abdominal examination

Jonathan Downham 2010

Abdominal ExaminationJonathan Downham Advanced Nurse Practitioner 2008

Jonathan Downham 2010

Abdominal Examination

•Gastrointestinal•Weight loss•Nausea, vomiting•Dysphagia• Regurgitation, flatulance, heartburn• Abdominal pain• Stool frequency

Jonathan Downham 2010

Abdominal Examination

Jonathan Downham 2010

Abdominal Examination

Jonathan Downham 2010

Clinical History Taking- Review of systems.

• Gastrointestinal– Weight loss– Nausea, vomiting– Dysphagia– Regurgitation,

flatulance, heartburn– Abdominal pain– Stool frequency– Surgery

– Medications– Last Period– Family History– Alcohol– Diet– Stress

Jonathan Downham 2010

Abdominal ExaminationPatient Position• Good lighting• Undressed nipple to knees• Modesty blanket• Flat on couch with single pillow for head• Arms by their sides• If unable to fully relax abdomen than flex

hips to 45 degrees and knees to 90 degrees.

Jonathan Downham 2010

Abdominal ExaminationGeneral Inspection• Pain, distress, cachexia, pallor or jaundice.• Hands• Metabolic flap- hepatic encephalopathy,

carbon dioxide retention or ureamia• Aneamia

• Eyes• Face• Abnormal pigmentation around lips• Angular stomatitis

• Oral cavity• Lymph glands

Jonathan Downham 2010

Abdominal Examination

Jonathan Downham 2010

Abdominal Examination

Inspection.• Symmetry• Abdominal pulsation• Shape• The five F’s• Scars• Sinuses• Fistulas e.g. crohns• Visible peristalsis due to intestinal

obstruction• Distended veins

Jonathan Downham 2010

Abdominal Examination

Auscultation• May be best to do this before palpating.• Listen specifically for bowel sounds• Place stethoscope to right of umbilicus and do

not move it. • Normal sounds occur every 5-10 seconds• Listen above umbilicus over aorta for bruits• Place stethoscope 2-3cm above and lateral to

umbilicus and listen for renal artery bruits.

Jonathan Downham 2010

Abdominal Examination

Percussion• Percuss over whole abdomen• Pay attention to any masses you may have

detected.• If ascites is suspected test for shifting

dullness• Orientate your hands correctly

Jonathan Downham 2010

Abdominal Examination

PalpationAsk the patient where the pain is.

Warn the patient you are about to put your hand on them.

Light palpationDeep palpation

Specific palpation of the intra-abdominal

organs

Jonathan Downham 2010

Abdominal ExaminationLight Palpation• Commence palpation at a site remote from any

area of discomfort.• All areas must be palpated systematically• Use the nine quadrants as a guide.• Is performed to elicit

any tenderness or guarding• Lie hands and fingers flat• Press very gently.

Deep Palpation

Jonathan Downham 2010

Abdominal Examination

Jonathan Downham 2010

Abdominal ExaminationPalpation of intra abdominal organs.Liver• Start with hand at right iliac fossa, fingers

pointing to head• Palpate deeply whilst patient breathes in and

out deeply• If nothing is felt repeat the process moving

the hand up slightly.• If edge is palpable describe:• Size• Contour• Texture• Tenderness

Jonathan Downham 2010

Abdominal ExaminationPercuss out liver edges

Jonathan Downham 2010

Abdominal ExaminationPalpation of the spleen

Jonathan Downham 2010

Abdominal ExaminationPalpate the Kidney

Jonathan Downham 2010

Abdominal Examination

Abdominal Aorta

Jonathan Downham 2010

Abdominal Examination

Hernias• Examine groin with patient standing upright• Inspect inguinal and femoral canals and scrotum

for any lumps and bumps• Ask patient to cough; look for any impulses• Ask the patient to lie down and establish if the

hernia reduces.• Press two fingers over the internal inguinal ring at

the mid inguinal point and ask patient to cough• If it reappears it is a direct hernia, if not it is

indirect.

Jonathan Downham 2010

Abdominal ExaminationRectal Examination• Explain• Position- left lateral, knees drawn up• Examine peri-anal area• Lubricate• Pulp of finger at 6 0’clock an anal margin• Anal spasm- stop, try again, local suppository

may be required.• Ask patient to squeeze your finger• Identify cervix/prostate• Withdraw finger and examine for colour/blood

Jonathan Downham 2010

Abdominal Examination

Common abdominal conditions•Dysphagia/odynophagia•Questions• Trouble swallowing both solids and liquids?• Where does blockage seem to be?• Intermittent or persistent• Has it been getting worse?• Coughing or choking when starting to swallow• Heartburn or acid indigestion• Weight loss

Jonathan Downham 2010

Abdominal Examination

Common abdominal conditions• Pain• SOCRATES• Site• Onset• Character• Radiation• Associated symptoms• Timing• Exacerbating or relieving factors• Severity

Jonathan Downham 2010

Abdominal ExaminationCommon abdominal conditions• Diarrhoea• Secretory• Osmotic• Abnormal intestinal motility• Exudative• Malabsorption

Jonathan Downham 2010

Abdominal ExaminationCommon abdominal conditions• Diarrhoea- questions• How many stools per day• What do they look like• ?urgency• Woken at night?• Blood mucus or pus?• Pale, greasy, smelly?• Lost weight?• Recent travel?• Antibiotics?• Family history• Recent fevers?

Jonathan Downham 2010

Abdominal Examination

Nausea and vomiting• Questions• Acute or chronic?• Vomiting with or without nausea?• How long after meal?• What does it look

like..blood/bile/faeculent• Abdo pain• Weight loss?• Medications?