Abdominal Exam

History
Pain, Nausea/Vomit, Bleeding, Weight change, Distension (fat, fluid, foetus, faecal, flatulence), Stool/Urine
Observation
General

Demeanour
Breath

Hands

Facial appearance
Skin
Habitus
Sweaty
Temp
Colour
dupuytren's contracture
Spider naevi

Nails

Haemangeoma
Leuconychia
Koilonychia
Brown
Splinter hemorrhage
Clubbing

Feet

Pitting oedema

Face

Temp and colour

Colour

Peripheral central
Distress on exertions. Wind (diet?), Belching (excess swallowing hiatus hernia?)
Smelly Liver
Sweet Diabetes
Pruritis - Jaundice
Oedema, Gynacomastia (liver-oestrogen), Obesity/cachexia
anxiety, hyperthyroidism
Cold + blue peripheral cyanosis
Warm + blue central cyanosis
Red, erytheama Liver, hyperthyroidism, RA, nicotine stains
Liver, alcohol, diabetes, smoking
Not >5 on hands+trunk above nipples.
Chronic liver disease, Oestrogen, pregnant
Cambell de Morgan spots, dots, no legs harmless
White nails Liver, chronic hepatitis
Iron deficiency, possibly blood loss
Kidney failure
Small emboli under nail. Manual worker, infective endocarditis
Fluctuation nail/bed angle, nail curvature, ST bulk
Heart Subacute bact endocarditis, Cyanotic congenital heart disease
Lung Bronchial carcinoma, Fibrosing alveolitis
GI Cirrhosis, Ulcerative colitis, Crohns disease
Idiopathic
press 20 sec, again higher up. R heart fail, congested vena cava, liver, kidney disorder,
DVT, hypoalbuminia (osmotic pressure), low protein diet
As in hands
Yellow jaundice
Silver/grey Iron
Pallor Oxygenated Hb in skin
Blue Cyanosis
Malar flush rosy cheeks

Eyes

Sclera
Conjunctiva

Mouth
Tongue

Around orbit
Ulcers
Angular stomatitis
Colour

Chest

Sub-lingual
Gynacomastia
Spider Naevi

Abdomen

Scars
Striae
Bruised umbilicus
Distension
Varicose veins
Caput medusa
Engorged superficial veins

Yellow jaundice
Blue Osteogenesis imperpecta
Corneal arcus Silvery whit line (>50), in young hyperlipedemia
Pale Anemia
Blue cyanosis
Bleeding capillaries NSAID, hypertension
Xanthelasma yellow blisters, hyperlipedemia, poss liver dysfunction
Virus, HIV, rheumatological conditions
Crack at corners, dont heal well Anemia, malabsorbtion, iron/folic A, Vit B
Big beefy smooth red sore Glossitis, iron/folic A, Vit B
Pale Anemia
Brown/dry Mouth breathers, dehydrated , smokers
Blue central cyanosis
Creamy curd like Candida Albicus (Corticosteroids med)
Engorged sublingual veins Portal hypertension
Oestrogen, liver dysfunction ( breakdown)
Not >5 on hands+trunk above nipples.
Chronic liver disease, Oestrogen, pregnant
Surgery appendicectomy, C-section, Cholysystectomy (R subcostal),
Liver (B subcostal-mercedes-Benz scar)
Herniation umbilical, femoral, inguinal-in/direct
pink normal
dark Cushings syndrome
Hemorrhage, pancreatitis
look horizontally, stomach or pulsating aorta?
Longitudinal. IVC obstruction
Portal hypertension
around umbilicus IVC obstruction portal hypertension

Auscultation
Borborygma

Bruit

Rub
Palpation
Supraclavicular lymph
node (L drains
abdomen)
Each quadrant

Normal Bowel sounds every 5-10 sec

Absent paralysis, peritonitis
High pitch gas
Audible sounds bowel obstruction, dysmotility
Renal (2-3 cm above and lat to umbilicus) Stenosis, hypertension in young
Femoral (between ASIS, pubic tubercle) inguinal lig, Stenosis, aortic/iliac/femoral
aneurism
Liver (Below R nipple, ribs 510) Carcinoma, alcohol hepatitis
Liver if creak inflamed capsule
Spleen (L rib 911 in midline) inflamed capsule

Large palpable, soft

Shotty

Infection
Remains of old infection

Firm/rubbery/irregular
General lumps, masses
Rebound tenderness

Malignant disease
Peritoneal irritation

Liver

Spleen
(L axillary line,
rib 9 11)
Gallbladder
Appendix
Kidney
(Upper poles: L rib 11,
R rib 12. Lower poles:
3-4cm sup iliac crest)
Pulses

Downward displacement
Reidel lobe
Hepamegaly (enlarged)
+ smooth
+ irregular
Atrophy (small)
Splenomegaly
Splenectomy (absent)

Hyperinflated lung (percuss to check)

Lower lobe normal, especially in women
Right heart failure, malignant, hepatitis
Fatty liver. alcohol
Cirrhosis, Tumour
Cirrhosis, hepatitis
Portal hypertension, hemolytic anemia, virus, glandular fever
previous trauma, Hodgins disease

Murphys point
Murphys sign
Cholecystitis
Mc Burneys point
Rovsings sign
Iliopsoas sign
Atrophy

R mid cost margin

Press + inhale pain or catch breath
Inflamed from stones, cancer in pancreatic head
2/3 from ASIS umbilicus. Pain Appendicitis (pain start at umbilicus)
Press L iliac fossa pain R fossa = Acute appendicitis
Active resist psoas pain, inflammation = Retroiliac or Perinephic abscess
Most common. infection, trauma

Enlarged

Hydronephritis (blocked), polysystic kidney

Aorta
Femoral
Radiofemoral delay

Palpate between xiphisternum and umbilicus

Aneurysm pulsating, expanding at lat border of rectus abdominis
Between ASIS/pubic tubercle, below inguinal lig (get consent first!)
If weaker femoral aortic aneurysm or coarctaction (narrow)

Ascites

Below R nipple, Ribs 5 10

From resonant dull
L axillary line, Ribs 9 11
Fluid in peroteneal cavity ( albumin, osmotic pressure)

Percussion
Liver
Spleen
Peritoneum
Signs and Symptoms
Pain

Time
Type

Location
Nausea
Vomiting

With nausea
Without nausea

Flatulence

pain on empty stomach or at night peptic ulcers

pain after fatty diet, epigastric pain gallbladder
Visceral pain Deep at midline, diffuse, referred pain, sympathetic nerves from T5-L2
Perotineal pain Localised pain
Colicky pain From hollow structures (intestine) short (sec-min) intermittent pain.
If colicky pain suddenly become chronic poss mesenteric infarct
Epigastric area Foregut
Umbilical midgut
Supra pubic hind gut
Medication, pregnancy, upper GI (+vomiting)
Upper GI
With blood Oesophagus or gut
Green (bile) obstruct in deudenum past bile duct
Poss intra cranial pressure
lactase deficiency, intestinal malabsorbtion

Fluctuating distension
( day, night)
Diarrhoea

With pain
Without pain
Acute
Chronic
Type

Stools

Pale
Pale + greasy
Black tarry
Grey/black
Fresh blood
Mixed with pus
Watery with grain
Prehepatic (haemolytic)
Hepatocellular

Jaundice

Obstructive
Disorders
IBS
Liver disease
Cirrhosis
Primary biliary
cirrhosis
Anastomoses
Hepatitis

IBS, pregnancy
ovarian pathology
drugs (anti biotic), infection
IBS, hyperthyroid, cancer inflammation
Osmotic H20 absorption in colon, drugs, motility disorders
Secretory mucosal inflammation, viral/bacterial, ulcerative colitis, Crohns disease
Biliary obstruction (lack of pigment)
Fat malabsorbtion
Melaena, upper GI bleeding
Oral iron or bismuth therapy
Rectal/anal/large colon bleeding
ulcerative colitis, dysentery
Cholera (odorless rice water)
Stool + urine normal colour
Stool normal
Urine dark
Stool pale
Urine dark + pruritus

Abdominal pain, change of bowel habits and stool consistency, chronic, no rectal bleeding or weight loss.
Pt more sensitive to dairy, wheat, fat, caffeine.
Hepatomegaly, jaundice, ascites, Circulatory changes (palmar erythema, spider naevi), Endocrine (oestogen, libido,
breast size women- men, hair, irregular menses) Haemorrhage tendency (bruise, purpura, menorrhagia),
Portal hypertension, Hepatic encephalopathy; pigmentation, clubbing, leuconychia, low grade fever
Damage of liver structure, scars, nodules, poss from hypertension
Auto immune. >50 women. Granular inflammation destroy intra lobular bile ducts, unexplained pruritis
3 types: Oesophagus, umbilicus, anus
Portal hypertension round Carina, Caput medusa, haemorroids
Inflammation. Symptoms: Arthralgia, jaundice, pyrexia, fatigue, diarrhea, pigmentation
Hep A Faecal oral. Self-limiting. No TTT
Hep B Blood, body fluid, sex. Chronic infection rare. Anti virus TTT
Hep C Blood, body fluid 80% get chronic infection cirrhosis, liver fail
Hep D Only in Hep B patient cirrhosis , live failure
Hep E Oral contact with faces. No TTT. Self limiting