this is the second chapter of undergraduate abdominal examination

1. Abdominal Clinical
Examination (Ep. II)
PROF. DR. MOHAMED-NAGUIB WIFI
PROFESSOR OF MEDICINE AND
HAPATOGASTROENTEROLOGY
CAIRO UNIVERSITY

2. Any Local Examination
•Inspection
•Palpation
•Percussion
•Auscultation

3. Abdominal
Examination
(Palpation)

4. Palpation
• Patient should have an empty bladder
• Patient supine, arms at sides or folded across chest -
avoid arms above the head as this tightens the abdomen
• Before you begin, ask the patient to point to areas of pain
and examine last
• Warm hands and stethoscope; avoid long nails; approach
slowly
• Distract the patient with conversation or questions

5. Superficial Palpation
•Always start palpation away from any site of
pain. Palpate systematically all abdominal
regions. Always observe patients face for signs
of discomfort.
•Superficial palpation:
•Using light pressure assess for tone, tenderness
and any obvious abnormalities

6. Use the flat of the
palmar surface of
fingers to palpate
through the
abdominal wall

7. Abdominal Regions
•Conventionally the abdomen is divided into 9
regions
•There are 4 dividing lines:
• Midclavicular (2) -vertical
• Subcostal - upper horizontal
• Trans-tubercular - lower horizontal
•Alternatively they can be divided into 4 quadrants

13. Assessing muscle tone with
superficial palpation
• Gentle pressure applied to the abdominal wall should allow the
examiner to depress the anterior wall of the abdomen as the muscles
relax
• Contraction of the muscles underlying the hand as pressure is applied
is called “guarding” and may indicate some underlying inflammation
• A rigid abdominal wall, resisting any attempt to push back the
abdominal wall and usually not moving with respiration, indicates
underlying peritoneal inflammation and is called “rigidity”
• A marked, acute exacerbation of pain on sudden release of pressure
applied to the abdominal wall is called “rebound”.

14. Deep Palpation
•Deep!
•Using firm pressure to assess for deep
swellings/abnormalities
•Deep palpation must be done with the palmar
aspect of the fingers (get on the same level as the
abdomen)

15. Can be done using 1
or 2 hands. Making
sure not to push down
on fingertips

16. Abdominal
Examination
(Deep Palpation =
Organomegaly i.e.
HSM)

17. Hepatomegaly

18. Examination:
• Upper border by Tidal Percussion.
• Lower Border:
1.Radial border of right hand: right MCL and ML.
2.Tips of fingers from down upwards in right MCL
and ML.
3.Tips of fingers of BOTH HANDS (Hutchinson’s
method) under costal margin.
4.Hooking method.

19. •Bimanual (for pulsations):
• One hand below right costal margin and
the other in the loin. Press by both hands
against each other and ask the patient to
hold his breathing.
• Put one hand on the left lobe and other
hand on the right lobe. Press down and
ask the patient to hold his breathing.
• Dipping in ascites.
• Scratch method (Macleod’s method):
scratch from right iliac fossa till right
hypochondrium with the use of stethoscope.

20. Percuss for upper border
(Tidal percussion)

21. Percuss for lower border

22. 1

23. 2

24. 3

26. 4

27. Comment on:
1. Size
2. Edge
3. Consistency
4. Surface
5. Tenderness
6. Pulsation

28. Causes of apparent hepatomegaly
•Ptosed liver:
•Emphysema
•Right pneumothorax
•Visceroptosis
•Reidel’s Lobe: unusual tongue of liver
(DD with GB mass or right kidney)

29. Causes of tender liver
•Congestion: cardiac causes
•Inflammatory: hepatitis, abscess
•Malignancy

30. Splenomegaly

31. Some Pitfalls:
• If you find splenomegaly, it is enlarged more
than 3 times its normal size.
• Huge splenomegaly, if it cross umbilicus
VERTICAL or HORIZONTAL.
•Direct downward direction of enlargement: if
Malignant or traumatic.

32. Methods of palpation:
1- Tips of fingers from right iliac fossa till left hypochondrium.
2- If not found  bimanual approach to support.
3- If not found  palpate with the patient on his right side.
4- If not found  stand on his left side and do Hooking: palpate under
costal margin.
5- If huge: feel it from left iliac fossa to feel its border and direction of
descend.
6- Try to find the notch on its ant. border.
7- Dipping in ascites.

33. 1

34. 2

35. 3

36. 4

37. Causes of Huge spleen (10)
5 Hematology:
- CML - Thalassemia - Lymphoma -
Myelofibrosis - Polycythemia.
3 Parasites:
- Bilharziasis - Malaria - Kala Azar
1 Infiltrative: amyloid
1 Immune: Felty’s Syndrome