Abdominal
Examination
By Sam Gharbi
UBC Internal Medicine R3
Study Materials
Old Exam Questions
Physical Exam books:
Schwartz - Textbook of Physical Diagnosis
Bates – Guide to Physical Examination
* Recommend practicing scenarios with a friend.
Scenario
35 year old female presents with 3 day history of
nausea, vomiting, and severe left lower quadrant
abdominal pain.
Conduct a focused physical examination.
Tip: Have a differential diagnosis in mind prior to
starting the station.
Step 1: Intro
Prepare stickers (2) and hand them to examiner
Wash hands with hand sanitizer
Introduce yourself to the patient
Explain to them what you will be doing
Step 2: Prepare the patient
Appropriate lighting
Patient lying flat with arms at the side
Appropriate draping
Stand on patients right side
Relax abdominal wall by flexing knees
Step 3
Vital Signs!
Hint
As you do exam, only mention to examiner your
findings (both positive and negative)
Do NOT narrate through your actions!
Step 4: Inspection
Distended?
Bulging flanks?
Scars?
Dilated veins?
Caput medusae
Striae (stretch marks)
Recent: pink
Cushing’s: purple
Silver: obese / old
Step 5: Auscultation
Listen to each abdominal quadrant with
diaphragm of stethoscope
Note frequency of sound
Normal is clicks and gurgles
Increased: diarrhea or early intestinal
obstruction
Decreased then absent: adynamic illeus
and peritonitis
Step 6: Percussion
Percuss all 4 quadrants for sound and pain:
Normal: Tympany
Abnormal: Dull (Due to fluid)
A proturberant abdomen that is tympanic
throughout suggests intestinal obstruction
Step 7: Palpation
Light Palpation
Ask where it hurts and palpate this quadrant last
Keep hand horizontal and flex fingers gently
Palpate all 4 quadrants
Lift hand completely off between quadrants
Deep palpation
Use same technique as above but push harder.
**DO not forget to palpate for rebound tenderness
Step 8: Hepatomegaly
Start with gentle pressure in the right lower quadrant
(midclavicular line)
Ask the patient to breathe in gently and slowly to
bring the liver edge down to the examiners
fingertips
At each exhalation, move the fingers up roughly 2
cm.
If the edge is not felt, no further examination is
suggested
If the edge is felt, mark the location where the lower
edge was felt and then proceed to percussion
Hepatomegaly (…)
Begin percussion at the level of the third rib
space, at the midclavicular line
Move down one rib space at a time until the
tone of your percussion changes. This is due to
the interposition of the dome of the liver behind
the lung
Step 9: Splenomegaly
Castell’s sign:
With the patient in full inspiration and then full
expiration, percuss Traube’s space.
If the note does not change (ie. remains tympanic)
then it suggests the presence of a normal spleen,
and the sign is considered negative.
If the note changes from resonant on full expiration
to dull on full inspiration, the sign is regarded as
positive, and suggests splenomegaly.
Step 10: Ascites
Very unlikely that you will be required to test for
ascites.
The most useful findings for making the diagnosis
of ascites are a:
positive fluid wave
shifting dullness
peripheral edema.
Step 11: Special Signs
McBurney’s point tenderness
Murphy’s sign
Place Fingers under coastal margin on right side at
mid-clavicular line and have the patient to a deep
breath while you push. Arrest of deep inspiration will
cause pain.
Important
At the end of the examination, do not forget to
mention that you would also do a pelvic and
rectal examination (if appropriate)
Note: not mentioning this, or other crucial details,
may result in failing the station.
End of station question
With one minute left in the station, the examiner will
ask you a question, for example:
What is this patient’s diagnosis?
Or
What further management would you do?
Other hints & tips
Be confident!
Be empathic!
Dress professionally.
Points are given subjectively based on the
examiners assessment on your interaction with
the patient.
Good
Luck!
Thank you for attending the
AIMD BC Fall 2010,
Education Sessions
If you have any question or
suggestion regarding the
Association, feel free to contact us
at
[email protected]
