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Purple Sky

Abdominal Exam

1) Introduction: Introduce yourself to the patient..

For eg. "For the next few minutes I am going to do an abdominal exam where I will look, feel, press, tap, listen on your abdomen. Also, I will be asking you to do some movements and manoeuvres, if you feel any discomfort or pain, please do not hesitate to let me know and I will stop right there. How does that sound?"

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2) Vitals: In OSCEs it is always good to ask for the patient's vitals before you proceed.

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3) General exam (Comment on the following):

  • The patient is comfortably with no apparent distress

  • Eyes: Look for Scleral Jaundice (look down) or Conjunctival Pallor (look up)

  • Mouth: Look for signs of dehydration or vomiting, central cyanosis, dental hygiene, oral ulcers or angular stomatitis

  • Hands: Temperature (moist skin), Capillary refill (<2 seconds), Look for nail changes (clubbing, Koilonychia or leukonychia), no palmar erythema or Depuytrens contracture, Look for muscle loss of the thenar muscles

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4) Abdominal exam (drape the patient appropriately, patient should lie supine with knees flexed and arms on the side):

Inspection (Say: Now I will look at your abdomen):

  • Comment if the abdomen is flat, distended, normal contour, umbilicus is inverted, moving with respiration, Look for  scars, rash, engorged veins, ecchymosis or bruises,  obvious bulging flanks or masses.

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Note: After abdominal Inspection always perform Auscultation, as palpation and/or percussion can alter bowel sounds

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Auscultation (Say: Now I will listen to your abdomen):

  • 4 quadrants (Listen for friction rubs over the liver and spleen)

  • 2 inches above the umbilicus for  Aortic bruits

  • 2 inches above + 2 inches bilateral from umbilicus for renal bruits

  • 2 inches below + 2 inches bilateral from umbilicus for iliac bruits

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Percussion (Say: Now, I am going to tap on your abdomen, can you point to your painful are. "start away from there"):

• Percussion tenderness: evaluate for acute abdomen/peritonitis (inflammation or perforated viscus).

• Percussion of liver: percuss at mid-clavicular line from third intercostal space downwards; asses each rib space looking for change from resonance to dullness to obtain superior margin of liver

• Percussion for splenomegaly: Castell's point (most sensitive test) - last intercostal space on Left anterior axillary linefor dullness

• Percussion to evaluate for presence of ascites: flank dullness, shifting dullness, fluid wave

• Percussion over bladder for suprapubic dullness (bladder distension)

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Palpation (Say: Now I will feel your abdomen):

  • Superficial Palpation on all 4 quadrants for tenderness, guarding or rigidity

  • Deep palpation for liver (from RLQ to RUQ) and spleen (from RLQ to LUQ) for organomegaly and masses (comment on the  size, shape location, consistency, mobility and pulsitility)

  • Bimanual ballottement: for kidney enlargement or tenderness

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5)Special tests:

If you're suspecting Appendicitis:

  • Mcburneys point: Tenderness at McBurney's point (1/3rd of the distance from ASIS to umbilicus).

  • Rovsing: Apply pressure on LLQ. Patient should experience pain in RLQ.

  • Obturator: Flexion of the right hip and knee, followed by internal rotation of the right hip causes RLQ pain.

  • Psoas: With patient lying on their left side, hyper-extend the right hip. Positive if pain on RLQ.

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Perotonitis:

  • Rebound tenderness: Apply steady pressure over an area of tenderness. Test is positive if patient experiences tenderness pain upon abrupt withdrawal of hand.

  • Rigidity: Involuntary reflex contraction of abdominal muscles

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Cholecystitis:

  • Murphy's sign: Sudden cessation of inspiration when the examiner's hands are hooked below the hepatic margin

 

Ascitis: to save time perform this test while doing percussion (if you're suspecting ascites)

  • Fluid wave: Place edge of patient's hand on umbilicus tightly, tap on one side of abdomen, and feel for fluid wave on opposite hand

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4) Nice to mention/perform if you have time: CostoVertebral Angle tenderness + Listen to the back of the lungs.

5) Thank the patient!

6) Always mention: I would like to complete my exam by doing pelvic/vaginal exam, checking the Inguinal LNs and performing Digital Rectal Exam (DRE)

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Summary: Introduction _ Ask for Vitals _ General Inspection _ Abdominal inspection _ Auscultation _ Percussion _ Palpation _ Special tests _Ending statement

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