascites (offer if not distended)
• Auscultate
  • Bowel sounds:
    • Tinkling = mechanical bowel obstruction
    • Absent = ileus or peritonism
  • Bruits: AAA, renal

 

Legs

• Peripheral oedema (right heart failure, pregnancy, hypoalbuminaemia secondary to liver disease or nephrotic syndrome)
• Bruising
• Erythema nodosum (IBD)

 

Closure

• Thank patient
• Patient comfortable?
• Help getting dressed?
• Wash hands
• Turn to examiner, hands behind back, holding stethoscope (try not to fidget!) before saying: “To complete my examination, I would like to…”
  • Fully examine
    • Hernial orifices
    • Inguinal lymph nodes
    • External genitalia
  • Perform a DRE (important, don’t forget this one!)
  • Bedside Invx:
    • Look at obs chart and repeat set of obs
    • Urine dip
    • Pregnancy test
  • If ascites is found, do a full cardiac exam –need to examine volume status.

 

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Common Abdominal Examination exam questions for medical students, finals, OSCEs and MRCP PACES

 

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Perfect revision for medical students, finals, OSCEs and MRCP PACES