Abdominal Exam

1. Examination of abdomen

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2. Abdominal regions

e Conventionally the abdomen
Micctavicular is divided into 9 regions

line
e There are 4 dividing lines:

Alena ica = midclavicular (2) -
0
Umbilical

! vertical
NT

Subcostal
line

horizontal
= Trans-tubicular - lower
horizontal
e Alternatively they can be
divided into 4 quadrants

[Trans-tuberculai

= subcostal - upper
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3. Remember to always do a general
Inspection

e This can be undertaken with the patient upright
e General appearance

m Demeanour, Pallor, Jaundice, Cachexia, etc.
e Hands and nails

= Ask the patient to dorsiflex at the wrist (cock their hands
back) to observe for a liver flap (a flapping of the hands
back and forth associated with metabolic disorders)

= Vital signs (BP, Pulse, RR, Temp)
e Mouth, teeth, tongue and breath

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4. Palpation of lymph nodes

e They may enlarge for a number of reasons,
including infection, malignancy and systemic
disease.

e Certain groups are assessed as part of
limited local examinations:-

= Cervical and Supraclavicular in abdominal
examination.

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5. Lymph nodes for abdominal examination

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6. Abdominal examination

e The patient should be relaxed in a warm environment

e Lying flat on their back, with hands by their sides and a
single pillow under the head

e Hips and knees may be flexed to relax abdominal
muscles

e The abdomen should be exposed (from xiphisternum to
the suprapubic area - inguinal and genital areas are
covered until they are to be examined)

e Examiner should have warm hands

e Should position him/herself to be on level with the
abdominal surface

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7. Inspection of the torso

e Should be done with the patient supine
= Look for spider nivae (only on the chest)
= Gynaecomastia in males
= Scars
m Skin
m Distension
= Swellings
= Dilated veins
= Visible peristalsis
= Abdominal wall movement

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8. Causes of abdominal distension

ARANA

ANR:

LL /

y)

e Flatus (gas)

e Faeces

e Fluid (ascites)

e Fat

e Foetus

e F****ing big tumours

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9. Superfical Palpation

e Always start palpation
away from any site of pain.
Palpate systematically all
abdominal regions. Always
observe patients face for
signs of discomfort.

e Superficial palpation
m Using light pressure
assess for tone,

tenderness and any
obvious abnormalities

Use the flat of the palmar
‘ace of fingers to palpate
rough the abdominal wall
De

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10. Assessing muscle tone with superficial
palpation

e Gentle pressure applied to the abdominal wall should allow the
examiner to depress the anterior wall of the abdomen as the
muscles relax

e Contraction of the muscles underlying the hand as pressure is
applied is called “guarding” and may indicate some underlying
inflammation

e Arigid abdominal wall, resisting any attempt to push back the
abdominal wall and usually not moving with respiration, indicates
underlying peritoneal inflammation and is called “rigidity”

e A marked, acute exacerbation of pain on sudden release of pressure
applied to the abdominal wall is called “rebound”

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11. Deep palpation

° Deep: a Can be done using 1 or 2
at Using fin pressure te nds. Making sure not to push
assess for deep
swellings/abnormalities
e Deep palpation must
be done with the
palmar aspect of the
fingers (get on the
same level as the
abdomen)

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12. Organ Palpation

e Organ palpation

Use the edge of the index finger

= Liver
= Gall bladder to detect organ edges
= Spleen
m Kidneys
= Aorta
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13. Palpation

e When palpating organs or masses feel for the edges

e The edges provide a better contrast between
surrounding organs/tissues and the mass/organ

e Palpation of masses or organs may be assisted by
assessment of mobility in relation to respiration

m liver descends towards right iliac fossa on

inspiration

m spleen descend inferio-medially on inspiration

towards the right iliac fossa

= the kidneys descend on inspiration

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14. >= u > e The liver lies predominantly

under the ribs on the right side,
although it does cross the mid-
ö o line

e The lowermost edge of the liver
lies approximately parallel with
the costal margin (the lower
edge of the rib cage)

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15. How liver moves on insperation

fe y So
The liver moves

o o inferiorly on
inspiration

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16. How liver enlarges

zn

Enlargement of the
liver also occurs in
an inferior direction

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17. How liver is palpated

AA >= e In view of the direction of enlargement,
"yu palpation for the liver should
commence well away from the costal
margin in the right iliac area

e The thumb is extended to expose the
lateral margin of the index finger

e The hand is positioned so that the
lateral margin of the index finger is
parallel with the costal margin

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18. How liver is palpated 2

AL y DT e The patient is asked to take a

deep breath in and pressure
applied to the abdominal wall by
the examining hand

e lf the liver is not palpated, the
examining hand is moved closer to
the costal margin by about 1 cm

e The patient is asked to repeat
deep inspiration and the process is
repeated

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19. How liver is palpated 3

AL u > e The process is repeated until the

liver edge is palpated or the
costal margin reached
Mg e A normal liver may be palpated

close to the liver costal margin

e An enlarged liver may be
palpated distal to the costal
margin

e The distance is measured in cms
from the costal margin

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20. Feeling the liver edge 1

The hand is placed on the
abdominal wall at the right iliac fosa
distance below the right costal
margin. The border of the index
finger is exposed by extending the
thumb.

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21. Feeling the liver edge 2

==

Pressure is applied to the
abdominal wall so that the hand
presses slightly depresses the
superficial surface

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22. Feeling the liver edge 3

<=

The patient is asked to
breath in deeply through
their mouth. This flattens the
diaphragm and the liver
moves inferiorly.

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23. Feeling the liver edge 4

An enlarged liver will
move towards the lateral
border of the index finger
as inspiration reaches
maximum

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24. Feeling the liver edge 5

As the enlarged liver continues
to move downwards it lifts the
the finger and the edge can be
appreciated. The point at which
the edge is palpated at
maximum inspiration can be
measured from the right costal
margin

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25. e The spleen lies entirely

LI underthe ribs on the left

side

e The normal spleen is
approximately fist sized

e The long axis of the spleen
lies along the the line of
the 10th rib

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26. Position of spleen in health

e The spleen moves inferio-

pu D DK medially on inspiration

o o e Even on deep inspiration
the normal spleen cannot
be felt on palpation

e To be palpable the spleen
must enlarge to at least
twice normal size

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27. Position of an enlarged spleen

e Enlargement of the spleen also

Fe D DK occurs in an inferio-medial

direction

e Indeed, a massive spleen may
extend into the right lower
abdomen

e When very large you may be able
to palpate the distinctive splenic
notch

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28. Palpation

of the spleen 1

es .

In view of the direction of
enlargement, palpation for the
spleen should commence well
away from the costal margin in
the right iliac area

The thumb is extended to expose
the lateral margin of the index
finger

The hand is positioned so that the
lateral margin of the index finger
is parallel with the left costal
margin

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29. Palpation of the spleen 2

a o DN e The patient is asked to

take a deep breath in
and pressure applied
by the examiners hand
to the abdominal wall

e If the spleen is not
palpated, the
examining hand is
moved closer to the
costal margin by about
1-2cm

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30. Palpation of the spleen 2

Cet Hf the spleen is not

palpated

e The patient is asked to
repeat deep inspiration
and the process is
repeated

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31. Palpation of the spleen 3

an DB e The process is repeated until

the spleen is palpated or the
costal margin reached

e Anormal spleen will not be
palpated

e An enlarged spleen may be
palpated distal to the costal
margin

e The distance is measured in
cms from the costal margin

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32. If palpation is difficult

=

e Palpation for the spleen can be

facilitated by placing the left hand
under and behind the lower left rib
and applying traction in the
direction shown

This may encourage an enlarged
spleen, otherwise not palpable, to
appear beyond the costal margin
on inspiration

Some clinicians prefer the patient
to roll onto their right side to
achieve the same effect

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33. e Extend from the twelfth
thoracic vertebrae to the L ES
third lumbar vertebrae. (E

e Not normally palpable
unless the patient is thin |

e The right kidney is lower |
than the left due to the es sl
position of the liver

e They have a firm
consistency and smooth

surface ARS
e They move downwards af
towards the end of |
inspiration | | |
Posterior view
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34. Renal angle

e They are retroperitoneal
organs and deep
bimanual palpation is fe
required. |

e To examine position the |
patient close to the edge „,, | |
of the bed |

e Tuck the palmar surfaces
of one hand into the
patients flank

Posterior View

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35. Bimanual examination of the kidneys 1

One hand under the patients The other hand with fingers flat
flank, fingers in the renal angle placed below the costal margin,
(between posterior costal lateral to the rectus muscle

margin and spine
Le
a

Hands should be opposite one another

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36. Bimanual examination of the kidneys 2

e apa the lower pole
of the kidney between
the fingers of both
hands

e Asks the patient to
breathe in deeply and
press the fingers of

oth hands tiem
together

e The rounded lower ;
pole of the kidney = end
may be felt passing > E BY
between the opposing
fingers as the patient
breaths in and out

¥

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37. Percussion

e Assess the need to perform percussion
depending on your clinical findings.

e It is important to distinguish kidney
enlargement from splenomegaly on the left
and hepatomegaly on the right

+ Percussion of an enlarged liver or spleen will
be dull whereas over the kidney it should be
resonant due to the overlying bowel

+ The kidneys can be “balloted” this a
technique where by a structure that is not

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38. Percussion technique

e Take note of the technique
e Use the tip of the finger
The blow is delivered by a
sharp wrist movement
Strike the middle phalanx
firmly. Two — three taps
only.
Remove striking finger
immediately

e PRACTISE!
Please see basics of examination

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39. Percussion

e General abdomen - should be resonant
e Organs
m Liver - dull
= Spleen - dull
= Kidneys - resonant
m Bladder - dull
e Ascites
= Shifting dullness
= Dullness peripheral
e Ovary
[| m Dullness central

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40. Detecting shifting dullness

e Determines cause of abdominal distension, distinguishes
between fluid and gas.

e There has to be a lot of fluid (ascites) present which can flow
freely for the method to work

e With the patient lying on their back the highest point of fluid is
detected by percussion and marked

e The patient rolls to an angle and is allowed to rest in this
position for a short time to allow the free fluid to flow and
establish a new upper level

e Percussion is repeated and fluid confirmed by detecting
dullness “above” the previous level

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41. Auscultation

Sites of abdominal bruits

> eo Femoral

e Bowel sounds - Listen in
one area, bowel sounds
should be heard within 2-3
minutes.

e Bruits

e Liver

e NBA full abdominal
examination should
normally include
examination of the groins,
external genitalia and
rectum

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42. Recording your findings

e Don’t forget when recording your findings
= Patient identifier, date (and time), signature and name

e When documenting the size, position and shape of
a swelling, a diagram may often be useful. Where
possible remember to comment on the consistency,
surface and mobility of the swelling also.

e Remember examination techniques will vary
depending on the patient and clinician

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