Abdominal Examination

By Ali Mansour

#Abdomen

Wash hands, Introduce self,

General survey:
Body built
Surrounding : vomit bowels etc

Hands :
Tremor :
Flapping tremor (hepatic encephalopathy)
Fine : Alcoholic , Tacrolimus toxicity
Nails:
clubbing (cirrhosis, IBD, coeliacs),
leukonychia (hypoalbuminemia in liver cirrhosis), ‫خطوط بيضا عاالظفر‬
koilonychia (iron deficiency anaemia) ‫زي التجويف او الممر باالظفر‬
Palms:
palmar erythema (hyperdynamic circulation due to ↑oestrogen levels in liver
disease/ pregnancy),
Dupuytren’scontracture (familial, liver disease),
fingertip capillary glucose monitoring marks (diabetes)

Arm :
AV fistulae
radiocephalic [seen at the wrist],
brachiocephalic [seen around the antecubital fossa] or
brachiobasilic [palpable medially from around the antecubital fossa (ACF) to
towards the axilla]
Comment on :
 Functioning or not (presence or absence of thrill)
Recent or old use (scab or scar)
Complicated or not
Other methods of RRT
Underlying cause of renal failure

If there is no palpable thrill but a bruit is audible, this could signify a synthetic graft.

Eyes:
sclera for jaundice (liver disease),
conjunctival pallor (anaemia e.g. bleeding, malabsorption),
periorbital xanthelasma (hyperlipidaemia in cholestasis)

Mouth:
Gingival hyperplasia
Telangiectasia
Pigmentation
glossitisstomatitis (iron B12 deficiency anaemia),
aphthous ulcers (IBD),

Parotid gland

Neck veins

Chest inspection:
spider naevi (>5 significant),
gynaecomastia, loss of axillary hair (all due to ↑oestrogen levels in liver disease/
pregnancy)

Lower limb
edema (ask about pain while pressing and looking at the patient) then start local
inspection from the foot of the bed (hypoalbuminaemia)

Abdomen :
 Inspection :
Distention : (Fluid, Flatus, Fat, Foetus, Faeces)
Swelling ( any swelling )
Scars ( revise it )
striae (pregnancy,Cushing’s)
Dilated veins (if present look for vein below umbilicus and do milking and check
direction of filling)
Ask the patient to Cough & Take a deep breath

Palpation:
1. Superficial
Ask the patient to flatten the bed
Kneel
Ask about pain in any area and make that your last area to examine
Palpate while looking to patient face roll fingers of one hand over the 9 regions
2. Deep
Start in the right iliac fossa with side of the index going up
Ask the patient to take deep breath and wait to feel the border of the organ
“hitting” your hand
If not felt, go again from right iliac fossa with the tip of your fingers going up a few
centimeters after each breath
After feeling the right border of the liver confirm by light percussion from right iliac
fossa
Then heavy percussion from above to check for liver span
Then palpate the left border of the liver with the tips of the fingers starting just
above the umbilicus till the xiphisternum
Palpate the spleen starting from the right iliac fossa
If not found then palpate from the left iliac fossa
If not found turn the patient on his right lateral position, support with your left and
palpate with your right hand until you reach costal margin
If not found then percuss the last three spaces expecting to find dullness, not
splenectomized (evident scar as well)
If found from the beginning then percuss in the plane the spleen was found
confirming
Try to find the medial border of spleen and notch (in some patient left lobe of liver
 could be confused with splenomegaly)
Bimanual examination of the kidney on both sides
3. Assess for shifting dullness
Start above the umbilicus so to not confused with full bladder and go down under
the umbilicus (light percussion)
Keep percussing until the note changes
Turn the patient to his other side without removing your hand
Wait for a few seconds then percuss the abdomen again
If resonant note then you have demonstrated shifting dullness

Auscultation:
If organomegaly then auscultate the organ for rubs
If hepatic bruit =perihepatitis in Gonorrhea)
If splenic bruit =splenic infarction
Venous hum (indicates portal htn)
Renal bruit (2.5 cm to the side and above the umbilicus)

Back:
Inspect for spider naevi “upper back”
Sacral edema ask for pain and press while looking at his face
If renal case auscultate the basal long zones to know if he is well dialyzed or not
 Lymph nodes (superficial cervical and supraclavicular)

Finish examination by covering the patient and thank him…

“To complete my exam, I would examine the external herneal orifices, the external
genitalia and do a digital rectal examination”

How to present your case

This gentleman comfortable/ breathless at bed
Average/ over/ underbuilt
Has/ No/ peripheral stigmata of CLD “palmar erythema, spider nevi, gynecomastia,
Duputryn contracture, inverted hair distribution “
He has NO clubbing , pallor, jaundice, lower limb edema
The abdomen is flat/ scaphoid / distended (mention positive inspection signs as scars,
Bulge…)
Right lobe of liver is palpable (Not) ..cm below RCM with sp… cm, left lobe palpable..
Cm below xiphisternum
Sharp/ rounded border, smooth / irregular surface, firm soft hard consistency, tender
or not, pulsatile or not, Brit heard over it or not
Spleen palpable (Not) … cm below left coastal margin ..rounded / sharp border ,
smooth surface, firm/ soft/ hard consistency non ballotable, can’t get above it, dull on
percussion with dullness continuous with splenic bed dullness, notch felt or not
Kidneys (not) bimanually palpable
Shifting dullness is positive or negative
Other masses if any describe ..site size surface share borders percussion note intra or
extra peritoneal and bruit heard or not

So, my diagnosis this gentleman has

Hepatomegaly / splenomegaly /Hepatosplenomegally / shrunken

liver +/- ascites

(clinical Dx )

For DD

(etiology)
Complicated or not

(Varices, hypersplenism , SBP, HRS)

Functional status (in liver cell failure or not = jaundice,

coagulopathy, encephalopathy)
How to investigate abdominal case
Basic
CBC , ESR, CRP, area and electrolytes
LFT
Confirm Dx by ultrasound +
Evidence of hemolysis if you put CHA on top of your list “bilirubin,
haptoglobin, LDH, reticulocytes”
Ascitic tap if there is Ascites
CT chest and abdomen if evidence of lymphadenopathy*
Investigations of the cause
In CLD : bilharzial Ag in stool, hepatitis serology, HBA1c, lipid profile*
In CHA : HB electropharesis, osmotic fragility, sickling test and blood film*
If lymph nodes take biopsy *
In myeloproliferative : BM biopsy*
Investigations for complications*
CLD alpha fetoprote… upper git endoscopy*
CHA iron study and hepatitis serology as well as hormonal as say… *

Q..what are indications of diagnostic ascitic tap*

Q..what are indications of upper git endoscopy *

Treatment of abdomen case

Non pharmacological
Education and counseling *
Stop alcohol*
Vaccination against HAV, HBV*
If splenectomy vaccination against: *
H.influenza /10 y
Pneumococcal /5y
Meningococcal /3y
Social, psychological, financial, nutritional support *
Pharmacological
o* Treatment of the cause
o* *Treatment of complications *