🩺 Abdominal Examination

The abdominal examination is a structured physical assessment of the gastrointestinal and genitourinary organs within the abdominal cavity. It follows the sequence of Inspection, Palpation, Percussion, and Auscultation. The procedure aims to identify signs of organ enlargement, fluid accumulation (ascites), inflammation, or obstruction. It is a core clinical skill essential for diagnosing conditions ranging from simple dyspepsia to surgical emergencies like appendicitis or a ruptured aneurysm.

An abdominal examination is indicated for symptoms such as abdominal pain, nausea, vomiting, altered bowel habits (constipation/diarrhoea), jaundice, or weight loss. It is also used to assess for organomegaly (liver, spleen, kidneys) in haematological or metabolic diseases. It is a routine part of screening for Abdominal Aortic Aneurysm (AAA) and is necessary for evaluating patients with suspected hernias or gastrointestinal malignancy.

There are no absolute contraindications, but the exam must be performed with extreme caution in patients with suspected 'acute abdomen' where peritonitis is possible (sharp, severe pain). In cases of known large aortic aneurysms (AAA), deep palpation should be avoided to prevent rupture. If the patient has a very distended, painful abdomen, prioritize imaging and surgical review. Always ensure the patient's bladder is empty before starting to improve comfort and accuracy.

The examination requires a stethoscope to listen for bowel sounds and bruits. A flat examination couch is necessary so the patient can lie completely supine with their arms by their side to relax the abdominal musculature. Privacy and adequate exposure from the 'nipples to knees' (while maintaining dignity with a sheet) are essential. Hand hygiene equipment must be used before and after the procedure.

Inspect the hands (clubbing, leukonychia), eyes (jaundice, anaemia), and mouth (aphthous ulcers). Inspect the abdomen for scars, distension, or striae. Perform light palpation in all 9 regions, then repeat with deep palpation. Palpate for the liver, spleen, and kidneys. Percuss for the liver span, splenic enlargement, and 'shifting dullness' if ascites is suspected. Auscultate for bowel sounds (for at least 30 seconds if absent) and renal bruits. Complete by assessing for hernias and offering a rectal/genital examination.

Rebound tenderness and guarding are signs of peritonitis. Abdominal distension, tinkling bowel sounds, and resonance suggest intestinal obstruction. Shifting dullness indicates the presence of ascites (e.g., in cirrhosis or malignancy). A palpable, pulsatile, and expansile mass in the midline suggests an AAA. Hepatomegaly with a smooth edge may indicate congestion (heart failure), while an irregular edge suggests malignancy or cirrhosis. Splenomegaly is typically identified by a notch and an inability to 'get above it' at the left costal margin.

A very common error is failing to ask the patient 'do you have any pain anywhere?' before beginning palpation, which can lead to unnecessary distress. Students often palpate too deeply too quickly; light palpation must always precede deep palpation. Neglecting to look at the patient's face during palpation for signs of guarding or discomfort is a major marking pitfall. Many also forget to auscultate for bowel sounds before percussing or palpating extensively in suspected obstruction, or they fail to check for hernias and the external genitalia.

Start by asking the patient to point to where the pain is and leave that area until last. Always kneel or squat so that your eyes are level with the abdomen during inspection and palpation to better see pulsations or organ movement. During palpation of the liver and spleen, ask the patient to take deep breaths in through their mouth and 'feel' for the organ edge as it descends. Don't forget to state you would complete the examination by checking for hernias, examining the external genitalia, and performing a digital rectal examination (DRE).

Relates to MLA 'Acute abdomen', 'Gastrointestinal bleeding', and 'Liver disease'. Students should be familiar with the 'signs' of chronic liver disease (spider naevi, palmar erythema, caput medusae). Understanding the 9 regions of the abdomen helps in localising pathology (e.g., epigastric pain in peptic ulcers vs right iliac fossa pain in appendicitis). Knowledge of Murphy's sign and Rovsing's sign is often tested in surgical stations.