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Examination of the Abdomen

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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

 

Watch the Video on Examination of the Abdomen

 

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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Categorised in: Gantrointestinal, Medicine, Surgery

1 Response »

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