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