CLINICAL EXAMINATION

2. Tropical medicine department
• Gastroentrology and hepatology unit
• Faculty of medicine
• Zagazig university
• Egypt

4. Also, The abdomen is divided into 9 regions by:
lines, continued downwards, to the mid-point between the
anterior superior iliac spine and the pubic symphysis (right
and a left lateral line drawn vertically through points halfway
between the anterior superior iliac spines and the middle
line).
abdomen to connect the lowest points on the costal margin);
and the interiliac (passing across the abdomen to connect the
tubercles of the iliac crests)

5. subcostal
interiliac

8. Anterior
Anterior Back
Back

9. Inspection of the Back

10. Inspection of the Anterior Abdominal Wall
Inspection of mid-line
from above downward
Inspection of the sides
1- Subcostal angle
2- Epigastric pulsation
3- Divarication of recti
4- Umbilicus
5- Suprapubic hair distribution
6- Hernial orifices
1- Contour of the abdomen
2- Collateral (dilated veins)
3- Skin
4- Scars
5- Movement with respiration
6- Visible peristalsis

15. III. Hernia
IV. Dilated veins
V. Skin
internal hemorrhage)
VI. Discharge:

20. slightly full abdomen
Scaphoid abdomen
but not distended

21. • examination of abdominal
contours
– Standing at the foot of the table
– Lower yourself until the anterior
abdominal wall
– ask the patient to breathe
normally while you are inspect
the abdomen.

22. Generalized abdominal
distension
Localized abdominal
distension
1- Fluid (ascites)
2- Fat (obesity)
3- Flatus and Faeces
4- Foetus (pregnancy)
5- Full urinary bladder
1- Site
2- Shape and size
3- Pulsate on cough (hernia
or not)
4- Movement with
respiration
5- Extra-abdominal or Intra-
abdominal (by asking the pt.
to sit up in bed unsupported)

23. Localized bulge

24. Generalized abdominal distension

25. IVC obstruction Portal vein obstruction
1- Site of
collaterals
Laterally (Sides) Around umbilicus (caput
medusa)
2- Blood
flow
From below upwards
“towards the head”
(to bypass the
bypass the IVC via
abdominal wall veins to
the thorax)
Away from the
umbilicus”towards the legs”
(the blood pass from the left
branch of portal vein to para
umbilical vein to anterior
abdominal wall veins through
the umbilicus)
3- cause in
hepatic Pt
Functional compression
on IVC by tense ascites
Intra-hepatic causes of portal
hypertension

26. Methods of Detection
- The 2 index fingers of both hands are used to milk the blood
then can be lifted one by one, while observing the rate of
will be seen coming more rapidly from the direction of blood
flow.

27. Caput medusa
Head of medusa

28. Caput medusae accentuated by marked ascites.
An extensive plexus of veins is seen radiating from the umbilical region
and radiating across the anterior abdominal wall. Note the large vein
coursing inferiorly along the right flank (arrows). This is the superficial
epigastric vein.

33. It is often difficult to understand whether tiny red spots arising on skin
surface are Petechiae or Purpura. However, Petechiae spots have a very
small diameter that is maximum 3 mm in size. Purpura rashes are larger
in size. These have a diameter that is about 5 mm. A spot that is bigger
than Purpura is known as common bruise or echymosis
Echymosis
Abdominal
petichae

39. General rules for palpation

40. General rules for palpation

42. Normally palpable structures
1. Contracted muscles of abdominal wall in muscular persons
2. Colon (caecum and sigmoid) is felt when it is spastic (full of gas or
fluid)
3. Vertebra (L4 – L5)
4. Pulsations of abdominal aorta (usually felt below the umbilicus)
in thin persons
5. Lower pole of Rt. Kidney (especially in female with thin lax
abdominal wall)
6. Liver edge descends 1-3 cm below the costal margin on deep
inspiration, but the consistency is soft and difficult to feel.
7. Occasionally, a tongue-like process (reidel’s lobe) is felt (which is
an anatomical variation of the Rt. lobe), moves with respiration

43. Types of Palpation
Superficial
Superficial Deep
Deep

44. For:
-Confidence of the patient
-Superficial masses
-Tenderness
-Rigidity
-Temperature
till the suprapubic area”
Superficial Palpation

45. • Technique
– Use pads of three fingers (palmar surface of fingers) of
one hand and a light, gentle, dipping maneuver to
examine abdomen
– Abdominal wall depressed approximately 1 cm

46. Palpating the abdomen – Light palpation

47. Palpating the abdomen – Light palpation

48. Deep Palpation
For :
-Organs “liver, spleen, gall bladder, kidney, colon, urinary
bladder”
- Masses (ask the patient to flexes his neck as this contracts rectus muscles)
-Areas of deep tenderness and rebound (pain induced or
increased by letting go)
Deep palpation include the following methods
-Ordinary technique “classic”
-2 handed method
-Bimanual
-Dipping
-Hooking
-Rolling

49. • Technique
– Entire palm (use palmar surface of fingers of one hand; greatest
number of fingers) and a deep, firm, gentle maneuver to examine
abdomen
– Either one- or two handed technique is acceptable (When deep
palpation is difficult, examiner may want to use left hand placed
over right hand to help exert pressure)
– Palpate tender areas last
– Palpate deeply with finger pads (do not “dig in” with finger tips)
– Abdominal wall depressed around 4 cm or Push as deeply as
patient will allow without significant discomfort.

50. Palpating the abdomen – Deep palpation

53. Surface anatomy of the Spleen
11th
rb
Medial end
Lateral
end
10th
rb
9th
rb
10th
rb

54. Diaphragmatic surface
Visceral surface
u
p
p
e
r
b
o
r
d
e
r
Lower
border

55. under the subcostal margin
becomes palpable subcostaly
direction of further enlargement is downward and towards
the Rt. Iliac fossa
but it can be said that the spleen is not felt

56. Methods of Deep Palpation
- in the supine position - in the Rt lateral position)

57. Classical method (single-handed method)

58. Two handed method

59. Bimanual examination in supine position

60. Palpating the spleen – Bimanual
palpation in supine position

61. Palpating the spleen – Bimanual palpation in
supine position

62. With the patient in the right lateral position, minimal splenic
enlargement can be detected
Palpating the spleen – Bimanual palpation in
Rt. Lateral position

63. Palpating the spleen – Bimanual palpation in Rt.
Lateral position

64. Palpating the spleen – Bimanual palpation
in Rt. Lateral position

65. Examining for the spleen from behind the patient, in the right
lateral position. In this case, the fingers are "hooked" over the
costal margin.
Hooking method

66. Nature of this palpable spleen (put a comment on):
1. Size
2. Border
3. Surface
4. Consistency
5. Tenderness (e.g. due to splenic infarction, septicemia,
SBE)

67. Applied anatomy and physiology of the spleen
so, any condition “infectious; immunologic; metabolic; malignant or
idiopathic” that causes hyperplasia of the lymphoid/RES may cause
splenomegaly
interference with its venous drainage as in portal hypertension will
cause splenomegaly “congestive splenomegaly”
forming organ throughout life, so, in myelosclerosis and myelofibrosis,
extramedullary hematopoiesis may occur in the spleen with
splenomegaly
anemias, this function is increase with splenomegaly “except in sickle
cell anemia”

68. Causes of Huge Spleen (below the umbilicus)

69. Hypersplenism
- Whenever the spleen is enlarged, hypersplenism may occur
-It is characterized by
normochromic anemia, neutropenia, thrombocytopenia in
the CBC) due to hyperfunction of the spleen

70. Characters of splenic swelling to be differentiated
from the Lt. kidney
(upper) border “PATHOGNOMONIC”
costal margin to get above its upper pole
angle)
dullness

73. Upper border is marked by joining the following points:
Lower border is marked by curved line joining the following points:

74. Xiphisternal junction
Rt. 5th
rib
Rt. 7th
rib
Rt. 9th
rib
LT. 5th
space
umbilicus

75. Rt. 9th
costal
cartilage
LT. 5th
space
LT. 8th
costal
cartilage
Midway
between
umbilicus
&xiphisternum
umbilicus
Rt. 10th
rib

76. Technique of detecting the liver
dullness”
percussion
After palpation of the lower border of the liver, you must
comment on
I. Liver span : Distance between the upper and lower
borders of the liver; which is
lobe”
lobe”

77. II.Nature of this palpable liver (put a comment on):
1. Size “in finger breadth or cm”
“liver cirrhosis and fibrosis”
2. Surface
- smooth “congestion, inflammation, infiltration”
- fine irregular “cirrhosis”
- nodular “malignancy”
2. Edge
- sharp “cirrhosis, fibrosis”
- rounded “congestion, inflammation, infiltration”

78. 4. Consistency
- soft “congestion, inflammation, infiltration”
- firm “cirrhosis, fibrosis”
- hard “malignancy”
5. Tenderness: congestion, inflammation, infiltration, malignancy
6. Pulsation: TI, TS, hemangioma

79. Methods of Palpation
- Single-handed palpation is used for lean individuals, while the
bimanual technique is best for obese or muscular individuals. Using
either technique, the liver is felt best at deep inspiration.

80. Single-handed
method
- For single-handed palpation, the examiner's right hand is initially placed on the
patient's abdomen in the right lower quadrant and parallel to the rectus muscle in
the MCL. This is done so that palpation of the rectus is not confused with palpation
of the underlying and adjacent liver
- Gently pressing in and up, ask the patient to take a deep breath.
be recognizable.

81. index finger. In this method the anterior hand is placed flat on the
anterior abdominal wall with fingers parallel to the costal margin

82. the left hand is held posteriorly,
between the 12th
rib and the iliac crest.
It is lifted gently upward to elevate the
bulk of the liver into a more easily
accessible position, while the right
hand is held anterior and lateral to the
rectus musculature. The right hand
moves upward using gentle, steady
pressure until the liver edge is felt.
Bimanual palpation
of Liver

83. Bimanual palpation
of Liver

84. – Is useful when the
patient is obese or
when the examiner is
small compared to the
patient.
– Stand by the patient's
chest.
– "Hook" your fingers
just below the costal
margin and press
firmly.
Hooking method

85. Hooking
method

86. Causes of ptosed liver
Causes of upward displacement of the liver

87. Percussion is a method of tapping on a surface to determine the
underlying structure

88. Technique
-It is done with the middle finger of Rt. hand (plexor) tapping on DIP of
the middle finger of the Lt. hand (pleximeter) using a wrist action.
-The non striking finger (pleximeter) is placed firmly on the abdomen,
remainder of hand not touching the abdomen.
-Remember that it is easier to hear the change from resonance to
dullness – so proceed with percussion from areas of resonance to areas
of dullness.
pleximeter
plexor

89. There are two basic sounds
– Resonant sounds indicates hollow, air-filled structures. The
abdomen gives resonant note which varies according to the
amount of gas present in the intestine.
– Dull sounds indicates the presence of a solid structure (e.g. liver)
or fluid (e.g. ascites) lies beneath the region being examined

90. Percussion of the abdomen
-The abdomen gives a resonant note which varies according to the
amount of gas present in the intestine
-Type of percussion: Light percussion
-Values:
organomegaly).
dullness) in;
- Perforated peptic ulcer and colon
- Subphrenic abscess with gas forming organisms

91. • The two solid organs which are
percussable in the normal
patient
– Liver: will be entirely covered by
the ribs.
– Spleen: The spleen is smaller and
is entirely protected by the ribs.

92. Percussion “liver”
Upper border
percussing the 2nd
intercostal space in the Rt. MCL (Start just
below the Rt. breast in RT. MCL). Percussion in this area should
produce a relatively resonant note
about ½ to 1 cm at a time (in the intercostal spaces).
space in the RT. MCL
Lower border
proceed upward until dullness is encounter.

93. The liver span is estimated by percussion
The distance between the two areas where dullness is first encountered is the liver span.

95. Percussion “spleen”
- Percussion of Traube’s area
- Splenic percussion sign “Castell’s method”
- Nixon’s method

96. Traube's area
6th
rib in MCL to the Lt 9th
rib in mid-axillary line)
in MCL to the Lt. 8th
costal cartilage)
mid-axillary line)
to Lt. 11th
space in mid-axilary line )

98. 1. Full stomach/ gastric tumours.
2. Left sided Pleural effusion / pericardial effusion “from above”.
3. Ascites/abdominal tumour “from below”
4. Splenomegaly “from left side”.
5. Enlargement of left lobe of liver “from the right side”.

99. Castell’s method “Splenic percussion sign”
line (usually the 8th or 9th IC space) while patient inhales and
exhales deeply
positive Castell’s sign)

100. Castell’s point

102. Nixon’s method
margin, this indicates possible splenomegaly

103. Ascites is free collection of fluid within the peritoneal cavity.
The classical signs of ascites include; abdominal distension, shifting
dullness, fluid thrill.

104. Bilateral shifting dullness
1.The patient is examined in the supine position.
2.Percussion is done over the abdomen, from the umbilicus to one flank.
3.The spot of the transition from tympany to dullness is detected.
4.The patient is then turned to the opposite side, while the examiner keeps his
hand unmoved.
5. Percussion of the same spot (which is top now) gives a tympanic note.
Note: The tympany over the umbilicus occurs in ascites because bowel floats
to the top of the abdominal fluid.
air
air
fluid
fluid

105. Transmitted fluid thrill
Pathognomonic foe ascites when the amount of fluid is large
1.The patient is examined in the supine position.
2.The patient or an assistant places one hand in the midline and
presses firmly with the ulnar border of the hand , so cut off any
vibrations transmitted by the abdominal wall.
3.The examiner places one palm on one flank, while giving a sharp tap
with the finger tips on the opposite flank.
4.Positive test: a definite wave “impulse” will be distinctly felt by the
receiving hand.

107. • Diaphragm of stethoscope used
• Skin depressed to approximately 1 cm
• Listening in one spot is usually sufficient
• Listening for 15-20 or 30-60 seconds

108. Values of auscultation
fluid in intestine) sounds.
obstruction
N.B. Bowel sounds cannot be said to be absent unless they are
not heard after listening for 3-5 minutes.

109. 2. To hear vascular sounds
Arterial bruit Venous hum
(Wind at sea shore)
Systolic murmur Systolic and diastolic sound in the
epigastrium, and Lt. hypochondrial
region “Kenawy sign”
Occurs in cases of
-Abdominal aortic aneurysm
-Renal artery stenosis
-Over very vascular tumour
“e.g. hemangioma”
Occurs in cases of
- portal hypertension due to porto-
systemic anastomosis (collateral)

110. a dry, grating sound heard with a stethoscope during auscultation; may
be heared over enlarged liver or spleen
perisplenitis
with perihepatitis (inflammatory changes or infection in or
adjacent to the liver). If detected in a young woman, the
examiner should consider gonococcal peritonitis of the upper
abdomen (Fitz–Hugh–Curtis syndrome).
N.B. A hepatic rub and bruit in the same patient usually indicates
cancer in the liver. A hepatic rub, bruit, and abdominal venous
hum would suggest that a patient with cirrhosis had developed a
hepatoma.

111. 4. To detect lower border of the liver (scratch method)
scratching sound heard in the stethoscope will increase significantly
5. To detect minimal ascites (Puddle’s sign)
It is useful for detecting small amounts of ascites (as small as 120 mL;
shifting dullness and bulging flanks typically require 500 mL).
The steps are outlined as follows:

112. Scratch Test
Start in the same areas
above and below the
liver as you would with
percussion. Instead of
percussing lightly,
scratch moving your
finger back and forth
while listening over the
liver. Since sound is
conducted better in
solids than in air, when
the louder sounds are
heard you are over the
liver. Mark the superior
and inferior boarders of
the liver span in the
midclavicular line

113. stomach with gas and fluid)
hours after a meal will generate a splash sound.