Abdominal examination

Abdominal examinationCreated OnApril 15, 2020Last Updated OnApril 15, 2020byadmin You are here: Main Clinical Examination Abdominal examination < All Topics Table of Contents Abdominal examination INSPECTION The first part of any examination is inspection, Ideally patient should exposed from nipple line to mid-thigh but due to modesty of patient exposure, exposure at least from xiphisternum to inguinal ligament is mandatory. Before starting abdominal examination, we must do a thorough general examination General Inspection Patient supine with both the hands by the side of the body and palm facing upwards. Observe patient from the end of the bed Note if any respiratory distress or abnormal posture due to pain Medication around the bed or patient controlled analgesia Hands Koilonychias (consider iron-deficiency anaemia) Leukonychia (consider causes of hypoalbuminemia e.g. nephrotic syndrome, liver failure) Clubbing (abdominal causes include cirrhosis, Ulcerative colitis & Crohn’s disease) Palmar erythema  (due to chronic liver disease or increased levels of circulating oestrogens) Dupuytren’s contracture (often seen in patients with liver cirrhosis and diabetes) Ask patient to stretch out arms in front of them with wrist and fingers extended. Note if there is a liver flap present (seen in hepatic encephalopathy) Bluish discolouration (cyanosis) Radial pulse (rate, rhythm, and pulse volume) Face/ Neck Conjunctiva: for any pallor Sclera: any jaundice Kayser-Fleisher rings in the eye (Wilsons disease) Buccal mucosa for any ulceration (Crohn’s disease), angular stomatitis (vitamin deficiency) Tongue: anaemia, cyanosis, glossitis (anaemia, infection), leukoplakia (tobacco use), yellowish discolouration at floor of mouth (jaundice) Look for visible swellings Look for raised JVP or other engorged neck veins (Superior vena cava obstruction) Specific examination Stand at the right side of the patient Adequate exposure as mention above Look for symmetry of abdominal wall movements during respiration (absent in case of peritonitis) Note for any abdominal distension Position of the umbilicus (pushed/everted- in case of intra-abdominal mass) Skin for striae , spider naive (cirrhosis of liver) & surgical scars (refer picture below for common abdominal scars) Bluish discolouration of umbilicus- Cullen’s sign / Bluish discolouration of flanks- Grey Turner’s sign (due to retroperitoneal haemorrhage – e.g. acute haemorrhagic pancreatitis/rupture aortic aneurism) Engorged veins (portal hypertension/ inferior vena cava obstruction) Presence of stomas Cough impulse at the hernia orifices/ old operative scar ( incisional hernia) Mass/Lumps (inspect from several angles) Abdominal wall mass is more prominent on tensing of abdominal wall muscles. Ask patient to raise head against your hand or feet off the bed for better appreciation of mass Intra-abdominal mass will be less prominent on head raising test. However, abdominal wall mass will be more prominent Examination of the abdominal mass is similar to any other lumps in any parts of the body Describe all masses in relation to the abdominal region& consider relationship of intra-abdominal organs to establish a diagnosis. Always try to appreciate the movement of the lump with respiration. Intra peritoneal mass moves with respiration and retroperitoneal mass does not moves with respiration Besides intra-abdominal masses, parietal mass can arise as well Examples are : Swelling of skin and subcutaneous tissues (lipoma, sebaceous cyst, fibroma, neurofibroma or angiofibroma) Cold abscess, lumbar abscess (from Pott’s Disease) Hernias – epigastric, umbilical, periumbilical, or incisional hernia Hematomas – rectus hematoma Malignancies – Desmoid tumour (fibroma from the deeper part of rectus abdominis) Urachal cyst in the suprapubic region PALPATION All nine regions of the abdomen should be identified during palpation and percussion Ask patient to point the area of greatest pain (palpate this region at the last) Palpation generally starts from right illac fossa region and follow an orderly manner clockwise Palpation is divided into superficial and deep Superficial: Gently examine the abdominal wall and try to confirm presence of tenderness, guarding. Note any feeling of crepitus (subcutaneous gas) and any obvious irregularities (lipoma or hernias of abdominal wall etc.) Deep: use right hand/two-handed palpation (using the lower hand to feel and the upper hand to exert pressure). During expiration insinuate the palpating finger and during inspiration palpate for enlarged organ (as diaphragm will push the intra-abdominal organ down hence make it easy to palpate).Palpate each region in orderly manner leaving the most painful region for the last Enlarged Kidney is appreciated by ballottement Palpate draining lymph nodes, both cervical and inguinal lymph nodes. Tips: don’t forget the left supraclavicular lymph node (Virchow’s node/Troisier’s Sign) which suggest metastatic deposits of gastro-intestinal malignancy, palpated in between two heads of the left sternocleidomastoid muscle FEATURES of LIVER MASS Mass over the right hypochondrium Cannot insinuate hand between the mass and costal margin Continuous with liver dullness on percussion LEFT HYPOCHONDRIUM MASS SPLEEN VS KIDNEY Spleen enlarges towards umbilicus (right iliac fossa) whereas kidney enlarges towards left lilac fossa Splenic mass is smooth and uniform with a sharp anterior border, the splenic notch Splenic mass moves with respiration, but kidney not Cannot insinuate hand between the swelling and costal margin in case of spleen mass On percussion over mass, it is dull in splenic mass but resonant in kidney mass as there is colon over the kidney There is dullness over Traube’s space for spleen mass Kidney mass is ballotable whereas splenic mass is not Abdominal palpation, finger pulp is used Palpation of the liver. The patient inspires deeply, bringing the liver edge to the examiner’s fingertips Two handed palpation. The left hand is used to push down on the right hand, and thus examine any mass Palpation of the spleen. The left hand exerts pressure against the left lower rib cage, pushing the spleen anteriorly to be palpated by the right hand PERCUSSION Starting in the midclavicular line at about the 3rd intercostal space, lightly percuss and move...

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