Heartwood CM2 ABDO worksheet 2024
ABDOMINAL EXAMINATION WORKSHEET
KEY PRINCIPLES
Correct hygiene followed (eg handwashing)
Introduce self, maintain eye contact and pleasant manner
Examination routine fluently performed
Explain examination to patient and give clear instruction, ask consent where appropriate
Couch position flat, patient sat for observation, then lying down
Abdomen exposed
Pillow under head and knees to ensure muscles relaxed
Ask if patient needs to empty bladder before begin
Ask female patient as to whether menstruating or pregnant
Equipment needed: Stethoscope, (urinalysis sticks and pots)
Observation of hands, face, eyes and mouth
Patient sat on edge of couch:
Hands leuconychia, clubbing, koilonychia, palmar erythema, Dupuytren’s contracture, flapping tremor (arms outstretched, wrists in full dorsiflexion)
Face cachexia, pallor, yellowing, rhinophyma, parotid swelling, xanthelasma
Eyes (ask px to pull lower eyelid down) conjunctival pallor, yellowing of sclerae
Mouth (use pen torch to observe inside mouth, tongue depressor to move inside cheek, ask patient to stick tongue out, move tongue side to side to observe sides of tongue, pull lower lip down to observe gums) ulceration, glossitis, angular stomatitis, gingivitis, Candida, lichen planus, leukoplakia
Palpate supraclavicular nodes (assess both sides, esp left-side)
Virchow’s node
Patient lies down, exposes abdomen:
Observe
Skin scratch marks, bruises, spider naevi, gynaecomastia, yellowing
Abdomen scars, veins, striae, lipoma, herniae, rigidity, masses, distension
**ASK PATIENT IF ANY AREA of abdomen PAINFUL
AND remember to ASSESS LAST
Auscultation of abdomen
(performed first to establish ‘lie-of-the land’)
Bowel sounds/borborygmi (esp right lower quadrant, listen for 2 mins before concluding absence in that area, move then to another area and auscultate to establish area of absence)
Bruits (bell over epigastrium and upper quadrants –
abdominal aorta [know anatomical location],
hepatic bruit,
splenic bruit)
Percussion of abdomen
(ask patient if any tenderness and percuss last)
Percuss whole abdomen clockwise spiral from umbilicus
Percussion of liver beginning in right iliac fossa and up, and from c.5th
intercostal and down, to determine superior and inferior borders of liver
Percussion for spleen beginning below and right of umbilicus and moving diagonally across abdomen towards left costal margin
Percussion for spleen in Traube’s space [know anatomical location],
normally tympanic - dullness may indicate splenomegaly, left pleural effusion or after a large meal.
Splenic dullness will appear on percussion before you are able to palpate an enlarged spleen.
Test for ascites (fluid thrill and/or shifting dullness)
Not always necessary in a routine abdominal examination but you will be expected to demonstrate one of these techniques in your Clinical Skills live assessment
Light palpation of the abdomen
(ask patient if any tenderness and palpate last)
Of whole abdomen in clockwise direction from umbilicus
Keep checking patient comfort (ask them, and look at face)
Awareness of normal structures found (caecum, faeces in descending
colon, abdominal aorta, floating ribs, right kidney, liver edge, xiphoid
process)
Deep palpation of the abdomen
Explain procedures to patient before you begin
Keep checking patient comfort (ask them, and look at face)
Of whole abdomen in clockwise direction from umbilicus
Liver (deep palpation on late expiration and held during inspiration, move hand into next position as patient breathes out, hold in deep palpation as they breathe in again. Repeat until reach costal margin/inferior liver edge. Follow patient’s breath rather than instructing them. Remember deep palpation begins below level of elicited dullness)
Spleen (palpated with similar technique as liver but beginning below and to right of umbilicus, working your way diagonally across and up the abdomen towards the left costal margin and Traube’s space.
Overly aggressive palpation of an enlarged spleen is discouraged due to risk of possible rupture – if palpating, allow the spleen to find your fingers rather than the other way round)
Kidneys
Bimanual palpation – ask re pain before palpation, increase depth of palpation whilst px breathes in and hold whilst px breathes out, assess both sides and take care with bimanual palpation in certain conditions for example, inflammation of kidney
Kidney tap (also known as ‘kidney punch’) – place flat palm in costovertebral angle and gently but firmly tap the back of the flat hand with the heel of the fist of the other hand. Repeat on both sides. Pain/tenderness on tapping may indicate inflammation/infection of the kidney (+ve sign)
Assess gall bladder (Murphy’s sign – know anatomical location) As px breathes out, place straightened fingers in deep palpation beneath right costal margin, midline. If +ve Murphy’s sign, the px will gasp as breathes in.
Abdominal aorta first auscultate for bruits with bell of stethoscope, ask re pain before palpation, assess from lateral to midline
Inguinal lymph nodes ask consent, assess both sides one side at a time, correct hand placement to ensure safeguarding, palpate over underwear
You will not be asked to demonstrate splenic palpation in your Clinical Skills assessment but please be aware of the technique and location of this element of the routine
Findings in appendicitis
Awareness of McBurney’s point (know anatomical location)
Demonstrate assessment of rebound tenderness (slow deep palpation
and then quick withdrawal which elicits pain)
Demonstrate:
ROVSIGS sign - referred rebound tenderness
PSOAS sign - asking supine px to raise right leg against resistance elicits pain
OBTURATOR sign - px supine, flexed right hip and knee with internal rotation elicits pain
Be aware that accompanying symptoms include nausea, vomiting, fever, tachycardia, usually constipation (sometimes diarrhoea), urinary frequency. Patient looks and feels ill.
Other tests
Urinalysis
Please note that you will not be asked to perform this in your Clinical Skills assessment