Clinical examination of abdomen medicine

1. ABDOMINAL
EXAMINATION
Roha shad
Ram negi

2. Inspection
Palpation
Percussion
auscultation

3. INSPECTION
 Examine under good light and warm surroundings.
 Supine position.
 Head supported by pillow.
 Expose abdomen from xiphisternum to pubic symphysis.

5. INSPECTION
 Shape
 Movements of abdominal wall
 Umbilicus
 Skin and surface of abdomen

6. SHAPE
 Normal –FLAT or slightly SCAPHOID, symmetrical .
 Abnormal –
 DISTENSION
Generalized (5F’s) localized
 Fat Symmetrical asymmetrical
 fluid Small bowel obstruction organomegaly
 Flatus spleen
 Faeces Liver
 Fetus Ovary

8. umbilicus
 Normal- midline at the level of disc between L3, L4 vertebrae.
 Shape-retracted and inverted.
 Abnormal-
 Obese-sunken
 Ascitis - flat and everted

9. Movements
Normal= rise on inspiration and fall
on expiration
Free and equal on both sides
Abnormal=
Absent/diminished- generalized
peritonitis(still/silent abdomen)

10. Visible pulsation of abdominal aorta
 Noticed in epigastrium
 Nervous and thin patients
 Aneurysm of abdominal aorta
 Visible peristalsis-
 Obstruction at pylorus
 Obstruction in small or large bowel
 Normal in elderly - lax abdominal muscles.

12. Skin and surface
 Striae – white/ pink wrinkled linear marks
 Striae gravidarum or atrophica seen in
Pregnancy
Ascites
Wasting disease
Severe dieting

13. scar
red and pink- recent White –old scars

14. Superficial veins
Obstruction of
 SVC IVC portal vein
 Superficial abdominal veins are dilated- to provide collateral circulation.
 These veins represent opening up of anastomosis between portal and
systemic veins.

15. Ascitic abdomen

16. Direction of venous blood flow
 Umbilicus- watershed
 Above the umbilicus below umbilicus
 Blood and lymph downwards
flow upwards

18. Pigmentation
 Linea nigra
 Erythema ab igne – brown mottled pigmentation
 Seborrhoeic warts-pink, brown, or black
 haemangiomas-campbell de morgan spots
Campbell de
Morgan spots

19. ABDOMINAL EXAMINATION
PALPATION
1. Ensure that your hands are warm
2. Stand on the patient’s right side
3. Help to position the patient
4. Ask whether the patient feels any pain
before you start
5. Begin with superficial examination
6. Move in a systematic manner through the
abdominal quadrants
7. Repeat palpation deeply.

20. PALPATION
 Tenderness: discomfort and resistance to palpation. Note
for it’s site.
 Voluntary guarding- voluntary contraction due to pain
provoked by palpation.
 Involuntary guarding: reflex contraction of the abdominal
muscles(board like rigidity seen in parietal peritonitis)
 Rebound tenderness: patient feels pain when the hand is
released
 Tenderness + rigidity: perforated viscus
 Palpable mass (enlarged organ, faeces, tumour)

21. Palpation of liver
Place both the hands flat on
abdomen in the right sub costal
region.
Ask the patient to breath deeply.
Edge of liver is felt moving
downwards.
Hepatomegaly is measured in cms
below right costal margin.

22. Surface-
Smooth, soft and tender-
RHF
Firm and regular-
OBSTRUCTIVE JAUNDICE
Hard, irregular painless-
ADVANCED SECONDARY
CA

23. Gall bladder
 Normal gall bladder can not be felt.
 Distended- palpated as firm smooth globular swelling, distinct borders
lateral to rectus abdominus near the tip of 9th intercostal margin.
Painless gallbladder-
 Jaundice in patient with Ca head pancreas or CBD obstruction due to
malignancy.
 Mucocele.
 Carcinoma gall bladder.

24.  Pain in RUQ
 Inflammation of gallbladder
 (cholecystitis)
Courvoisier's law states that in the presence of an
enlarged gall bladder which is nontender and
accompanied with jaundice, the cause is unlikely to
be gallstones.
MURPHY’S SIGN

25. Palpation of spleen
 the spleen is not normally palpable. It has
to be enlarged to two or three times its
usual size before it becomes palpable, and
then is felt beneath the left subcostal
margin.
 Enlargement takes place in a superior and
posterior direction before it becomes
palpable subcostally.
 Once the spleen has become palpable, the
direction of further enlargement is
downwards and towards the right iliac
fossa

26.  Start from the umbilicus. Keep
your hand stationary and ask the
patient to breathe in deeply
through the mouth. Feel for the
splenic edge as it descends on
inspiration (Fig.A)
 Move your hand diagonally
upwards towards the left
hypochondrium 1 cm at a time
between each breath the patient
takes.
 Feel the costal margin along its
length, as the position of the
spleen tip is variable.

27.  If you cannot feel the splenic
edge, ask the patient to roll
towards you and on to his right
side; repeat the above. Palpate
with your right hand, placing your
left hand behind the patient's left
lower ribs, pulling the ribcage
forward (Fig. B).
 Feel along the left costal margin
and percuss over the lateral chest
wall to confirm or exclude the
presence of splenic dullness

28. Palpation of kidney
Left kidney
 The left hand is placed anteriorly in
the left lumbar region and the right is
placed posteriorly in the left loin Ask
the patient to take a deep breath in,
press the right hand forwards and the
left hand backwards, upwards and
inwards
 The left kidney is not usually palpable
unless it is either low in position or
enlarged.

29. Right kidney
 Place the right hand horizontally in
the right lumbar region anteriorly
with the left hand placed posteriorly
in the right loin. Push forwards with
the left hand, ask the patient to take a
deep breath in, and press the right
hand inwards and upwards
 The lower pole of the right kidney, is
commonly palpable in thin patients,
and is felt as a smooth, rounded
swelling which descends on

30. THE URINARY BLADDER
 Normally the urinary bladder is not palpable.
When it is full and the patient cannot empty it
(retention of urine), a smooth firm regular oval-
shaped swelling will be palpated in the
suprapubic region and its dome (upper border)
may reach as far as the umbilicus
 The fact that this swelling is symmetrically
placed in the suprapubic region beneath the
umbilicus, that it is dull to percussion, and that
pressure on it gives the patient a desire to
micturate, together confirms such a swelling as
the bladder

31. Palpation of abdominal aorta
 In most adults the aorta is not readily felt, but
with practice it can usually be detected by
deep palpation a little above and to the left of
the umbilicus.
 the fingertips are used as a means of palpation
 Press the extended fingers of both hands,
held side by side, deeply into the abdominal
wall in the position shown.
 Remove both hands and repeat the
manoeuvre a few centimetres to the right. In
this way the pulsation and width of the aorta
can be estimated

32. COMMON FEMORAL VESSELS
• The common femoral vessels are found
just below the inguinal ligament at the
midpoint between the anterior
superior iliac spine and the symphysis
pubis
• Place the pulps of the right index,
middle and ring fingers over this site in
the right groin and palpate the wall of
the vessel

33. PERCUSSION
 The normal percussion note over most of the abdomen is resonant (tympanic)
except over the liver, where the note is dull.
 A normal spleen is not large enough to render the percussion note dull

34. DEFINING THE BOUNDARIES OF ABDOMINAL
ORGANS AND MASSES
 Liver
Start anteriorly, at the fourth intercostal space, where the note
will be resonant over the lungs, and work vertically downwards.
Over a normal liver, percussion will detect the upper border at
about the fifth intercostal space (just below the right nipple in
men). The dullness extends down to the lower border at or just
below the right subcostal margin, giving a normal liver vertical
height of 12-15cm

35.  Spleen
Dullness extends from the left lower ribs into the left hypochondrium and left
lumbar region.
 Urinary bladder
The dullness on percussion, and clear difference from the adjacent bowel, provides
reassurance that the swelling is cystic or solid and not gaseous.
Other masses
The boundaries of any localized swelling in the abdominal cavity, or in the walls of
the abdomen, can sometimes be defined more accurately by percussion than
palpation, as for the urinary bladder.

36. DETECTION OF ASCITES AND ITS DIFFERENTIATION FROM
OVARIAN CYST AND INTESTINAL OBSTRUCTION
Shifting dullness (ascites) Examination sequence
With the patient supine, percuss from the midline out to the flanks (Fig.
Note any change from resonant to dull, along with the areasof dullness and
resonance.
Keep your finger on the site of dullness in the flank and ask the patient to
turn on to his opposite side. Pause for at least 10 seconds to allow any
ascites to gravitate, then percuss again. If the area of dullness is now
resonant, shifting dullness is present, indicating ascites

37. Percussing for ascites. (A and B) Percuss towards the flank from resonant to dull. (C) Then
ask the patient to roll on to his other side. In ascites, the note then becomes resonant

38. Fluid thrill
Place the palm of your left hand flat
against the left side of the abdomen and
flick a finger of your right hand against the
right side of the abdomen.
If you feel a ripple against your left hand,
ask an assistant to place the edge of their
hand on the midline of the abdomen. This
prevents transmission of the impulse via
the skin rather than through the ascites. If
you still feel a ripple against your left hand,
a fluid thrill is present (only detected in
gross ascites).

39. Clinical features of marked abdominal swelling
Gross ascites
Dull in flanks Umbilicus everted and/or hernia present Shifting
dullness positive Fluid thrill positive
Large ovarian cyst
Resonant in flank Umbilicus, vertical and drawn up Large swelling felt
arising out of pelvis which one cannot 'get below'
Intestinal obstruction
Resonant throughout Colicky pain Vomiting Recent cessation of
passage of stool and flatus Increased and/or 'noisy' bowel sounds

40. Auscultation
Auscultation of the abdomen is for detecting bowel sounds and vascular
bruits.
BOWEL SOUNDS
 The stethoscope should be placed on one site on the abdominal wall (just
to the right of the umbilicus is best) and kept there until sounds are
heard. It should not be moved from site to site. Normal bowel sounds are
heard as intermittent low- or medium-pitched gurgles interspersed with
an occasional high- pitched noise or tinkle
 Absence of bowel sounds implies paralytic ileus or peritonitis. In intestinal
obstruction, bowel sounds occur with increased frequency, volume and
pitch, and have a high-pitched, tinkling quality.

41.  VASCULAR BRUITS
Listen above the umbilicus over the aorta for arterial bruits, which suggest
an atheromatous or aneurysmal aorta or superior mesenteric artery
stenosis.
Now place the stethoscope 2-3 cm above and lateral to the umbilicus and
listen for renal artery bruits from renal artery stenosis.
Listen over the liver for bruits due to hepatoma or acute alcoholic hepatitis.
A friction rub, which sounds like rubbing your dry fingers together, may be
heard over the liver (perihepatitis) or spleen (perisplenitis).