[Music] in this video you'll see a demonstration of how to perform an abdominal examination please subscribe to the channel and like the video if you learned something new first of all wash your hands introduce yourself to the patient and confirm their identity for example by asking their name and date at birth briefly explain to the patient what the examination will involve and obtain their consent to proceed and check if the patient is in any pain before proceeding for the first part of the examination set the head of the bed to a 45 degree angle start off the main section of the examination with inspection explain to the patient that in order to assess their abdomen it's important that you can properly visualize it this will mean removing clothing to expose the abdomen appropriately exposure should be from the zifa sternum to the synthesis pubis give the patient privacy to remove their clothing from the end of the bed inspect for clinical signs suggestive of underlying pathology for example you might see scars suggestive of previous abdominal surgery abdominal distension jaundice cachexia or hernias you should also take time to look for objects or equipment on or around the patient for example stoma bags surgical drains or feeding tubes these can give you important clues about possible underlying conditions next move on to look at the patient's hands first inspect the palms looking for the following clinical signs palla which may suggest an underlying anemia palmer erythema which could be a sign of chronic liver disease and jupiter's contracture which can be seen in excessive alcohol consumption amongst other things next inspect for nail signs including cholinekia which is the term used for spoon-shaped nails which could suggest an iron deficiency anemia you also want to look for leukonychia which is whitening of the nail bed which could be suggestive of low albumin and can again be seen in liver disease or in chronic malnutrition for example with patients with celiac disease next assess for finger clubbing to do this ask the patient to place the nails of their index fingers back to back in a healthy individual you should be able to observe a small diamond shaped window known as shamroth's window when finger clubbing develops this window is lost which you can see demonstrated in this photo in relation to the abdominal examination finger clubbing can be present in conditions such as ulcerative colitis crohn's disease primary biliary cirrhosis cirrhosis of the liver and hepatopulmonary syndrome amongst other things next assess for asterixis or flapping tremor you can do this by asking the patient to extend their arms dorsiflex the wrists and spread their fingers ideally the patient should do this for 30 seconds asterixis or flapping tremor can be seen in patients with hepatic encephalopathy move on to assess and compare the temperature of the hands palpate and assess the radial pulse next inspect the patient's arms looking for things such as bruising which might suggest clotting abnormalities secondary to liver disease excoriations from the patient itching excessively which may be a possible sign of underlying cholestasis and needle track marks which may predispose an individual to hepatitis if they're an intravenous drug user you may also see spider nevi more than three spider nevite is considered to be pathological the exact cause of them is unknown however one hypothesis is due to build-up of excessive oestrogen due to insufficient hepatic metabolism inspect the axilla or armpits for acanthosis nigricans and hair loss i've produced a full video on arkanthosis nigricans and you can see the link on screen here if you want to learn more about this essentially acompositious nigricans is darkening or hyperpigmentation and thickening known as hyperkeratosis of the skin under the armpit and it can be associated with type 2 diabetes or sometimes stomach cancer it can also have no underlying cause in certain individuals you should also assess for hair loss which could be associated with iron deficiency anemia and malnutrition now move on to inspect the eyes for signs suggestive of gastrointestinal pathology this may include conjunctival pala which is suggestive of underlying anemia jaundice this is normally most evident in the superior portion of the sclera so ask the patient to look downwards as you lift their upper eyelid corneal arcus and again its presence in patients under the age of 50 may suggest an underlying hypercholesterolemia as well as xanthelasma these are yellow raised cholesterol-rich deposits around the eyes which are associated with hypercholesterolemia you should also look for casa fleischer rings these are dark rings that encircle the iris associated with wilson's disease this is essentially where there's abnormal copper processing by the liver which can result in liver cirrhosis move on to inspect the mouth for signs suggestive of gastrointestinal pathology for example you may notice angular stomatitis and glossitis both which suggest an iron deficiency to go into slightly more detail angular stomatitis is a common inflammatory condition affecting the corners of the mouth it does have a wide range of causes amongst other things iron deficiency but it can also suggest gastrointestinal malignancy and malabsorption glossitis is where there is a smooth erythematous enlargement of the tongue again this can be associated with iron deficiency b12 and folate deficiency anemias next move on to palpate for lymphadenopathy paying particular attention to the supraclavicular fossa on the left hand side looking for something called verchoff's node trostia's sine is where there is left supraclavicular lymphadenopathy due to potential metastatic thoracic or abdominal malignancy you can also inspect the chest for signs of gastrointestinal pathology looking for things such as spider nevi gynecomastia and hair loss following this initial inspection phase reposition the patient lying them flat on the bed arms by their side and legs uncrossed the abdominal examination varies from other clinical examinations in that occultation is done prior to palpation and percussion this is because pressing the abdomen could alter and distort the bowel sounds when auscultating the abdomen first listen for bowel sounds you can do this by using the diaphragm of the stethoscope you should listen for up to two minutes to try and determine if bowel sounds are present or absent if you can't hear bowel sounds in one location then try another area you can also auscultate over the renal arteries for breweries this can be done two centimeters to the left and right of the midline above the umbilicus you could also auscultate over the aorta for breweries however this has been omitted in this particular examination you will now move on to palpation check if the patient has any abdominal pain before palpating because if so these areas should be examined last if the bed is low either kneel beside it or raise the bed it's important for this part of the examination to be at the same level as the patient you can also ask the patient to bend their knees so that abdominal muscles are not tense however in some patients with limited range of movement this may not be possible the abdomen is divided into nine regions as you can see in this diagram here perform light palpation of the abdomen across all nine regions try to start in the area where the person is not experiencing pain look carefully here as to how the doctor looks at the patient's face each time he presses on the abdomen to see if there are any subtle clues that the patient might be in pain also look at how he's using the right hand keeping it flat in contact with the abdominal wall next perform deep palpation of all nine regions if you find a mass try to describe it by its site size shape and consistency next assess for hepatomegaly by palpating the liver start by placing your hand flat on the skin of the right iliac fossa palpate for the liver with one or two hands palm down moving upwards two to three centimeters at a time moving towards the lower costal margin palpate the spleen begin palpation in the right leg fossa starting at the edge of the superior iliac spine ask the patient to take a deep breath and as they begin to do so palpate the abdomen with your fingers aligned with the left costal margin repeat this process of palpation moving one to two centimeters superiorly towards the left costal margin next block the kidneys starting on the right hand side to do this place your left hand behind the patient's back below the ribs underneath the right flank and place your right hand anteriorly push your fingers together pressing upwards with your left hand and downwards with your right hand this is a bimanual movement called blotting ask the patient to take a deep breath and try to feel the lower pole of the kidney moving down between your fingers once you've completed this repeat the process on the opposite side palpate the aorta do this by placing both hands superior to the umbilicus in the midline if you feel a pulsatile mass pushing outwards this may suggest an abdominal aortic aneurysm however this is a crude test and if you suspect something like a aaa imaging is needed if indicated you may want to palpate the gallbladder and bladder however in most healthy individuals the gallbladder is not palpable and in most healthy patients who are passing urine regularly the bladder will also not be palpable now we've completed palpation you should move on to percussion perform hepatic percussion to identify the liver's borders percuss upwards one to two centimeters at a time from the right leg fossa towards the right costal margin once you've percussed for the lever perform splenic percussion upwards again one to two centimeters at a time from the right iliac fossa towards the left costal margin once you've done this assess for shifting dullness which could be present in ascites with the patient lying flat percuss from the midline out to the flank note any change from resonant to dull keep your finger on the site of dullness in the flank and ask the patient to turn onto their opposite side pause for 10 seconds to allow any ascites to gravitate and then percuss again moving on now to other assessments that you may want to do please assess for pedal edema which may suggest low albumin for example caused by liver cirrhosis or a protein losing enteropathy you may also want to suggest further assessments and investigations typically i remember four important key investigations that you may want to mention to the examiner these include assessment of the hernial orifices a digital rectal examination or dre examination of external genitalia if indicated and abdominal imaging once you've done this explain the examination is finished and thank the patient for their time finish by washing your hands summarizing and documenting your findings that concludes this video if you enjoyed it and learned something new please remember to subscribe to the channel give the video a thumbs up and if you have any questions queries or comments leave them in the comments section below please also check out the description box for this video for a full list of resources and references for further reading as well as credits thanks for watching and until next time bye [Music]