Abdominal Examination

Suez Canal University Faculty of Medicine Clinical Skill Laboratory

STEP/TASK PREPARATION OF THE PATIENT 1- Greet the patient respectfully and with kindness. 2- Explain the procedure to the patient. 3- Exposure: Ask the patient to undress from the nipple line to the pubis, allow the patient to cover with a clean sheet. 4- The patient's position: ask the patient to lie flat on his back with the legs extended. You may also ask the patient to flex the hips to 45 and the knees to 90 in order to relax the abdominal muscles. INSPECTION: 1. Look from both ends of the bed 2. Look from both sides 3. Look tangentially (get down to your knees to have the eyes at the same level with the abdomen) 1. Take your time to observe: a. Breasts b. Abdominal movements with respiration (Type of breathing) c. Pulsations (Epigastric pulsations) d. Any bulges that are elicited by coughing (Hernia) e. Any bulge elicited by flexion of the trunk (Divercation of recti) f. Genitalia Comment upon:
Gynecomastia Shape (contour) Sub-costal angle Divercation of recti Position and shape of the umbilicus, presence of any nodules Hair distribution Skin pigmentations Scars Genitalia Dilated veins Hernia Visible movements

PALPATION: 1. Stand by the right side of the patient 2. Make sure that your hand is warm 3. Instruct the patient to: a. Flex the hips and knees in order to relax the abdominal muscles b. Open the mouth and breathe quietly in and out. 4. Ask the patient whether there is a painful area or a mass. Always start palpation in the region diagonally opposite to any lesion or pain, and proceed systematically to other regions approaching the affected area last of all. 5. Proceed with palpation in a predetermined sequence (S or G sequence); so as not to miss any of the nine abdominal quadrants. A. LIGHT PALPATION 1

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Tenderness: Ask the patient to locate the site of tenderness. Ask the patient to take a deep breath or to cough to confirm the site of maximum tenderness. b. Rigidity: Differentiate it from guarding which is voluntary and disappears on expiration. c. Swelling: Ask the patient to contract the abdominal wall muscles by raising the head (to determine whether the swelling is intra or extra abdominal) Notice the swelling mobility with respiration (determines the relation of the swelling to the diaphragm) Try to reach the lower border of the mass , if you can insinuate your fingers between the mass and the symphysis pubis it is an abdominal mass , if not, it is a pelviabdominal mass d. Hernia orifices: Examine the anatomical sites of hernia for swelling and any expansile impulse with cough. e. Dilated veins: Determine the direction of the flow by placing two fingers on the vein, sliding one finger along the vein to empty it and then releasing one finger and watching to see which way the empty segment fills. B. DEEP PALPATION Deeply palpate all quadrants in a systemic way C. PALPATION OF THE ORGANS Start palpation of the normal solid viscera (the liver, the spleen and the kidneys): A. The Liver Place your right hand on the right iliac fossa (MCL), resting transversely parallel to the costal margin (at a right angle with the linea semilunaris) Place the other hand in the right loin. Ask the patient to take a deep breath. Keep your hand still during inspiration As the patient to expire, slide the hand a little nearer to the right costal margin till you palpate lower border of the right lobe of the liver. Put your hand in the midline and repeat the above steps till you palpate the lower border of the left lobe of the liver. If the liver is enlarged, put one hand on the liver anteriorly and the other hand at the back. Ask the patient to hold his breath and feel for pulsation Comment on the findings:
o The degree of enlargement (fingerbreadths below the costal margin in both MCL & ML) The character of the edge (sharp or rounded). o The surface (smooth or nodular) o The consistency (soft, firm, hard or heterogeneous The presence of pulsations) The presence of tenderness

B. the spleen: The standard method or bimanual examination: o Start palpation from the right iliac fossa with the tips of the examining hand directed towards the left axilla. o The left hand is placed over the lateral aspect of the left costal margin, exerting a certain amount of compression. o Follow the rules of palpation moving toward the left hypochondrium until you feel the spleen. The right lateral position method: o Ask the patient to turn to the right side o Insinuate the hand below the costal margin o Ask the patient to take a deep breath Press till you feel the lower edge of the spleen C. the kidneys: o To feel the right kidney: o Put your left hand behind the patient's right loin (between the last rib and the iliac crest) o Lift the loin and the kidney forward. o Put the right hand on the right lumbar region just above the anterior superior iliac spine and ask the patient to take a deep breath. o During expiration push your right hand deeply but gently and keep it still during inspiration o Repeat as the patient takes his breath. To feel the left kidney: o Repeat the same procedure on the left side by either standing on the patient's left side or by leaning across the patient o Put the right hand in the left loin and feeling the kidney with the left hand. D. TESTING FOR REBOUND TENDERNESS E. DETECTION OF ASCITES BY FLUID THRILL: Instruct the patient to lie in the supine position Place one hand flat over the lumbar region on one side Get the patient to put the hand in the midline of the abdomen Tap or flick the opposite lumbar region A thrill will be felt in the other hand F. PALPATION IN THE PRESENCE OF TENSE ASCITES: THE DIPPING METHOD Place your hand in the right hypochondrium and push the abdominal wall downwards by a quick pushing movement from the wrist. An enlarged liver will rebound and hit your hand Place your hand in the left hypochondrium and push the abdominal wall downwards by quick pushing movement from the wrist. An enlarged spleen will rebound and hit your hand. PERCUSSION: Percuss for ascites and over any masses.

 In the abdomen only light percussion is necessary. Start from resonant to dull in the midline A. Percussion of the liver (span of the liver): Determine the upper border of the liver by heavy percussion starting from the 2nd intercostal space opposite the sternocostal junction Percuss down along each inter-costal space in the MCL and when you reach the dullness ask the patient to take a deep breath and hold it Percuss again, (tidal percussion), if it became resonant this will denote infra diaphragmatic cause (liver). If it remain dull, this will denote supra diaphragmatic cause(pleural effusion) Measure the distance between the upper border (by percussion) and lower border (by palpation) in the right mid- clavicular line, this is the span of the liver. B. Percussion of the Spleen: Percussion of the Traube space: th Area defined by the anatomical apex (5 ICS in MCL), left sixth and eighth ribs superiorly, the left midaxillary line (9th, 10th&11th ICS) laterally, and the left costal margin inferiorly. If Traube space is dull, the spleen is enlarged. C. Percussion for Shifting Dullness: Instruct the patient to lie in the supine position Percussion for the upper border of the fluid Place the hand transversely above the umbilicus and below the hepatic dullness, move towards the symphysis pubis till you elicit a dull tone. Percussion for the lateral edge of the fluid Place your fingers parallel to the flanks Start percussion from the region of the umbilicus down to the flank till you elicit a dull tone. Percussion for the shifting dullness: On detecting dullness, ask the patient to turn to the opposite side, while keeping the examining hand over the exact site of dullness. Keep your hand in position till the patient rests on the opposite side, Repeat percussion; if the flank returns a resonant note and percussion at the umbilicus returns a dull note, that indicates the presence of moderate free ascites. AUSCULTAION: 1. Intestinal sounds 2. Bruits 3. Venous hum 4. Rub EXAMINATION OF RELATED AREAS