The Abdominal Examination

Introduction

• Introduce yourself to the patient
• Wash your hands
• Briefly explain to the patient what the examination involves
• Position the patient flat
• Assess the patient from the end of the bed
  • Look for any obvious discomfort, jaundice, or distention
  • Comment on any items of clinical note around the bed (intravenous fluids, stool sample pots etc.)

Always start with the hands and proceed as below unless instructed otherwise; be prepared to be instructed to move on quickly to certain sections by any examiner.

The Hand and Arm

• Assess for signs of liver disease
  • Leuconychia, spider naevi, palmar erythema, or Dupuytren’s contracture
  • Checking for hepatic flap is important if significant liver disease is suspected
• Look for other peripheral stigmata of GI dysfunction
  • Koilonychia (seen in iron deficiency anaemia)
  • Pale palmar creases (anaemia)
• Pulse

Neck and Face

• Assess the sclera for jaundice
• Check the lips and mouth
  • Around the mouth for angular chelitis (seen in iron deficiency anaemia)
  • Oral ulcers (any underlying Crohns Disease)
  • Tongue disease
• Palpate lymph nodes
  • Submental, Submandibular, Pre-auricular, Anterior Cervical, Supraclavicular, Posterior Cervical, Post-Auricular, and Occipital
  • Troissier’s Sign = Enlarged Left Supraclavicular Node (Vircow’s Node), often considered a sign of metastatic abdominal malignancy

Abdomen

• Expose the patients abdomen
• Look for surgical scars, skin changes, stomas, distention, visible peristalsis,
  • Periumbicial ecchymosis = Cullen’s sign; Flank ecchymosis = Grey’s Turner sign

• Ask patient any pain or tenderness in the abdomen
  • If pain present in certain area, palpate this area last
    • Asking the patient to “blow their tummy up like a balloon” and then “suck their tummy in” is good way of detecting any peritonism with minimal discomfort to the patient

• Kneel down next to them and examine them from bedside height
• Palpate 9 areas lightly, looking at the patient’s face for any signs of discomfort
• Palpate 9 areas deeply, continuing to look at the patients face for any signs of discomfort
• Assess for percussion tenderness
• Listen for bowel sounds
  • Typically done in the right iliac fossa

• Palpate for the liver
  • Start in the RLQ
  • Ask patient to breath out and place hand on abdomen
  • As patient breathes in, feel for a liver edge
  • Move hand gradually up the abdomen to RUQ with every breath expired
• Percuss for the liver, moving up from RLQ to RUQ
  • Any enlarged liver percussed, subsequently percuss down from thorax to determine a rough liver size
• Auscultate over the liver for liver bruits

• Palpate for the spleen
  • Start in the RLQ
  • Ask patient to breath out and place hand on abdomen
  • As patient breathes in, feel for a spleen edge
  • Move hand gradually up the abdomen to LUQ with every breath expired
• Percuss for the spleen, moving up from RLQ to LUQ

• Ballot the kidneys
  • Place one hand under patients flank, pressing fingertips of other hand into the same flank from above
  • Feel any enlarged kidney between your fingers
  • Repeat for the opposite side

• Press fingers gently into the patients abdomen, either side of the midline above the umbilicus, to feel for the abdominal aorta
  • Assess for any pulsatile and expansile mass (indicative of an aneurysm)
• Palpate for the bladder, pressing gently into the abdomen from the umbilicus and moving towards the pubic symphysis
  • If an enlarged bladder found, percuss down from the umbilicus to assess its size
• If the abdomen appears swollen, or there is any suspicion of ascites, the examiner should test for ‘shifting dullness’
  • Percuss the abdomen, starting at the midline and moving towards you, making note of any area of dullness
  • Ask the patient to roll onto their side away from you, waiting for 30secs, then re-percuss the same area
  • Any change to percussion note (i.e. it is no longer a dull tone), indicates peritoneal fluid is likely to be present and is a positive shifting dullness test

Completing the Examination

Remember, if you have forgotten something important, you can go back and complete this.

To finish the examination, stand back from the patient and state to the examiner that to complete your examination, you would like to perform a:

• Hernial orifice examination
• External genitalia examination
• Digital Rectal Examination (DRE)