Clinical Examination Guide

Abdominal Examination

Components of the examination

• Introduction • General Inspection • Peripheral examination: nails, hands, arms, neck, face • Close inspection of chest and abdomen • Palpation and percussion: - General palpation, - Liver - Spleen - Abdominal aorta - Bladder - Kidney - Ascites and gallbladder tenderness • Auscultation: bowel signs, renal bruit

Surface markings for abdominal examination

Image: Moore and Agur, Essential Clinical Anatomy 3e RUQ – Right Upper Quadrant, LUQ – Left Upper Quadrant RH/LH – Right/Left Hypochondrium E – Epigastrium RL/LL – Right/Left Lumbar (or Flank) RI/LI – Right / Left Iliac P - Suprapubic Document Owner: Clinical Skills/LK Last Updated: May 2019

Introduction

• Introduce yourself, confirm patient ID • Explain examination and gain consent, position patient at 450 and expose abdomen. Ask if they are in any pain • Gel hands and clean stethoscope

General Inspection

• Consider if patient looks well/unwell, position in the bed, colour, scars, paraphernalia (urinary catheter, stoma, surgical drains, NG tube, vomit bowl)

Peripheral Examination

• Nails, Hands, Wrists and Arms • Face - Inspect nails for clubbing, koilonychia, - Inspect eyes – conjunctival pallor, yellow leukonychia, sclera, xanthelasma, corneal arcus - Ask patient to turn palms over and inspect for - Inspect mouth – moist mucus membranes, palmer erythema, Dupytrens contractures angular stomatis, ulcers, macroglossitis, odour - In suspected liver failure, ask patient to hold • Neck hands outstretched with wrists dorsiflexed and - Palpate supraclavicular fossa for possible hold for 30s to assess for asterixis Virchow's node (full lymph node examination - Examine for presence of Atriovenous Fistulae only if indicated e.g. evidence of - Take Pulse and BP hepato/splenomegaly indicating possible haematological malignancy)

Close Inspection

Lower bed, ask patient to lie flat with arms by sides, legs straight • Look for spider naevi, distended umbilical veins, gynaecomastia, abdominal distension, surgical scars, bruising, scratch marks, obvious masses

Palpation and percussion

• Position the patient flat on the bed, asking them to keep arms by their sides, legs straight. • Raise the bed/crouch down so that you are palpating with forearm horizontal • Clarify site of any pain and start palpation AWAY from this site • Watch the patient’s face for signs of discomfort throughout

General palpation • Start with light palpation, hand flat, flexing at the • Ask the patient to tell you where exactly the pain is MCP joint, palpate all 9 areas felt, as your examination may elicit referred to • If there is tenderness, consider if the patient is pain. voluntary of involuntary guarding. • If guarding is elicited on superficial palpation, • If applicable, examine for Rosving’s sign for observe for rebound tenderness. appendicitis: palpation of LLQ (i.e. away from the • Palpate again the 9 areas more deeply, avoiding base of the appendix in most people) elicits pain in those areas which were tender on superficial the RLQ. Palpation generates stretch across the palpation. whole peritoneal lining which will only elicit pain in • You can palpate more deeply by using your other those areas where it is irritating the muscle. hand on top of the palpating hand. Again, consider if guarding is present

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Voluntary guarding is contraction of the abdominal muscles in response to pain from palpation and may be accompanied by a gasp or the patient bringing their hand towards the area. Involuntary guarding is reflex contraction of the abdominal muscles overlying inflamed peritoneum. Rebound tenderness is a sign of internal abdominal pathology including peritonitis and can be elicited by quickly remove your hand from the abdomen, or asking the patient to cough whilst performing palpation, or by gentle percussion. Note that in an acute abdomen percussion can be extremely painful and for this reason is not performed routinely

Liver palpation +/- percussion The upper margin of the liver lies under 5th and 6th ribs, and the lower margin at the costal margin in midclavicular line. • To palpate for hepatomegaly, start in RLQ and is hepatomegaly, note in terms of cms below the reposition hand upwards with each breath, keeping costal margin and if border is smooth or irregular. fingers parallel with the costal margin. • Palpate deeply, and keeping hand still, ask the • If the liver is palpable or there is otherwise patient to breathe in deeply. The liver descends 1-3 suspicion of liver disease, percuss the liver starting cm on inspiration and so can normally be felt at the 5th intercostal space in the mid-clavicular during deep inspiration. line and work downwards to discern lung-liver and • Observe if the liver edge meets your hand on overall liver span. The liver is dull to percussion, inspiration. If not move your hand 1cm up whilst with resonance of lung and bowel heard above and the patient exhales and observe again. below. Span of <13cm reduces probabliilty of • You will not be able to palpate a normal sized or hepatomegaly shrunken liver (as in advanced cirrhosis). If there

Spleen palpation and percussion The normal spleen lies beneath ribs 9-11 and must enlarge 3-fold before it is palpable, but you may be able to discern notch on the medial border in some patients. • To palpate for splenomegaly, start in the RLQ and • Percuss from in the right iliac fossa and move with fingers pointing towards left shoulder. diagonally towards the left shoulder. • Palate and feel for the spleen moving down to meet your fingertips on inspiration. Reposition whilst patient exhales.

Abdominal aorta palpation In a young slim patient, it is quite normal to be able to feel or even see a pulsatile aorta, but it should not be expansible i.e. pushing up and outwards. • With the patient lying flat, palpate for an abdominal aortic aneurysm by placing fingers of both hands either side of the midline midway between the xiphisternum and the umbilicus. • If aneurysm is suspected, do not press hard, to minimise risk of rupture.

Bladder palpation The bladder is not normally palpable, being contained within the pelvis, but distended bladder may reach the umbilicus.

• Ask if patient recently emptied their bladder. Gently palpate downwards from the umbilicus for the top of the bladder. • Palpation usually worsens urge to micturate and the bladder is dull to percussion

Kidney palpation Between the twelfth rib and the posterior iliac crest lateral to the paravertebral muscles. Anteriorly, the hilum lies on transpyloric plan 3 fingers-breadth from midline on transpyloric plane. Right kidney lies 2-3cm lower than the left. Because the kidneys are not normally palpable except when enlarged, a bimanual technique is used to ballot them. The left kidney is generally more difficult to feel than the right.

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• With the left hand under the patients back in the • Percussion is usually done at the end of the renal angle, use the right hand over the patients examination with the patient sitting up. flank to sandwich the right kidney between the • To percuss, place your left hand over the renal flexed fingers of each hand. If it is sufficiently large, angle and gentle tap it with the lateral border of the you will feel the right kidney move up against your other hand held as a fist. right hand (balloting) and it will move with • There will be no percussion note, but the technique breathing. can elicit discomfort in certain renal conditions • To ballot the left kidney, place your right hand (e.g. perinephric abscess, pyelonephritis, renal under the patients back and your left hand on the stone) left flank.

Ascites Suspected ascites is assessed initially by percussion. • Percuss across the abdomen from the midline to the flanks, noting where there is a change from resonance to dullness • Ask the patient to roll onto their side and wait 30 seconds to allow any ascites to move • Percuss again and note if the area of dullness is now resonant (shifting dullness = ascites)

Eliciting shifting dullness

Tympanic (air) Dull (fluid)

Patient SUPINE Patient on their side for 30sec Percuss from midline to flanks whilst supine Percuss from midline to flanks Note transition point where dullness is first elicited Note transition point has shifted

Gallbadder tenderness In suspected cholecystitis, palpate for gallbladder tenderness. • Ask the patient to breathe deeply as you palpate the RUQ. When the liver descends, an inflamed gallbladder will cause pain as it meets your hand, causing interruption of the inspiration (Murphey's sign). Note that a palpable gallbladder in a jaundiced patient is unlikely to be gallstones (Courvoisier’s Law)

Auscultate

• Listen for bowel sounds. Check for 30 sec, ideally over 3 sites, before determining no bowel sounds heard • Listen for renal bruit on both sides (2-3 cm above and lateral to umbilicus)

Conclusion

• Thank patient, ask them to get dressed, report/record findings • Consider rectal examination, pelvic/external genital examination, hernial orifice examination and urine dip as relevant. Consider full lymph node examination if evidence of hepato/splenomegaly indicating possible haematological malignancy

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