Abdominal Examination.

1) WASH HANDS.
2) Obtain consent.
3) Draw curtains.
4) Stand at end of bed and place hands behind back: I am now examining from
the end of the bed- Note environment: Medications.
Infusions.
Nil by mouth.
5) Ask patient to expose between nipples and knees and sit at 45 on bed. (Cover
woman's breasts) Move to the right side of the bed.
6) General appearance:
Comfortable at rest?
Confusion- ask DOB/count backwards from 20 (chronic
liver dz.)
Colour:
Cyanotic.
Pallid (anaemia (microcytic, normocytic,
macrocytic)).
Jaundice- bilirubin in blood (norm<
17umol/L, jaundice occurs> 35 umol/L (Chronic liver dz).
Hyperpigmented.
Weight loss/gain.
Gynaecomastia- (hormone treatment for prostate cancer,
spironalactone, chronic liver dz.)
Syndromes:
Paucity of axillary hair- (chronic liver dz)
Abdominal scarring (hernia.)
Ascites.
Skin: Spider naevi- telangectasic arteriole in skin w/
radiating capillary branches in region of SVC (chronic liver dz).
Pruritis- scratch marks on skin.
7) ASK PATIENT ABOUT ARTHRITIS/PAIN.
8) Hands:
Hydration- stretch skin.
Clubbing (liver abscess, hepatocellular carcinoma, chronic liver dz).
Pitting of nail.
Palmar Erythema- reddening of palms (chronic liver dz).
Leukonychia- opaque white nails (chronic liver dz, nephritic syndrome (low
serum albumin).
Wrist: tendon xanthoma [yellow deposit over extensors] (type II
hyperlipidemia).
Dupuyterons Contracture- painless thickening of palmer aponeurosis
(chronic liver dz).
Pallor of palmar creases (malabsorption).
Koilonychia- nails are brittle and flat- spoonlike (iron deficiency).
Pulse:
Rate (100<60).
Rhythm (regular, irregular).
Character (collapsing pulse (aortic valve problems), water hammer
pulse (hits you hard- Dr's 4 fingers horizontal over pt's palmar wrist, as flex and
extend pt's elbow), slow rising (does not hit you hard- aortic stenosis.)
9) Face:
Eyes: Anaemia
Xanthelasma [yellow periobital deposits] (hypercholestolemia,
DM).

Lid oedema (myxedema, SVC syndrome, nephrotic syndrome,

etc).
Corneal arcus (severe hypercholesterolemia).
Subluxated lenses (superior: Marfan's, inferior:
homocystenuria).
Mouth:Tongue:

Central cyanosis (hepatopulmonary shunt).

Dryness/moisture.
Smooth/clean- atrophy of papillae (iron, B12

deficiency).
Furring- (dehydration).
Enlarged (acromegaly, myxoedema, amyloidosis).
Small/ spastic (motor neurone disease (MND)).
Jaundiced palate.
Breath:
Alcohol?
fecor hepaticus (chronic liver dz)
Sweetness/ pear drops (ketoacidosis, DM).
Halitosis (mouth debris, carious teeth, gingivitis,
stomatitis, atrophic rhinitis, tumours of the nasal passage, pulmonary
suppuration).
Angular stomatitis- painfull inflamed cracks at corners of
mouth- can get infected w/ candida albicans (ill fitting dentures, iron or
riboflavin).
Gingivitis- inflamed gums.
10) Palpate for nodes Supraclavicular fossa- (L for Virchows node- intra-abdominal malignancy
(esp gastric)).
Posterior triangle- behind sternocleidomastoid.
Anterior triangle- infront of sternocleidomastiod.
Submandibular region.
Submental region.
11) Abdomen: ASK PATIENT TO LIE AS FLAT AS POSSIBLE, w/ arms by sides.
A) Inspection: Describe using zones of abdomen.
Scars. (laparotomy= all way down midline).

Stomas: abnormal opening of bowel lumen to the anterior abdominal wall,

created by surgery.
Deformities, dressings, stitches, etc.
Use of abdominal muscles for breathing- (peritonitis).
Swelling: Ascites- fluid in peritoneum (liver failure w/ portal hypertension,
1/2 malignancy). Test for Shifting Dullness.
Fat.
Flatus.

Faeces.
Fetus.
Fibroids.
Nodules.
Herniae: Incisional/Epigastric- ask patient to raise head or legs. Hernia will
have a cough impulse.
Visible peristalsis- observe at eye level for min (intra-abdo obstruction).
B) General Palpation: NB/ Ask pt. if any part is tender (examine that last).
Use flat of hand.
Watch face for signs of pain.
Light palpation for tenderness- one handed.
Deep palpation for masses- place other hand on top.
Organ Palpation:

1) KIDNEYS- Put L hand in the renal angle posteriorly and the R

hand on the anterior abdominal wall+press firmly. Ask patient to
breath in deeply, and then out (whilst pressing in deeper) x2. The
kidney will move with respiration. Try to ballot kidney between your
2) SPLEEN- Put L hand firmly behind L costal margin (ribs)+raise
gently. Place upper edge of R hand in right iliac fossa moving up
towards L costal margin, pressing in an up on pts INSP. The spleen
descends with respiration so get the patient to take deep breaths as
3) LIVER- Put L hand behind R costal margin+raise forwards gently.
Place upper edge of R hand in the R iliac fossa, moving upwards
towards R costal margin, pressing in and up on pts INSP, to feel for a
liver edge. The liver descends with respiration so ask the patient to
4) ABDOMINAL AORTA- Place flat of R hand in epigastruim (above
umbilicus- as aorta bifurcates at level of umb). Feel for an expansile
pulsatile mass for several s.
If one is felt try to assess its size, by placing fingers of each hand
C) Percuss: place L hand on abdo, tap w/ R middle finger. Determine the
extent of solid organs (liver, then spleen, then kidneys) or the extent of a mass
lesion undetected by palpation, AND elicit the presence or absence of peritoneal
irritation (watch patients face for wincing).
Rebound Tenderness (peritonitis):
Place flat of R hand over the tender area, ask patient to take deep breaths in and
out, gradually pressure and indent the peritoneum. Suddenly release the hand
which causes sudden movement of the peritoneum-.
Shifting Dullness (ascites):
Start by percussing centrally and move laterally towards dull area. Ask patient to
roll away from you 45 while keeping hand in position. Dull area will now be
resonant. Ask patient to roll back, percuss again this will now be dull as fluid level
settles back. (Other method for is fluid thrill: pt puts hand vertically down front of
abdo (to stop fat impulse). Dr puts L hand in their L flank and w/ R hand slap R
flank- feel for fluid impulse).
D) Auscultate: Use diaphragm to listen for Bowel sounds (for >1min before
saying they are absent). If you can hear bowel sounds from the foot of the bed=
borborygmus.

In obstruction bowel sounds are high pitched and tinkling. Always listen to herniae
for bowel sounds. Listen for arterial Bruits (brewies)= L and R of umbilicus for L
and R renal art; centre, above umbilicus for aorta; say I would listen for femoral
Bruits.
12) SUMARISE.
13) Request to do:
Genital examination.
Urine dipstick (for protein, ketones, blood, uro-bilinogen)
Rectal examination.