The document provides guidance on performing an abdominal examination, including inspection, palpation, percussion, and auscultation of the abdomen. It describes how to examine the liver, spleen, kidneys, abdominal aorta, hernias and abdominal masses. Key steps include systematic inspection for abnormalities, deep and superficial palpation using both hands, percussion to determine dullness and resonance, and auscultation of bowel sounds and vascular bruits. Practice is emphasized to gain skill in abdominal examination techniques.

1. ABDOMINAL EXAMINATION 3 rd June Dr. YL Cheong

2. General Condition Consciousness, confuse Gait ill-looking Built Hydration Color, pallor, cyanosis, jaundice, carotinaemia Stigmata of liver disease Fetor

4. ABDOMINAL EXAMINATION Inspection Palpation Percussion Auscultation Per rectal examination Hernia and scrotum

7. ABDOMINAL EXAMINATION Patient lying down supine Bed Pillow supporting head Hands by side of body Examiner sitting down on the right of patient Patient adequately expose

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10. INSPECTION Normal abdomen: Scaphoid Moves with respiration

11. ABNORMAL ABDOMEN Distended Everted umbilicus Dilated veins Ecchymosis Striae Pigmentation Surgical scars Peristalsis

12. DISTENDED ABDOMEN Feces Fat Fluid Flatus Fetus

13. EVERTED UMBILICUS Ascites Umbilical hernia Paraumbilical hernia

17. DILATED VEINS Caput medusae secondary to portal hypertension Dilated upward flowing veins secondary to IVC obstruction

21. ECCHYMOSIS Cullen sign Grey Turner sign

23. STRIAE Whitish—stretch marks or striae gravidarum Purplish—Cushing disease or syndrome

25. PIGMENTATION Linea nigra in pregnancy Addison disease Café au lait—Von Recklinhausen (neurofibromatosis ) Vitiligo—loss of pigmentation

27. SURGICAL SCARS Names and sites of incision Reddish– recent Whitish—old Stretch—likely incisional hernia

29. PERISTALSIS Thin patients: visible Intestinal obstruction

33. PELVIC ORGANS Urinary bladder Gravid uterus Ovarian tumuor

36. PALPATION Right side of patient Sitting down Hands and forearm at level of patient’s abdomen Looking at patient’s face all the time Two rounds of palpation—superficial and deep Systematically—clockwise or anticlockwise Usually the non tender side first

42. LIVER Right subcostal region Normally not palpable Enlargement measure in cm. or finger breadths below right costal margin Descend with inspiration Not able to get above it Non ballotable Liver span ( percussion )

46. SPLEEN Left subcostal region Normally not palpable Enlarges three times before palpable Descend downwards and medially with inspiration Cannot get above it Splenic notch Non ballotable Traube’s space dull on percussion (10 th , 11 th and 12 th intercostal space midaxillary line)

51. Kidneys Normally non palpable Sometimes in thin patients – right lower pole can be felt Descends downwards with respiration Ballotable Cannot get above it Resonant to percussion

54. PELVIC ORGANS Urinary bladder, uterus, ovarian tumour Unable to ‘ get below it ‘ Globular in shape Dull on percussion in the centre Internally ballotable

57. ABDOMINAL AORTA Palpable in thin patients Deep palpation slightly above and left of umbilicus Use fingertips Aneurysm of aorta—expansile pulsation cf. to transmitted pulsation

61. FEMORAL ARTERY Mid inguinal point—between ASIS and symphysis pubis Midpoint of inguinal ligament—between ASIS and pubic tubercle, 2cm. above is the internal ring ( indirect inguinal hernia )

63. TENDERNESS Sign of inflammation ( rubor, calor, dolor, tumor and loss of function ) Local– epigastrium, pelvic, RIF Generalised –peritonitis

65. TENDERNESS Rebound tenderness Contralateral tenderness ( Rovsing sign ) Murphy sign—arrest of inspiration with a gasp when patient takes a deep breath as the gallbladder is palpated ( acute cholecystitis ) Guarding– local or generalised Board-like rigidity

66. COURVOISIER’S LAW In the presence of jaundice, a palpable gallbladder is unlikely to be due to gallstone More likely to be due to carcinoma eg, carcinoma of head of pancreas

67. PERCUSSION The middle finger ( pleximeter finger ) of the left hand is placed on the part of the body to be percussed and the back of its middle phalange is then struck with the tip of the middle finger of the right hand

68. PERCUSSION Dullness Shifting dullness Resonance

71. DULLNESS Liver span Traube’s space—enlarged spleen; dullness in 10 th , 11 th and 12 th intercostal space at mid axillary line Margin of enlarged organs—sometimes easier to define by percussion than palpation eg. Urinary bladder, ovarian tumour Ascites– small amount use shifting dullness. Large amount use fluid thrill

72. RESONANCE Presence of air Hyper-resonance – intestinal obstruction and paralytic ileus Loss of liver dullness—perforated peptic ulcer

73. GROSS ASCITES Dull in flanks Umbilicus transverse and or hernia present Shifting dullness positive Fluid thrill presence

77. LARGE OVARIAN CYST Resonance in flanks Umbilicus vertical and drawn up Large swelling felt arising out of pelvis and one cannot ‘get below it’

78. URINARY BLADDER Dullness suprapubically Resonance superiorly and in the flanks

79. INTESTINAL OBSTRUCTION Resonance throughout Colicky pain ( no pain in paralytic ileus ) Vomiting Constipation Absence of flatus

81. AUSCULTATION Bowel sounds Sucussion splash Vascular bruit

82. BOWEL SOUNDS Right of umbilicus for a minute Not move from place to place Normal sounds– sometimes can be heard without stethoscope esp. when hungry Acute small bowel obstruction—loud, excessive and exaggerated ( very angry) same time when the patient is feeling bouts of colicky pain

83. BOWEL SOUNDS Silent –no bowel sound heard after a minute of auscultation Generalized peritonitis Paralytic ileus

84. SUCUSSION SPLASH Patient supine Stethoscope in epigastrium Roll the patient side to side Hear splashing sound if stomach or small intestines is filled with fluid

85. SUCUSSION SPLASH Pyloric stenosis– chronic peptic ulcer disease, ca pylorus Mechanical bowel obstruction Paralytic ileus

86. VASCULAR BRUIT Bruit over a blood vessel is a signicant finding indicating turbulent flow Umbilicus– above and left ( abdominal aortic aneurysm or stenosis ) Iliac fossa—iliac artery Groin—femoral Epigastrium –coeliac or superior mesenteric artery Mid abdomen either side of midline—renal artery stenosis Liver—hepatoma Thyrotoxicosis--neck

87. HERNIAS Inguinal hernia—direct and indirect Femoral incisional

88. HERNIA Protusion of a viscus through a weakness in the wall Produce by standing, straining or coughing Reduce by lying down

91. INGUINAL HERNIA Neck of sac—above and medial of pubic tubercle Above inguinal ligament Indirect enters scrotum Direct does not Occlusion of internal ring– indirect hernia not emerge; direct will come out

97. FEMORAL HERNIA Neck of sac—below and lateral to pubic tubercle Below inguinal ligament

99. INCISIONAL HERNIA Previous abdominal incisions

101. SCROTAL MASS ‘ can get above’ the scrotal mass If unable– it is an inguinal hernia

103. PER RECTAL EXAMINATION

107. ABDOMINAL MASS Intra or extra abdomen ( inside or outside the abdominal cavity? Lift the head up to tense the abdominal muscle If intra– mass is less obvious If extra or in the wall—mass is the same

108. ABDOMINAL MASS Site—organs below Size and shape Surface ,edge and consistency—hard and nodular implies neoplasm Regular, round, smooth and tense– likely to be a cyst Solid, ill defined an tender – inflammatory mass

109. MASS Mobility— Moves with inspiration—liver, spleen, kidneys, gallbladderand distal stomach and cannot ‘get above it’ Not move—rest of intestine and omentum but mobile on palpation Completely fixed—retroperitoneal organs eg.pancreas; advanced neoplasm fixed to abdominal walls or inflammatory mass Fibroid or gravid uterus moves side to side Bladder or ovary fixed

110. ABDOMINAL MASS Ballotable or bimanually palpable kidneys

111. ABDOMINAL MASS Pulsatile Transmitted or expansile

114. HOW TO BE SKILLFUL IN ABDOMINAL EXAMINATION? 3 WAYS: Practice More practice Practice, practice, practice and more practice

115. THE END