Abdominal Examination

Examination

6 minutes

Introduction + Inspection

WINDEC:

• Wash hands, introduce yourself

• Ask for name, ask in any pain

• Explain the examination and ask for consent

Exposure

• Lying 45 degrees- abdomen exposed, if male ask to take top off and move shorts onto hips; female- shorts onto hips and top to below the bra line (and chest inspection when do it, then re-cover up)

Inspection

End of the bed 

• Patient: jaundice, ascites, masses, caput medusa, tattoos, scars, nutritional status, bruising

• Medications/ devices around the bed- creon, oxygen

• Breathe to calm own nerves + steady self 

Peripheral

Lying at 45 Degrees

Lower limbs

• Peripheral oedema

Hands

• Tremor: fine/ coarse

• Flap (ideally 10s)

• Hands: duputyren's contracture, palmar erythema, jaundice

• Nails: finger clubbing, leukonychia, kolionychia,

• Pulse: regular, rate

Arms

• Lines or fistulas (!)- recent access, buzz palpate, thrill

Face

• Eye- conjunctival pallor, scleral jaundice

• Mouth- tongue: central cyanosis, mouth ulcers (Crohns)

Neck

• JVP- hepatojuglar reflex is normal [at 45 degrees!]

Sit up right at 90 degrees

Neck cont.

• Cervical lymphadenopathy

• Auxillary lymphadenopathy  [ :-( ] : end of exam with gloves

Chest & Back

• Inspection: spider naevi > 5; gynaecomastia (palpate)

• Important to look at the back for posterior nephrectomy scars (easy to miss)

Abdomen

Adjust the patien's bed: the patient should be lying flat- not doing this could result in a fail

Inspection

• Scars- use finger to trace outline to highlight to examiner

• Jaundice, masses, bruising

Palpation

• Superficial for tenderness, (start in LIF as nil masses there)

• Deep for masses (two hands)

• Palpate liver edge- if able to feel liver: hepatomegaly, RIF to RUQ, push on inspiration

• Palpate spleen edge- splenomegaly if able to feel, RIF to LUQ, push inspiration

• Ballot kidneys- loin- just above iliac posteriorly, normal to feel aorta in young skinny

• Aortic aneurysm- normal to feel aorta (pulsatile mass, not expansile) in young skinny

• Palpate Bladder

Percussion

• Hepatomegaly- RIF to right shoulder, above (nipple line) and below; typically 5th intercostal space to lower costal margin

• Splenomegaly- RIF to LUQ

• Shifting dullness- percuss across abdomen, 

  • Roll onto their right side facing you and repeat percussion on raised left flank- ?fluid moved; 

  • Repeat splenomegaly palpation with patient on side 

Auscultation

• Bowel sounds in RIF (ileocecal valve)

• Renal bruit- either side of umbilicus ?renal artery stenosis

• Auscultate liver ?hepatic bruit

Conclusion

• Thank patient, shake hands & assist to cover up, wash hands. 

Core Presentations

Summary

1. Kidney

   1. End Stage Kidney Disease

      1. Transplant

      2. Dialysis- peritoneal, haemodialysis

   2. Polycystic Kidney Disease, diabetes,

   3. Surgery: nephrectomy

2. Liver

   1. Chronic Liver Disease

   2. Hepatomegaly

   3. Surgery: liver transplant, intrabdominal surgery, liver biopsy

3. Spleen

   1. Hepato-splenomegaly +- lymphadenopathy

   2. Splenomegaly 

4. Normal Examination

Structure

1. Introduction: I've examined Mrs Jones today. 

Can mention examination done to give yourself time and mention age if young. 

2. My positive findings are: ...

The examiner cannot give you mark for signs you've seen unless you mention them. It can be reasonable to talk aloud whilst examining to allow the examiner to give you a second chance and help prompt yourself. If there are a lot of signs I'll often state I've identified 6 positive signs. State the signs with minimal intepretation. 

3. My differential is: , overall differential if clear or for each sign is reasonable. 

4. Severity: signs of organ decompensation- if not 'euvolaemic' is a good term to state nil liver or renal failure. 

5. Underlying aetiology evidence- if nil, state what would be most common for age group

6. Complications- particulalry transplant medication side effects

7. To complete my assessment: history, examination, observations,

8. Investigations: bedside, body samples, imaging, interventions

9. Management: MDT, lifestyle, medical, surgical 

Kidney

End stage renal disease

• Fistula

• Central lines

• Causes - diabetes, 

• Abdominal scars

Renal Transplant

• Large scar in LIF and RIF

• Bilateral ballotable kidneys

• End stage renal disease (fistula/ lines)

• Commonest cause (4) of renal transplant: diabetes, hypertension, ADPKD, glomerulonephritis

Kidney Transplant

• Mass in LIF or RIF with scar. 

• Often the original kidney is left, worth checking for a scar to see if it has been removed. 

• Signs of end stage kidney disease- fistula: haemodialysis or peritoneal dialysis. 

• Questions of kidney disease ?polycystic ?diabetes, e.g.. 

Chronic kidney disease- dialysis

• Signs of end stage kidney disease- fistula: haemodialysis or peritoneal dialysis. 

• Cause of kidney disease ?polycystic ?diabetes, e.g.. 

Polycystic Kidney Disease

• Signs: bilateral ballotable kidneys +- hepatomegaly +- renal transplant/ ESRD

• Genetic: autosomal dominant

• Types: ADPKD1, ADPKD2

• Diagnosis: imaging + genetic testing

• Investigations: 

5. Kidney Transplant with RRT

I examined Ms Jones. There was a J shaped scar in the right iliac fossa with a palpable mass beneath. This would be consistent with a renal transplant. There were two abdominal scars- one 3cm midline below the umbilicus and another 2cm scar laterally, which could be consistent with peritoneal dialysis. There was a fistula with a palpable thrill and no needling skin changes consistent with recent use. The patient is euvolaemic, therefore this suggests the renal transplant is functioning. In the absence of ballotable masses or evidence of needlestick signs from diabetes, the most common cause would be hypertensive nephropathy. 

6. Polycystic Kidney Disease

I examined Ms Jones. There were mass in the left and right flank that I was able to get above and were ballotable. This would be consistent with polycystic kidney disease. There were no signs of renal replacement therapy and Joe was euvolaemic therefore I believe Ms Jones has not entered end stage renal failure.

Liver 

Decompensated liver disease

• Signs: jaundice, ascites, bleeding- oesphageal/ rectal varices, bruising, encephalopathy

• Chronic

  • Causes: Alcohol, MASLD, viral HBV + HCV, haemochromatosis, paracetamol 

  • Signs: portal hypertension- caput medusa; chronic changes- palmar erythema, duputyren's contracture

• Acute

  • Causes: acute hepatitis- alcohol, viral hep A, B, E; drugs- paracetamol OD (rarely causes ascites)

Liver Transplant

• Stigmata of chronic liver disease- dupuytren contracture, palmar erythema, finger clubbing

• Cause of liver decompensation- e.g. metabolic syndrome

• Scar

Chronic Liver Disease

• Dupuytren contracture, palmar erythema, finger clubbing

• Decompensation- jaundice, ascites, encephalopathy (flap), bleeding- oesphageal/ rectal varices, caput medusa (portal hypertension)

Hepatomegaly 

Aetiology

• Chronic liver disease: Alcoholic hepatitis, Fatty liver disease- MASLD; with portal hypertension it is common to not be able to detect the splenomegaly

• Liver Cancer

• Polycystic liver disease- may have polycystic kidney massess palpable

7. Liver Transplant

I examined Ms Jones. There were stigmata of chronic liver disease- palmar erythema and duputyrens contracture and a large 15 cm transverse scar across the upper abdomen. This scar could be consistent with a liver transplant, although other hepatobiliary surgeries such as malignant liver resection or bilateral adrenalectomies would also be possibilities. In summary these signs would be consistent with chronic liver disease resulting in a liver transplant. There were no signs of hepatic decompensation on examination. Given the patients normal weight, the commonest cause of chronic liver disease in this patient would be alcohol related.

8. Chronic Liver Disease

I examined Ms Jones. There were stigmata of liver disease- palmar erythema, duputyrens contracture, gynaecomastia, ascites, jaundice and hepatosplenomegaly. The ascites and jaundice are consistent with liver decompensation and the duputyren's contracture and gynaecomastic suggest a chronic disease. Given Ms Jones' metabolic profile, the likely cause of her decompensated liver disease would be MASLD. 

9. Hepatomegaly

I've examined Ms Jones. My positive findings are hepatomegaly of 3cm below the sternal margin, non tender; and a midline umbilical scar 3cm which could be consistent with an umbilical hernia.

Spleen

Hepatosplenomegaly 

Aetiology

• Chronic liver disease with portal hypertension- note it is unusual to be able to detect the splenomegaly

• Reactive (spleen is lymph node): 

Splenomegaly 

Aetiology

• Felty's syndrome, 

• Reactive (spleen is lymph node): EBV

Massive splenomegaly: myelofibrosis, CML, primary splenic lymphoma

10. Hepato-splenomegaly

I've examined Ms Jones. My positive findings are hepatosplenomegaly. The hepatomegaly was 4cm below the sternal margin and tender. There was a mass in the left upper quandrant that I was unable to get above, consistent with splenogemaly 3cm below the sternal margin. The commonest cause of hepatosplenomegaly would be portal hypertension and given the patients BMI, alcohol would be the commonest cause. There was no signs of liver decompensation. 

11. Splenomegaly

I've examined Ms Jones. My positive findings are splenomegaly 5cm below the sternal margin. There was a mass in the LIF that I was unable to get above. In the abscence of other clinical signs my differential would be broad, but include haematological malignancy, infection and inflammatory. 

12. Lymphadenopathy

Everything Else

Abdominal Scar 

Signs

• Describe scar: transverse, longitudinal, estimate length, laparoscopic or laparotomy

• Location in abdomen

• Function: within which cavity ?abdominal and close to which organs

• No signs of CLD, CKD or splenic disease

• Differentials: intrabdominal surgery, stoma, ports, liver biopsy; skin/ soft tissue 

Presentation

I've examined Mr Smith's abdomen. My only positive finding was a 6cm transverse scar on the left side of the anterior abdomen at the level of the umbilicus. This scar's length suggests it may be caused by an incision, rather than laparoscopic port. It could be used for surgical operations of the abdomen and I note its proximity to the liver. I note it may be caused by a superficial skin malignancy or trauma. Mr Smith was euvolaemic and I identified no signs of liver, kidney or systemic disease that may have resulted in the indication for this scars procedure. I identified no complications from this scar or its associated condition. 

Abdominal Mass 

Signs

• Location

• Palpate abdominal mass: painful, round/ craggy

• Unable to get above (liver & spleen), ballotable (kidneys)

• Estimate size

• Differentials: malignancy- lymphoma, ovarian, metastatic disease; benign- uterine fibroids

Presentation

I've examined Mrs Smith's abdomen today. My positive findings were a large abdominal mass located in the left side of the abdomen. I was able to get above but not able to ballot. It felt smooth and was midly painful. I did not identify any sign of Mrs Smith appeared euvolaemic and there were no signs of organ decompensation or any signs of liver, renal or systemic disease that may have caused the mass or be caused by the mass.

Normal Examination

• Don't make up signs 

I've examined Ms Jones. My examination was normal and I did not elicit any positive clinical signs of disease. Ms Jones appeared euvolaemic and there was no signs of liver, renal or other organ decompensation or signs of an underlying GI or systemic disease. In order to complete my assessment I would like to take a history, asking in particular about why she seeked medical advice or any symptoms she may be having. The presentation would guide the requirement for further examination, observations, investigations and management.