Abdominal Examination

Subject summary

An abdominal exam, like with any other system examination, not only includes examining the abdomen. There are other areas of the body which can give signs of pathology within the gastrointestinal system. As such the examination starts with the hands, then the face, chest and finally the abdomen.

Ensure that you have explained to the patient what you will be doing and that if they feel any discomfort to let you know.
1. Introduction to the patient
First you should take a general inspection of the patient. This includes whether they are comfortable at rest, do they appear to be tachypnoeic, are there any obvious medical appliances around the bed (such as patient controlled analgesia), and are there any medications around. Each of these should be reported to the examiner.
1. Perform a general inspection
Initially you should examine the patient’s hands. You are looking for the presence of koilonhychia, leukonychia, clubbing, palmar erythema, tar staining or Dupuytren’s contracture. Next ask the patient to hold their hands out in front of them looking for a any tremor and then get them to extend their wrists up towards the ceiling keeping the fingers extended and look for a ‘liver flap’.
1. Inspect the patients hands
2. Inspect for clubbing
3. Look for a 'liver flap'
Next is a good time to assess the radial pulse. There is some argument as to whether this should be performed or not in an abdominal exam, however, it can be a good indication of sepsis or thyroid disease.
1. Assess the radial pulse
You should now move onto examining the face. Initially check the conjunctiva for pallor which could be a sign of anaemia. Also check the sclera for jaundice. Next move to the mouth asking the patient to open it. Look at the buccal mucosa for any obvious ulcers which could be a sign of Crohn’s disease. Also look at the tongue. If it is red and fat it could be another sign of anaemia, as could angular stomatitis.
1. Assess the patient's eyes
2. Inspect the patient's tongue
There is one particular area of the neck which should be examined. This is the left supraclavicular lymph node. A palpable enlarged supraclavicular (Virchow’s) node is known as Troisier’s Sign. This is the node which drains the thoracic duct. This receives lymph drainage from the entire abdomen as well as the left thorax. Therefore, enlargement of this node may suggest metastatic deposits from a malignancy in any of these areas.
1. Inspect the left supraclavicular lymph node
Next, examine the chest. In particular you should look for gynaecomastia in men and the presence of 5 or more spider naevi. These are both stigma of liver pathology.
The next part of the examination is checking the abdomen. Initially you should inspect the abdomen. Comment on any obvious abnormalities such as scars, masses and pulsations. Also note if there is any abdominal distension.
Palpation of the abdomen should be performed in a systematic way using the 9 named segments of the abdomen: right and left hypochondrium, right and left flank, right and left iliac fossa, the umbilical area, the hypochondrium and the suprapubic region. However where you start depends on the patient. If a patient has pain in one particular area you should start as far from that area as possible. The tender area should be examined last as they may start guarding making the examination very difficult.
Initial examination should be superficial using one hand. Place the hand flat over each area and flex at the metacarpophalangeal joints. You should feel whether the abdomen is soft but you should always be looking at the patient’s face for any signs of pain. If you feel any abnormal masses you should report these to the examiner.
1. Flex at the metacarpophalangeal joints
Once you have examined all 9 areas superficially, you should examine deeper. This is performed with two hands, one on top of the other again flexing at the MCP joints. You should still be looking at the patient’s face for them flinching due to pain. Again, examine all 9 areas.
Having performed a general examination of the abdomen, you should now feel for organomegaly, particularly of the liver, spleen and kidneys. Palpation for the liver and spleen is similar, both starting in the right iliac fossa. For the liver, press upwards towards the right hypochondrium. You should try to time the palpation with the patient breathing in as this presses down on the liver. If nothing is felt you should move towards the costal margin and try again. A distended liver feels like a light tap on the leading finger when you press down. If the liver is distended, its distance from the costal margin should be noted.
1. Feel for organomegaly
Palpating for the spleen is as for the liver but in the direction of the left hypochondrium. The edge of the spleen which may be felt if distended is more nodular than the liver.
1. Palpating for the spleen
To feel for the kidneys you should place one hand under the patient in the flank region and the other hand on top. You should then try to ballot the kidney between the two hands. In the majority of people the kidneys are not palpable, but they maybe in thin patients who have no renal pathology.
1. Feel for the left kidney
2. Feel for the right kidney
Next you should percuss. This can be also be used to check for organomegaly if it is suspected. Percussion over the abdomen is usually resonant, over a distended liver it will be dull. Percussion can also be used to check for ‘shifting dullness’ – a sign of ascites. With the patient lying flat, start percussing from the midline away from you. If the percussion note changes, hold you finger in that position and ask the patient to roll towards you. Again percuss over this area and if the note has changed then it suggests presence of fluid such as in ascites.
1. Percussion over the abdomen
2. Percussion over a distended liver
The examination is ended with auscultation for bowel sounds. You should listen with the diaphragm next to the umbilicus for up to 30 seconds.
1. Auscultation for bowel sound
You should mention to the examiner at this point that you would like to finish the examination with an examination of the hernial orifices, the external genitalia and also a rectal examination. It is also appropriate to perform a urinalysis at this point including a pregnancy test in females.