This presentation deals with Clinical examination of Abdomen

1. ABDOMEN
EXAMINATION
Dr. Akshay Shetty
Asst.Professor
Dept of Panchakarma
SSRAMCH Inchal

2. Contents
7/4/2018 Abdomen Examination 2
Objectives
Introduction
Inspection Palpation
Percussion
Auscultation Summary
Conclusion
References

3. Objectives
7/4/2018 Abdomen Examination 3
At the end of the presentation the
learners must be able to---
• Explain Introduction of Abdomen examination
• Demonstrate Inspection of Abdomen examination
• Demonstrate Palpation of Abdomen examination
• Demonstrate Percussion of Abdomen examination
• Demonstrate Auscultation of Abdomen
examination
1

4. Introduction
4
• According to Mosby's, "The abdominal exam
is performed as part of the comprehensive
physical examination or when a patient
presents with signs of symptoms of an
abdominal disease process.“
• Following are the steps involved in
examination
1. Introduction
2. Inspection
3. Palpation
4. Percussion
5. Auscultation

5. Cont….
5
• Wash your hands (ensure that your hands are clean and
warm with short nails)
• Introduce yourself Identity of patient – confirm name and
date of birth
• Permission (consent and explain examination: “I’m going
to examine your stomach and look for other signs of
abdominal problems, is that OK?”)
• Pain?
• Position Initially at 45⁰ for comfort, but must be lying flat
to palpate abdomen. A pillow under the head or raising
knees slightly might help this.
• Expose fully (nipples to knees). Important to see hernial
orifices. If this is inappropriate (e.g. in many exam
situations) tell the examiner the amount of exposure you
would ideally like but say you will not expose fully to
maintain dignity.

6. Inspection
6
• Inspection consists of visual examination of
the abdomen with note made of the shape
of the abdomen, skin abnormalities,
abdominal masses, and the movement of
the abdominal wall with respiration.
• The abdomen is inspected by positioning the
patient supine on an examining table or bed.
The head and knees should be supported
with small pillows or folded sheets for
comfort and to relax the abdominal wall
musculature.

7. Cont….
7
• The entire abdominal wall must be
examined and drapes should be positioned
accordingly.
• The patient's arms should be at the sides
and not folded behind the head, as this
tenses the abdominal wall.
• Good lighting is essential, and it is helpful to
have tangential lighting available, for this can
create subtle shadows of abdominal wall
masses.

8. Cont…
8
• First, the general contour of the entire
abdominal wall is observed.
• The contour should be checked carefully for
distention and note made as to whether any
distention is generalized or localized to a
portion of the abdomen.
• Similarly, the flanks should be checked for
any bulging.
• The abdominal wall skin should be inspected
carefully for abnormalities. Any areas of
discoloration should be noted, such as the
bluish discoloration of the umbilicus
(Cullen's sign) or flanks (Grey Turner's sign).

9. Cont…
9
• The skin should be inspected for striae, or
"stretch marks," and surgical scars. Careful note
of surgical scars should be made and correlated
with the patient's recollection of previous
operations.
• The skin of the abdomen should also be checked
carefully for engorged veins in the abdominal
wall and the direction of blood flow in these
veins.
• This is performed by placing the tips of the index
fingers together, compressing a visible vein. The
fingertips are then slid apart, maintaining
compression, producing an empty venous
segment between the fingers.

10. Cont….
10
• A finger is removed from one end and the
vein is watched for filling. The procedure is
then repeated, but the opposite finger is
removed and the vein again checked for
filling.
• Above the umbilicus, blood flow is normally
upward; below the umbilicus, it is normally
downward. Obstruction of the inferior vena
cava will cause reversal of flow in the lower
abdomen. In addition to these large dilated
veins, note should be made of any spider
angiomas of the abdominal wall skin.

11. Cont….
11
• Next, the abdomen should be inspected for
masses.
• This should be performed from several
angles.
• It is important to differentiate abdominal
wall from intra-abdominal masses.
• A mass of the abdominal wall will become
more prominent with tensing of the
abdominal wall musculature,
• whereas an intra-abdominal mass will
become less prominent or disappear.

12. Cont…
12
• Lastly, the abdominal wall should be
observed for motion with respiration.
• Normally, the abdominal wall moves
posteriorly in a symmetrical fashion with
inspiration.
• With peritonitis, there may be localized or
generalized rigidity of the abdominal wall so
that this motion is absent.

13. Cont….
13
• Inspection of the abdomen gives clues to the
diagnosis of intra-abdominal pathology.
• Combined with the patient's history, inspection
can often provide a preliminary diagnosis that
can be confirmed by auscultation and palpation.
• Generalized distention of the abdomen is usually
from 5 F’s
1. Fat
2. Fetus
3. Feaces
4. Flatus
5. Fluid

14. Cont…
14
• Cullen's and Grey Turner's signs (bluish
discoloration of the umbilicus and flanks,
respectively) are related to intra-abdominal
and retroperitoneal bleeding.
• Striae of the abdominal wall are a result of
rupture of the reticular dermis that occurs
with stretching.
• This is seen clinically in pregnancy, obesity,
ascites, abdominal carcinomatosis, and
Cushing's syndrome.

15. Cont…
15
• Surgical scars should be examined carefully,
both as to their position and their
characteristics.
• Often patients are unsure of what kinds of
surgery they have had, but the position of
the incision may give the examiner a clue.
• Even though a transverse right lower
quadrant incision suggests appendectomy,
however, it in no way proves it, and one
must be circumspect in making any such
assumptions.

16. Cont….
16
• Enlarged veins are seen in three clinical
situations:
1. emaciation,
2. portal hypertension, and
3. inferior vena cava obstruction.

17. Cont….
17
• Masses noted on inspection of the abdomen
may be related to organs in that area.
• Thus, a mass in the right upper quadrant
may represent hepatomegaly from hepatitis
or hepatic tumor, a distended gallbladder
from cholecystitis or pancreatic cancer, or a
carcinoma in the head of the pancreas.
• An epigastric mass is likely to be from acute
gastric distention. pancreatic pseudocyst,
pancreatic cancer, or aneurysm of the
abdominal aorta.

18. Palpation
18
• Before palpating the abdomen ensure the
patient is in the optimal position with their
head relaxed on the couch and the the arms
relaxed alongside the body.
• This ensures that the abdominal wall
muscles are relaxed and not tense.
• Placing a pillow underneath the patient’s
knees may also help, although this slightly
reduces access to the abdomen.

19. Cont…
19
• Ideally you should sit or kneel to the right of
the patient at the same level as the patient.
• Whilst palpating, your hand and forearm
should be in the same horizontal plane as
the front of the patient’s abdomen.
• The aim of palpation is to detect tenderness,
masses and organomegaly
• Before beginning, ask the patient if they
have any pain, and if so ask him/her to point
to where the pain is maximal.

20. Cont….
20
• Palpate gently but deliberately and ask
him/her to report any tenderness as you go
– avoid jerky or rapid movements
• In the presence of pain, start as far away as
possible from its maximal site, then move
systematically through the nine regions of
the abdomen lightly palpating each one in
turn to a depth of approximately one
centimetre until you reach the site of
maximal pain
• Always remember to watch the patient’s
face for discomfort.

21. Cont…
21
• Tenderness is an important sign and maybe
associated with guarding. Try to distinguish
between voluntary guarding (conscious
contraction of the abdominal musculature in
apprehensive patients anticipating a
potentially painful clinical examination)
• involuntary guarding (localized peritoneal
inflammation causing reflex contraction of
overlying abdominal muscles upon
palpation).

22. Cont…
22
• Generalised peritonitis – inflammation of the
whole peritoneal cavity – causes widespread
tenderness elicited by minimal pressure. The
abdominal wall muscles are held rigid (‘board-
like’) and breathing becomes increasingly
thoracic.
• Rebound tenderness is said to be present when
the sudden withdrawal of manual pressure
causes more pain than its application. This is a
specific sign of peritonism.
• Rebound tenderness is classically seen in acute
abdominal pathology such as appendicitis, so
may not be an appropriate test in all patients.

23. Liver palpation
7/4/2018 Abdomen Examination 23

24. Spleen palpation
7/4/2018 Abdomen Examination 24

25. Kidney & Aorta palpation
7/4/2018 Abdomen Examination 25

26. Percussion
26
• Routine examination of the abdomen should include
percussion. The whole abdomen should be percussed to
demonstrate the presence of bowel gas (resonant) and
solid or fluid-filled structures (dull). Percussion can also be
used to map out a tender area identified during
palpation.
• Use your nondominant hand as a base; most frequently,
the dorsal aspect of the middle third phalanx is struck.
• This finger should be firmly placed on the skin, away from
bony prominences.
• Use the middle finger of your free hand to deliver a series
of two blows in each position, with equal force.
• Blows must be delivered by bending the wrist only.

27. Shifting dullness
7/4/2018 Abdomen Examination 27

28. Fluid thrill
7/4/2018 Abdomen Examination 28

29. Auscultation
29
• First place the diaphragm of the stethoscope
to the right of the umbilicus and listen for
bowel sounds.
• If no sounds are heard, ausculatate all four
quadrants to make sure no sounds are
missed and to localise specific sounds.
• Normal bowel sounds are low-pitched
gurgles occurring every 5-10 seconds,
although frequency varies widely.
• Only conclude that they are absent after
listening for 2 minutes (some clinicians
contend that 5 minutes of continuous
listening is required).

30. Cont…
30
• Absence of bowel sounds indicates that
peristalsis has ceased, implying paralytic
ileus or peritonitis.
• Mechanical intestinal obstruction increases
the volume and frequency of bowel sounds,
which are often described as having a high-
pitched, tinkling quality.

31. Summary
31
1.Explain Introduction
of Abdomen
examination
1.Demonstrate
Inspection of
Abdomen
examination
1.Demonstrate
Palpation of Abdomen
examination
1.Demonstrate
Percussion of
Abdomen
examination
1.Demonstrate
Auscultation of
Abdomen
examination

32. References
32
1. http://www.oxfordmedicaleducation.com
/clinical-examinations/abdominal-
examination-detailed/
2. https://www.ncbi.nlm.nih.gov/books/NBK
420/#!po=0.862069

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