1. ABDOMINAL EXAMINATION
Afonso Sequeira
3rd year – General Medicine
Clinical Sessions 2011

2. GASTROINTESTINAL EXAMINATION
General examination
General inspection
Hands and arms
Face, eyes and mouth
Neck
Abdominal examination
Inspection
Palpation
Percussion
Auscultation

3. GENERAL INSPECTION Nutritional state (wasting) Pallor
Jaundice (liver disease)
Pigmentation (hemochromatosis)
Mental state (encephalopathy)
Nutritional state – record weight, height, waist circumference
May indicate
haemochromatosis
iron overload indicates accumulation of iron in the body

4. HANDS Nails Palmar erythema Dupuytren’s contractures Hepatic flap
Clubbing
Koilonychia
Leuconychia
Palmar erythema
Dupuytren’s contractures
Hepatic flap
Koilonychia (spoon shaped)
iron-deficiency anemia
Leuconychia
Are a sign of hypoalbuminaemia due to liver d., malabsorption, protein malnutrition or nephrotic syndrome.
Dupuytren’s contracture
is a painless thickening and contracture of tissue beneath the skin on the palm of the hand and fingers.
Presence of thickened scar tissue (fibrosis) and contracture
Hepatic flap
Asterixis describes a motor disturbance characterised by intermittent lapses of an assumed posture. It is commonly associated with liver failure where it produces the flapping tremor of hepatic encephalopathy characterised by jerky, irregular flexion-extension movements at the wrist and metacarpophalangeal joints, often accompanied by lateral movements of the fingers.

5. Dupuytren’s contractures
HANDS
Dupuytren’s contracture
is a painless thickening and contracture of tissue beneath the skin on the palm of the hand and fingers.
Presence of thickened scar tissue (fibrosis) and contracture
Palmar erythema
Dupuytren’s contractures

6. ARMS Spider naevi (telangiectatic lesions) Bruising Wasting
Scratch marks (chronic cholestasis)

7. FACE, EYES … Conjuctival pallor (anaemia) Sclera: jaundice, iritis
Cornea: Kaiser Fleischer’s rings (Wilson’s disease)
Xanthelasma (primary biliary cirrhosis)
Parotid enlargement (alcohol)
Uveitis, Iritis
Uveitis is swelling and irritation of the uvea, the middle layer of the eye. The uvea provides most of the blood supply to the retina.
Kayser-Fleischer rings
are dark rings that appear to encircle the iris of the eye. They are due to copper deposition as a result of particular liver diseases.

8. Parotid enlargement Xanthelasma
Xanthoma is a skin condition in which fat builds up under the surface of the skin.
Xanthelasma

9. … AND MOUTH Breath (fetor hepaticus) Lips Gums Tongue
Angular stomatitis
Cheilitis
Ulceration
Peutz-Jeghers syndrome
Gums
Gingivitis, bleeding
Candida albicans
Pigmentation
Tongue
Atrophic glossitis
Leicoplakia
Furring
Monilia is a yeast-like fungus (Candida albicans), which by nature is a saprophyte
Atrophic glossitis - B12 and folate deficiency
Leukoplakia
is a clinical term used to describe patches of keratosis. It is visible as adherent white patches on the mucous membranes of the oral cavity, including the tongue, but also other areas of the gastro-intestinal tract, urinary tract and the genitals.

10. Atrophic glossitis
Thrush

11. NECK AND CHEST Cervical lymphadenopathy
Left supraclavicular fossa (Virchov’s node)
Gynaecomastia
Loss of hair
Troisier's Sign
Enlargement of Virchov’s node
More widespread lymphadenopathy with hepato-splenomegaly suggests lymphoma.
Due to reduced oestrogen metabolism by the liver. In men may be a feminizing effect (gynaecomastia, loss of hair and testicular atrophy)

12. ABDOMINAL EXAMINATION POSITIONING
Abdomen can be divided in four quadrants
Patient should be lying on supine position
In order to accurately localize the findings on physical examination, one usually divides the abdomen into four quadrants:
Upper right and left
Lower right and left
The dividing lines are:
Vertically, a connecting line between the xiphoid process and the pubic symphysis;
Horizontally, a line across the umbilicus.
Examine the patient in good light and warm surroundings.
Position the patient comfortably supine with the head resting on one pillow in order to relax the muscles of the abdominal wall.

13. ABDOMINAL EXAMINATION INSPECTION
Shape and movements
Scars
Distension
Localised: mass, organomegaly
Generalized: 5 F’s
Prominent veins (caput medusae)
Striae
Bruises
Pigmentation
Visible peristalsis
Shape and movements with respiration – flat or slightly scaphoid (shaped like a boat)
Scars from previous surgical procedures
Distension
Localised: malignancy, hepatopathy, splenomegaly
Generalized: Fat (obesity), fluid (ascites), flatus (obstruction), faeces (constipation), fetus (pregnancy)
Prominent veins (caput medusae) in portal hypertension blood flows trough portocaval anastomoses. Image: end stage liver disease
Striae
Visible peristalsis

14. Tête de Méduse, by Peter Paul Rubens (1618)

15. Campbell de Morgan spots Ascitic abdomen
Pigmentation: Cherry angiomas "Campbell De Morgan spots," cherry red papules on the skin containing an abnormal proliferation of blood vessels. They are the most common kind of angioma.
Ascites – bulging flanks
Ascitic abdomen

16. ABDOMINAL EXAMINATION PALPATION
Ensure that your hands are warm
Stand on the patient’s right side
Help to position the patient
Ask whether the patient feels any pain before you start
Begin with superficial examination
Move in a systematic manner through the abdominal quadrants
Repeat palpation deeply.
Leave the painful area for last. Move in a systematic manner through the nine regions of the abdomen in the direction of the painful area.
Make sure you use the pads of your fingers and not the finger tips as this might hurt the patient.

17. ABDOMINAL EXAMINATION PALPATION
Tenderness: discomfort and resistance to palpation
Involuntary guarding: reflex contraction of the abdominal muscles
Rebound tenderness: patient feels pain when the hand is released
Tenderness + rigidity: perforated viscus
Palpable mass (enlarged organ, faeces, tumour)
Aortic pulsation
ABNORMAL FINDINGS

18. ABDOMINAL EXAMINATION MURPHY’S SIGN
Pain in RUQ
Inflammation of gallbladder (cholecystitis)
Courvoisier's law
Murphy's sign
sign of gallbladder disease consisting of pain on taking a deep breath when the examiner's fingers are on the approximate location of the gallbladder.
Pain on inspiration during gentle palpation below the right subcostal arch. As the patient breathes in, the liver moves down exposing the gallbladder to pressure from the examiners hand. Murpy’s sign may also be present with hepatitis.
The gallbladder (GB) is filled with echogenic sludge (Sl) and a gallstone (red arrow) is impacted in the gallbladder neck.  The gallbladder wall (red arrowheads) is markedly thickened indicative of wall edema and there are pericholecystic fluid (blue arrows) pockets surrounding the gallbladder.
Courvoisier's law
states that in the presence of an enlarged gall bladder which is nontender and accompanied with jaundice, the cause is unlikely to be gallstones.

19. ABDOMINAL EXAMINATION BLUMBERG’S SIGN
a.k.a. rebound tenderness
Pain upon removal of pressure rather than application of pressure to the abdomen
Peritonitis and/ or appendicitis

20. ABDOMINAL EXAMINATION MCBURNEY’S POINT
1/3 ASIS to umbilicus
Location of AV in retrocecal position
Deep tenderness (= acute appendicitis)
From ASIS (anterior superior iliac spine) to the umbilicus.
Determines:
- location of appendix (varies)
- deep point = acute appendicitis

21. ABDOMINAL EXAMINATION FLUID THRILL
Place the palm of your left hand against the left side of the abdomen
Flick a finger against the right side of the abdomen
Ask the patient to put the edge of a hand on the midline of the abdomen
If a ripple is felt upon flicking we call it a fluid thrill = ascites
IF IT IS NOT CLEAR

22. ABDOMINAL EXAMINATION PALPATION OF THE LIVER
Start palpating in the right iliac fossa
Ask the patient to take a deep breath in
Move your hand progressively further up the abdomen
Try to feel the liver edge
Try to feel the liver edge and work out if it is enlarged or displaced downwards.

23. ABDOMINAL EXAMINATION PALPATION OF THE SPLEEN
Roll the patient towards you
Palpate with your left hand while using your left hand to press forward on the patient’s lower ribs from behind
Feel along the costal margin
Try to feel the liver edge and work out if it is enlarged or displaced downwards.

24. ABDOMINAL EXAMINATION PERCUSSION
Dull sounds: solid or fluid-filled structures
Resonant sounds: structures containing air or gas

25. ABDOMINAL EXAMINATION AUSCULTATION
Place the diaphragm of the stethoscope to the right of the umbilicus
Bowel sounds (borborygmi) are caused by peristaltic movements
Occur every 5-10 sec.
Absence of b.s.: paralytic ileus or peritonitis
Bruits over aorta and renal a. could be a sign of an aneurysm and stenosis

26. VIDEO

27. ABDOMINAL EXAMINATION

28. THANK YOU FOR YOR ATTENTION.
Afonso Sequeira
3rd year – General Medicine
Clinical Sessions 2011