James Wight

Examination of the Abdomen • Wash your hands. • Introduce yourself to the patient, and ask permission to examine them. • Expose the patient, and lie them flat.

Inspection
Look around the bed Look at the patient Oxygen mask/nasal prongs, drips, cigarettes, special foods, diabetic diet Comfortable at rest, wound drain, catheter, NG tube, jaundice, scratch marks, spider naevi, gynaecomastia, striae, bruising, anaemia, pigmentation, cachexia, dehydration, abdominal distension, abdominal masses, scars (rooftop, Lshape, Mercedes-Benz, subcostal, midline, Lanz, Hockeystick, inguinal), Sister Mary Joseph Nodule, Grey-Turner’s/Cullen’s sign, stomas, acanthosis nigricans, tattoos Clubbing (cirrhosis, lymphoma, IBD, Coeliac disease), leukonychia (hypoalbuminaemia), koilonychias (iron deficiency), palmar erythema, Dupuytren’s contracture, anaemia, tendon xanthomata, liver flap Jaundice, anaemia, Kayser-Fleischer rings, xanthelasma Ulcers, pigmentation, telangiectasia, fetor hepaticus, Candida, angular stomatitis, gums, smooth tongue, leukoplakia, atrophic glossitis, macroglossia

Look at the hands

Look at the eyes Look in the mouth

Palpation
Feel the neck Supraclavicular Virchow’s node lymph nodes, particularly

→ Inspect the abdomen again, including asking the patient to raise their head or legs Light palpation Deep palpation Feel for the liver Feel for the spleen Ballot the kidneys Feel for a AAA In all 9 segments of the abdomen (ask if there’s any pain first, and watch the patient’s face) In all 9 segments of the abdomen, watching the face Starting in the right iliac fossa, asking the patient to breathe in each time you palpate Starting in the right iliac fossa, asking the patient to breathe in each time you palpate Put one hand posteriorly in the flank, and flick the kidney onto a hand positioned anteriorly Above the umbilicus (the aorta divides below this

point)

Percussion
Percuss the liver Percuss the spleen Check for shifting dullness Starting in the right iliac fossa until dull, then percuss out the upper border Starting in the right iliac fossa With finger in the midline, move down the flank until percussion note becomes dull. Ask the patient to roll away from you – ascites is suggested if the note becomes resonant. Ask patient to position their hand in the midline, and flick the abdomen to test for transmitted thrill

Check for fluid thrill

Auscultation
Listen for bowel sounds Listen for bruits Up to three minutes. Can be normal, absent or tinkling (in obstruction) Aortic, renal, iliac, femoral

Final manoeuvres
Examine the ankles for oedema Examine the hernial orifices (or say you would, as below)

I would complete my examination by….
“I would like to examine the hernial orifices, examine the genitalia, perform a digital rectal examination, dipstick the urine and look at the observation chart (temperature, BP, sats)”

Glossary
Spider naevi – telangiectasia with a central arteriole from which radiate numerous small vessels. Found in the distribution of the SVC, and due to hyperoestrogenic state in liver failure. Leukonychia – whitening of the nails due to hypoalbuminaemia Koilonychia – “spoon-shaped” nails due to iron deficiency Dupuytren’s contracture – thickening of the palmar fascia, seen in relation to excess alcohol intake, DM, epilepsy and hereditary. Sister Mary-Joseph nodule – umbilical nodule due to metastatic cancer Grey-Turner’s/Cullen’s signs – flank/periumbilical bruising seen in pancreatitis Kayser-Fleischer rings – green-brown rings seen in the iris in Wilson’s disease Fetor hepaticus – a musty-sweet smell found in liver failure Angular stomatitis – cracks seen at the corner of the mouth, seen in iron deficiency Leukoplakia – white tongue: smoke, spirits, sepsis, syphilis, sore teeth Atrophic glossitis – a smooth tongue, seen in vit B12 and folate deficiency (amongst other things) Acanthosis nigricans – velvety pigmented plaques in the axilla and back of the neck, seen in GI malignancy (and several other conditions)