Abdominal exam

Question 1

What is the correct positioning and exposure of the patient in an abdo exam?

Answer 1

• patient at 180° (can be sat upright for initial inspection)
• abdomen exposed

Question 2

What are you looking for during inspection of the abdomen and chest during an abdo exam?

Answer 2

1. Scars - laparoscopy scars
2. Jaundice
3. Anaemia
4. Abdo distension (ascites)
5. Dressings
6. Needle track marks
7. Spider naevi
8. Visible peristalsis (rare but v significant)
9. Caput medusae
10. Sister Mary Joesph’s sign
11. Cullen’s sign (periubilical bruising)
12. Grey turner’s (flank bruising)

Question 3

What does jaundice indicate?

Answer 3

cirrhosis/hepatitis

Question 4

What causes spider naevi and what are they a sign of?

Answer 4

• Caused by increased oestrogen in the blood
• Can occur in people with significant liver disease
  (however, can also occur in pregnant women/women on contraceptives)

Question 5

What is caput medusae and what doe it indicate?

Answer 5

• distended and engorged superficial epigastric veins

- indicates portal hypertension

Question 6

What is the Sister Mary Joseph’s sign and what does it indicate?

Answer 6

• palpable nodule bulging into the umbilicus
• painful on palpation
• metastasis of a malignant cancer in the pelvis or abdomen

Question 7

What is Cullen’s sign and what does it indicate?

Answer 7

• superficial bruising and oedema of the subcutaneous fatty tissue around the umbilicus
• indicates acute pancreatitis

Question 8

What is Grey turner’s sign and what does it indicate?

Answer 8

• bruising of the flank between the last rib and the top of the hip
• sign of retroperitoneal haemorrhage
• along with Cullen’s sign it indicates pancreatic necrosis

Question 9

What are you looking for upon inspection of the hands, mouth and eyes?

Answer 9

Nails: koilonychia, leukonychia
Hands: palmar erythema, Dupuytren’s contracture, hepatic flap/asterixis
Mouth: angular stomatitis
Eyes: jaundice, Kaiser-Fleischer rings

Question 10

What is koilonychia, what does it indicate?

Answer 10

• also called spoon nails, when the nails begin to detach from the nail bed
• sign of microcytic anaemia, usually as a result of iron deficiency

Question 11

What is leukonychia, what does it indicate?

Answer 11

• white discolouration appearing on the nails

- harmless and most commonly caused by minor injuries to the nail

Question 12

What is palmar erythema and what does it indicate?

Answer 12

• reddening of the thenar and hypothenar eminences

- sign of portal hypertension and chronic liver disease (chronic hepatitis)

Question 13

What is Dupuytren’s contracture, and what does it indicate?

Answer 13

• one or more fingers become permanently bent in a fixed position
• cane caused by alcoholism, smoking, liver disease, diabetes

Question 14

What is hepatic flap/asterixis and what does it indicate?

Answer 14

• tremor of the hand when the wrist is extended
• caused by metabolic/hepatic encephalopathies (such as in decompensated liver cirrhosis or acute liver failure)
• can also be a feature of Wilson’s disease

Question 15

What is angular stomatitis, and what does it indicate?

Answer 15

• inflammation of one or both corners of the mouth
• often the corners are red with skin breakdown and crusting
• can be painful and itchy
• caused by iron/B12 deficiency (has many causes)

Question 16

What are Kaiser-Fleischer rings and what do they indicate?

Answer 16

• orangey/copper rings around the iris

- sign of copper deposits, typically seen in Wilson’s disease

Question 17

What is the first step of the abdo exam after inspection?

Answer 17

Palpation of the 9 regions of the abdomen

• knee at the bedside and palpate lightly
• make sure to look at the patient’s face for signs of pain + discomfort
• then do deeper palpations

Question 18

If an area of the patient’s abdomen is painful should you palpate it?

Answer 18

Yes - just palpate it last so that there is no guarding of the other areas

Question 19

How should you palpate for the liver?

Answer 19

• liver moves downwards on inspiration due to contraction of diaphragm
• ask patient to breathe in, and feel the liver downwards
• may palpable about 3cm below right costal margin in the MCL
• hold the tips of index, middle and ring fingers upwards facing the liver edge
• start in the RIF and move upwards

Question 20

How should you percuss for the liver?

Answer 20

• lower margin: start below the lower edge, moving upwards towards the costal margin until dull
• upper margin: start from the 3rd intercostal space and percuss each intercostal space until shift from resonant –> dull

Question 21

What is the average liver span in the MCL in men and women?

Answer 21

Women: 8-10cm
Men: 10-12cm

Question 22

Describe the surface area that roughly marks out the size of the liver.

Answer 22

right angle triangle
1st line: between nipples
2nd line: right nipple down to 10th rib
3rd line: diagonal from left nipple to right 10th rib

Question 23

What are the different methods used to assess ascites?

Answer 23

1. Shifting dullness (if there dullness int he flanks)

2. Fluid thrill (this requires assistance so it’s v unlikely to come up)

Question 24

How is the shifting dullness test performed?

Answer 24

1. percuss from the midline to the left flank until the percussion note becomes dull
2. ask patient to roll towards you
3. wait for 1-2 minutes (allow fluid to settle)
4. percuss back to the midline
5. the dullness has shifted due to the position of the patient

Question 25

How is the fluid thrill test performed?

Answer 25

1. ask someone to place their handoff the medial edge on the centre of the patient's abdomen 2. flick the abdominal wall on one side 3. if there is ascites, the impulse will be felt on the other side

Question 26

How should you palpate for the spleen?

Answer 26

1. place one hand around the back side of the lower rib and gently lifting it forwards and use the other hand to palpate starting from the RIF with fingertips pointing at left costal margin and towards the axilla 2. on inspiration try to feel the edge of the spleen as it descends with fingertips 3. if not palpated move fingertips closer to left lower rib cage

Question 27

When is the spleen palpable?

Answer 27

- enlarges anteriorly, downward and medially towards the RIF | - usually only palpable when at least double in size

Question 28

How should you percuss for the spleen?

Answer 28

- percuss the 9th intercostal space anterior to the left anterior axillary line (Traub's space) - normally tympanic as it overlies the bowel - on inspiration with normal sized spleen, the percussion note remains tympanic, with splenomegaly it becomes less resonant/increased dullness

Question 29

In terms of surface anatomy, where is the liver found?

Answer 29

ribs 7-11 on the right, epigastrium and the left side of the abdo

Question 30

In terms of surface anatomy, where is the fundus of the gallbladder found?

Answer 30

transpyloric place crossing the MCL (under the point where the rectus abdominis muscle intersects with costal margin, coincides with tip of the right 9th rib)

Question 31

In terms of surface anatomy, where is the spleen found?

Answer 31

8-11th rib posteriorly in the mid-axillary line

Question 32

In terms of surface anatomy, where are the kidneys found?

Answer 32

retroperitoneal (T12-L3) - transpyloric place at the top of the left hilum - cuts through right upper pole (right as 2.5 cm lower than the left) - displaced by lower right lobe of liver

Question 33

How should you ballot for the kidneys?

Answer 33

1. Left kidney: place right hand behind left loin/flank (below and parallel to 12th rib with fingertips just reaching costovertebral angle) - lift trying to displace the kidney anteriorly - place left hand below left costal margin, lateral and parallel to the rectus abdominis - same applies to right kidney (switch hands) - aim to palpate lower pole of the kidney between both hands as the organ moves up and down with deep breathing

Question 34

How do you test for abdominal aortic aneurysm?

Answer 34

- feeling an expansive epigastric mass = 8x likelihood of an AAA - position fingers of btohhands on either side of the middle at point midway between xiphisternum and umbilicus - press down for pulsation of abdominal aorta - AAA can be felt as a large pulsatile mass above level of umbilicus

Question 35

How should you listen for bowel sounds?

Answer 35

- place stethoscope on the mid-abdomen/right lower quadrant - listen for ~30 seconds - in obstruction, bowel sounds will be absent of tinkling

Question 36

How should you listen for bruits?

Answer 36

Bruits = turbulent arterial flow - aorta (epigastric region just to the left of the midline) - renal arteries (listen 3-4 cps from umbilicus at 10 o'clock and 2 o'clock, or epigastrium, or even from the back - a bruit that extends into a diastole is highly suggestive of renovascular disease - iliac bruits on line between umbilicus and femoral pulse

Question 37

What is McBurney's point?

Answer 37

⅓ of distance from ASIS to umbilicus (location of appendix)

Question 38

What is Rovsing's sign?

Answer 38

- pressure in the LIF causes pain in the RIF - due to compression of air in the anti-peristaltic direction in the colon - results in distension of the caecum and irritating the inflamed appendix - may be due to peritoneal irritation

Question 39

What test can assess the presence of cholecystitis? Explain the test.

Answer 39

Murphy's sign - press gently beneath the right costal margin in the MCL - ask patient to breathe in - if the gallbladder is inflamed, the patient will feel a sharp pain as it comes into contact with the fingertips *pain should only be present on the right side