Clinical- Abdomen examination

Abdominal Examination
Introduce yourself
Exposure: submammary area to bikini line (ideally to midthigh)
General Examination “ I will start by general examination”
 1-         Hands (Clubbing1 (tangentially)– Koilonychia=spooning nail2 (tangentially)– Pallor – Palmar erythema3 – Dupuytren contracture4 – Flapping tremors)
2-         Eyes – retract both lower eyelids together (Jaundice in sclera– Pallor in conjunctiva)
3-         Mouth (Fetor Hepaticus – Cyanosis – Pigmentation of Peutz Jhugar synd.)
4-         Chest & Neck (Supra-clavicular L.N.s (abd. malignancy) – Spider naevi5 – Gyaencomastia6)
5-         LL (edema)

Local Examination
1-         Inspection   3 POSITIONS
Foot of bed  ·    Symmetry
                     ·    Contour (scaphoid/ normal/ distended flanks)
                     ·     mass
Rt Side (on knees =Tangential)    ·  Movement with resp.  → moves freely
                                                         ·  Epigastric pulsation اكتم نفسك → no
                                                         ·  Visible peristalsis → no
Rt Side (standing)   ·  Subcostal angle
·  Skin (Scars, Dilated veins, Redness)
·  Divarication of recti (هم برأسك)
·  Umbilicus: site (N / shifted downwards), shape (N / Everted), H, scars.     
·  Hair distribution: masculine (triangle apex up) or feminine (apex down)
·  Hernial orifices (expose & cough): intact 

2-         Palpation  On knees & hand at level of elbow
A-     Superficial : rest hand on abdomen
& feel by phalanx 4 fingers the 9 quadrants
(for tenderness & superficial masses)                7

B-    Deep: rest hand on abdomen
& press by phalanx 4 fingers
9 quadrants & Organs(for deep masses)

· 9 Quadrants: Mass 3S TT ESCRSS: mass is felt …cm
below C.M., …X…cm, edge (well defined), surface (smooth/irreg),
consistency (soft/firm/hard) – attachment (mobile in 2 directions)
not attached to skin & هم برأسك(intra/extra-abdominal)-
reducible (/not) – pulsatile (/not) – expansile imp. on cough (/not)

· Rt lobe liver: start at RIF (Rt iliac fossa) & upward +  خد نفس& feel during inspiration
      → ESC (not felt / felt …cm below C.M.), edge (well defined), surface (smooth/irreg), consistency (soft/firm/hard)     CONFIRM BY PERCUSSION & TIDAL PERCUSSION
· Lt lobe liver: start in midline above umbilicus & upward +  خد نفس& feel during inspiration
      → ESC (not felt / felt …cm below C.M.), edge (well defined), surface (smooth/irreg), consistency (soft/firm/hard)     CONFIRM BY PERCUSSION

· Spleen: start at RIF to below umbilicus then toward Lt hypochondrium
     If not felt → pt. on lat. position, Lt hand support lower ribs laterally & palpate by Rt hand
     If not felt → percussion Traub’s area (Lt thumb on lower rib & ant. to MAL). if dull → percuss below till RIF   CONFIRM BY PERCUSSION & Differentiate from kidney
→ ESC (not felt / felt …cm below C.M.), edge (well defined), surface (smooth/irreg), consistency (soft/hard)
· Kidneys (Bimanual examination): Lt hand on renal angle & Rt hand on lumbar (laterally)
→ ESC …..
3-         Percussion
a-   Liver (Upper border → Tidal percussion) [OR with palpation] خد نفس و اكتمه
b-   Spleen  [OR with palpation]
c-   Ascites (Shifting dullness) just above umbilicus downwards then from midline laterally
              If not dull→ no ascites
                  If dull → lat. position, wait 30 secs & percuss again,
→ If change note → +ve shifting dullness = ascites,
→ If still dull        -ve shifting dullness = fixed dullness 
d-   Bladder       
4-         Auscultation
·   LIF → Bowel sounds  
·    over Liver → Bruit (HCC or alcoholic hepatitis)  or Venous hum (P.H.)
·    over Epigastrium → Bruit (AAA)

I would like to finish my examination by:
1-         Auscultation of abdomen
2-         Examination of genitalia & PR (DRE) (+PV in females) & back

1 Clubbing = Obliteration of angle between nail & nail bed – chr. disease
2 Koilonychia = Spooning of nails in iron deficiency anaemia
3 Palmar erythems (sign of liver decompensation) in hypothenar, thenar, head of metacarpals & tip fingers
4 Dupuytren contracture = nodular or cord like fibrosis of palmar fascia of ring +/- little finger in (alcohol, CLD, DM, drug, manual workers) – D.D. ulnar claw hand
5 Spider naevi is sign CLD- central arteriole with radiating branches – in H& N (area drainage SVC)- > 5 is pathological
6 Gynecomastia is sign CLD- other causes: structural- drugs (cimitidine-spironolactone)- hormonal ttt – tumors secr hs
7 Midclavicular plane: Between mid clavicular point & mid point of inguinal ligament 
Transpyloric plane: (L1) midway between suprasternal notch & symphysis pubis
Intertubercular plane: (L4) between the highest points of iliac crest
Subcostal plane: (L3) lowermost limit of costal margin

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