An example of a perfect abdominal examination for OSCE/ISCEs for medical students, or in clinical practice for junior doctors. Step-by-step guide covering an examination from hands-neck-face-chest, including signs, symptoms and their relevance in forming a clinical differential diagnosis. Covers fu...
Abdominal Examination
Chest inspection – patient flat on back
W.I.P.E.E
- Lying down - Closer inspection for everything earlier
- Exposure = waist up, ideally no bra - Spider naevi - >5 = chronic liver disease
- Gynaecomastia – liver cirrhosis, digoxin,
General inspection: spironolactone
- Body habitus
- Scars? Laparotomy, appendectomy, cholecystectomy Palpation
- Jaundiced?
- Abdominal distension? Fat, Fluid, Flatus, Foetus, Faeces - Check again if any pain
- Masses? - 1st palpate soft, snake 9 regions, then 2 nd harder
- Stoma? o Check for guarding, masses, rebound tenderness
- Bruising? = peritonitis
- Hernias? - Palpate liver – patient breathe in + out, move up to
liver from hip, pushing hand in for in breath
- Palpate spleen – in same way, but across from hip
Hands - Ballot kidneys – push hand on top, flick underneath
- Clubbing – IBS, cirrhosis, coeliac disease with the other
- Koilonychia – spoon nails = chronic iron deficient - Palpate aorta – pulsatile = suggests abdominal aortic
aneurysm
- Leukonychia – white nails – liver failure
- Palmar erythema – liver disease/pregnancy
- Dupuytren’s contracture – alcohol excess Percussion
o Fingers permanently contracted
- Percuss up to liver from hip = hepatomegaly
- Percuss across up to spleen from hip
Wrists/arm - Down bellybutton to pubis – urinary retention
- Liver flap – hold hands out 30secs, asterixis - Test for shifting dullness if suspected ascites
o Across from bellybutton, then patient roll to
= hepatic encephalopathy (associated with severe liver
disease), uraemia other side, wait 30secs, test again
o Do both sides
- Scratch marks – cholestasis (bile salts under skin)
- Needle tracks – risk for viral hepatitis
- Bruising – coagulopathy/liver disease Auscultation
- Petechiae, red/purple spots – low platelets =
splenomegaly - Normal = gurgling
- Examine pulse – rate, rhythm, character - Tinkling = bowel obstruction
- Absent = ileus/peritonitis
Neck - Test for aortic bruit
- Check lymph nodes - incl. supraclavicular
o Malignancy/infection
Summarise
“no peripheral stigmata of gastrointestinal disease”
Face/mouth/eyes
“abdomen was soft and non-tender, with no masses or
- Xanthelasma – yellow deposits around eye organomegaly”
- Conjunctival pallor – anaemia
- Yellow sclera – jaundice, raised bilirubin “on auscultation, I heard normal bowel sounds”
- Blue/white ring around iris – corneal arcus
- Ulcers – Crohn’s or coeliac disease To complete the examination:
- Angular stomatitis – inflammation in corners of mouth
= iron/b12 deficiency - Examine hernial orifices
- Perform a digital rectal exam
- Glossitis/tongue swelling = iron/b12/folate deficiency - Examine the external genitalia
- Oral candidiasis – white stuff on tongue = iron or
immunodeficiency If appropriate!
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