Abdominal Exam

Abdominal Exam

·        Trying to filter symptoms for:

o   Upper vs. lower

o   Functional (motility) vs. structural (infection etc)

o   Alarm symptoms 

·        General:

o  Lie flat and comfortable (® relaxed muscles)

o  General appearance:

§  Jaundice

§  Weight and wasting (weight them)

§  Skin: pigmentation (eg haemochromatosis)

o  Mental state: hepatic encephalopathy

·        Hands for peripheral stigmata of abdominal disease (mainly liver):

o  Nails: Leuconychia (nail bed opacity in hypoalbuminaemia), clubbing in cirrhosis

o  Palms: Palmar erythema (reddened palms) in chronic liver disease, anaemia (from GI loss, malabsorption or chronic disease)

o  Dupuytren‟s Contracture: thickening of the palmar fascia ® permanent flexion, especially of the ring finger. In manual workers, alcohol, and familial

o  Hepatic flap: extend wrists and separate fingers for 15 seconds

·        Arms:

o  Bruising:

§  Large bruises (ecchymoses) from clotting disorders

§  Small bruises (petechiae) from alcohol toxicity ® ¯platelets (also portal hypertension ® splenomegaly ® ¯platelets)

o  Also muscle wasting, scratch marks, spider naevi (cirrhosis – usually alcohol, due to oestrogen excess)

·        Face:

o  Eyes for jaundice, anaemia, or scleritis/iritis (associated with inflammatory bowel disease)

o  Bilateral swollen parotids due to fatty infiltration with ­alcohol

o  Smell of breath: fetor hepaticus (sweet smell) or alcohol

o  Ulceration (eg in Crohn‟s) or candida in the mouth

o  Angular stomatitis: cracks at the corners of the mouth: causes include Vit B 6 and 12, folate and iron deficiency

·        Neck and Chest:

o  JVP

o  Cervical lymph nodes and especially supraclavicular nodes (always bad)

o  Gynaecomastia: due to ­oestrogen to testosterone ratio (alcoholic effect on Leydig cells), or due to spironolactone (used to treat ascites)

·        Examine chest:

o  Gynaecomastia

o  Spider naevi

o  Body hair

Abdomen

·        Regions:

o  Right & left hypochondrium, epigastrium

o  Right & left lumbar/mid-lateral region

o  Right & left iliac fossa, hypogastrium or suprapubic

·        Why examine:

o  Enlarged organs

o  Abnormal masses (e.g. tumour or inflammation – abscess) & fluid (ascites)

o  Signs of peritoneal irritation (hurts with cough)

o  Hernia

·        Inspection:

o  ?Abdomen moves with respiration (look from side on to view asymmetry Þ ?mass)

o  Scars: what were operations

o  Hernias - Hernial Orifices: Umbilical, Inguinal, femoral

o  Visible lumps/organs

o  Skin lesions/pigmentation (eg Shingles causes strange pains until it erupts)

o  Distension: Due to Fat, Fluid, Fetus, Flatus, Faeces, Filthy big tumour. Umbilicus is shallow or everted in ascites or pregnancy

o   Veins. Test direction of flow. In portal hypertension, flow is away from umbilicus (rare, = Caput Medusae). In IVC obstruction, flow is upwards

o   Striae: Ascites, pregnancy, recent weight loss, rarely Cushing‟s Syndrome

o   Pulsitations: abdominal aorta.  Visible in thin people.  If fat then ?aneurysm

·        Palpation:

o   Relax patient, use warm hands.  Bend knees up if necessary to relax muscles

o   Gently all round: look at face – check for tenderness/peritonism, obvious lumps. Do most painful quadrant last. If tense, use their hand

o   Percuss before palpation for organs.  Check for shifting dullness

o   More firmly: looking for organs, masses

·        What to palpate for:

o   Liver:

§  Don‟t usually feel in normal adult, may in child. Normal span in mid-clavicular line is 10 - 12 cm. Don‟t measure on lateral side, right lobe hangs down in some giving appearance of bigger liver (Riedel‟s lobe)

§  Describe as hard or soft, tender or non-tender, regular or irregular, pulsitile or non-pulsitile

o   Spleen: needs to be enlarged 3 or 4 times to palpate. Palpable spleen is ALWAYS bad. Start palpation inferior to the umbilicus

o   Kidney: if palpable either tumour or obstructed

o   Aorta: can nearly palpate in most people – key issue is width 

o   Gallbladder: Murphy‟s sign: lay fingers along costal margin, patient takes a deep breath and it hurts. Enlarged gallbladder is unlikely to be gallstones as chronic gallstones ® fibrosis that can‟t then expand. Instead, ?carcinoma of the head of the pancreas. 

o   Also palpate for bladder, uterus

·        What to note: Site, size, shape, consistency, tender, pulsitile

·        Signs of inflammation, infection or haemorrhage:

o   Tenderness: how severe is pain in response to pressure

o   Guarding: muscles resist pressure.  Can be voluntary or involuntary (latter suggests peritonitis)

o   Rigidity: muscles tight 

o   Rebound tenderness: push down surreptitiously then remove hand quickly – watch face for pain (peritonitis)

·        Percuss for:

o   Liver

o   Spleen: unreliable

o   Kidneys: but overlying bowel makes this problematic

o   Bladder: supra-pubic dullness indicates upper border of an enlarged bladder or pelvic mass

o   Shifting dullness in ascites

·        Ausciltate: 

o   Bowel sounds: just below umbilicus. Are either present or absent (increased or decreased meaningless)

o   Over liver, spleen, renal areas for rubs and bruits

·        Groin: genitalia, lymph nodes, hernial orifices

·        Rectal:

o   Observe for tags, haemorrhoids, pylonodal sinuses, blood, faeces colour

o   Feel for anal tone, masses or strictures in the rectum

·        Legs: bruising, muscle wasting, oedema (check sacral as well)

Causes of Splenomegaly

·        Chronic granulocytic leukaemia

·        Malaria

·        Lymphoma

·        Myelofibrosis

·        Polycythaemia