MODEL CASE PROFORMA – ABDOMEN

Examination of young/middle aged/ elderly male/female patient

GENERAL EXAMINATION
Patient is conscious/not
Oriented/not
Comfortable/not
Co-operative/not
Built
Nourishment
Febrile/afebrile
Pallor
Icterus
Cyanosis – central/peripheral
Clubbing – bilateral/unilateral, pandigital/limited
Pedal edema – bilateral/unilateral, painless/painful, pitting (soft/hard)/non-pitting, extension, regional
lymphadenopathy
Significant lymphadenopathy

TROISIER’S SIGN

EXTERNAL MARKERS OF LIVER CELL FAILURE/CHRONIC LIVER DISEASE -

HEAD AND NECK– alopecia, bitot spots, xanthelasma, subconjunctival haemorrhage, pallor, icterus,
Kayser-Fleischer ring, medial supraciliary madarosis, sunken eyes and cheeks, loss of facial hair, parotid
enlargement, bleeding gums, fetor hepaticus
TRUNK – spider nevi, gynaecomastia(males), atrophy of the breast(females), loss of pectoral/axillary hair,
dilated veins, wasting, abdominal distension, caput medusae, loss of pubic hair, testicular atrophy, scratch
marks, purpura
UPPER LIMBS – Dupuytrens contracture, bounding pulse, clubbing, flapping tremor, leukonychia, palmar
erythema, pruritic marks
LOWER LIMBS – Pedal Edema

EXTERNAL MARKERS OF HUMAN IMMUNODEFICIENCY VIRUS INFECTION -oral hairy

leukoplakia, oral candidiasis, molluscum contagiosum, recurrent, multidermatomal herpetic infections,
generalised lymphadenopathy
BONY TENDERNESS, GUM HYPERTROPHY, LEUKEMIA CUTIS

FUNDUS
VITAL SIGNS

PULSE: rate, rhythm, volume, character, felt in all peripheral pulses/not, radioradial/radiofemoral delay,
apex pulse deficit, condition of vessel wall

BLOOD PRESSURE: _____mm of Hg measured in the left Upper limb with the patient in sitting position

RESPIRATORY RATE: ____/min, regular/not, type-thoracoabdominal/abdominothoraxic

TEMPERATURE: ______ F measured in the Axilla

SYSTEMIC EXAMINATION

EXAMINATION OF THE ORAL CAVITY-

Oral thrush, tonsils, pharyngeal deposits, post nasal drip, fetor hepaticus, oral hygiene, dental caries, gum
hypertrophy

ABDOMEN:
INSPECTION:
1. Shape – scaphoid, flat, distended-uniform/localised
2. Flanks – free/full
3. Umbilicus – Position, Shape-slit/inverted/everted, nodules
4. Skin – stretched, shiny, scars, sinuses, striae, nodules, scratch marks, puncture marks
5. Divarication of recti
6. Dilated veins – front/back
7. Movements of the abdominal wall, visible gastric peristalsis, visible intestinal peristalsis
8. Hernial Orifices, cough impulse
9. External genitalia
10. Renal angle

PALPATION:

Superficial Palpation – Tenderness, Warmth, Direction of Blood Flow in Veins

Deep Palpation
1. Liver
A tender/non-tender,
Pulsatile/non-pulatile, swelling is palpated in the
Right hypochondrium about
_____cms below the Right costal margin in the Mid clavicular line and ____ cms in the Mid axillary
line and ____ cms in the midline from the Xiphisternum
Which moves with respiration and is
Soft/firm/hard in consistency with a
Smooth/nodular(umbilicated/non-umbilicated)/irregular surface
And a sharp/rounded edge
And I am not able to make out the upper border on Palpation
Probably an Enlarged liver

2. Spleen
A tender/non-tender swelling is palpated in the
Left Hypochondrium enlarging towards the Right Iliac Fossa
____cms below the Left Costal Margin in the Mid clavicular line
Which moves with respiration and is
Soft/firm/hard in consistency with a
Smooth/nodular/irregular surface and a notch along the medial border
And a sharp/rounded edge
Which is not bimanually palpable or ballotable
Neither could I feel the upper border nor could I insinuate my fingers below the Left Costal Margin
Probably an Enlarged spleen

3. Kidney
A tender/non-tender swelling is palpated in the
Right/Left Lumbar region about _____ cms long
Which moves with respiration
Which is soft/firm/hard in consistency
With a smooth/nodular/irregular surface and no notch with a
Sharp/rounded edge
Which is bimanually palpable and ballotable
And I am able to feel the upper border (as well as insinuate my fingers below the left costal margin)
 Probably an Enlarged Right/Left Kidney

Any other Palpable swelling

Palpation by Dipping in the case of Tense Ascites
Measurements - Abdominal Girth, Spino-Umbilical Distance, Distance between the
Xiphisternum-Umbilicus and Umbilicus-Pubic Symphysis
Hernial Orifices
Murphy’s Punch/Renal angle tenderness
External Genitalia

PERCUSSION:
1. Fluid Thrill/Shifting dullness/Puddle’s sign
2. Percussion of Liver for Liver Span
3. Percussion of Spleen for Splenomegaly – Nixons method, Castell’s method, Barkun’s method of
percussion of the Traube’s space
4. Percussion of colonic band of resonance in the presence of Renomegaly
5. Tidal Percussion

AUSCULTATION:
1. Bowel sounds – 10 to 15/min for small bowel, 3 to 5/min for large bowel
2. Bruit – Aortic, Hepatic, Renal Bruit
3. Venous Hum
4. Rub

PER RECTAL EXAMINATION:

PER VAGINAL EXAMINATION IN FEMALES:

EXAMINATION OF OTHER SYSTEMS

CARDIOVASCULAR SYSTEM:
S1, S2, RV S3, TR murmur.

EXAMINATION OF RESPIRATORY SYSTEM:

Added sounds

EXAMINATION OF NERVOUS SYSTEM:

Flapping tremor, Peripheral Neuropathy

DIAGNOSIS

CHRONIC DECOMPENSATED LIVER DISEASE, CIRRHOSIS WITH PORTAL

HYPERTENSION WITH OR WITHOUT EVIDENCE OF HEPATIC ENCEPHALOPATHY

or

ASCITES UNDER EVALUATION, I WOULD LIKE TO OFFER A DIFFERENTIAL DIAGNOSIS.

or

HEPATO/SPLENO/HEPATOSPLENOMEGALY WITH OR WITHOUT LYMPHADENOPATHY

UNDER EVALUATION, I WOULD LIKE TO OFFER A DIFFERENTIAL DIAGNOSIS.