Clincical examination for UG part 2

1. Clinical Examination of
Abdomen (Part II)

2. After inspection examination of the abdomen is carried out with
Palpation,Percussion and Auscultation.
Palpation: Palpation is further divided into superficial and deep palpation
Superficial palpation:
Gently palpate all the four quadrants starting from the right lower quadrant.
Superficial palpation gives us information about the potential areas of tenderness,superficial swelling of abdominal wall where as deep
palpation permits inspection of internal organs and delineation of intra abdominal masses.
The eaxaminer stand on the right hand side of the subject,the patient is asked to lie down supine.
The best method is to palpate with relaxed moulded right hand and slight flexion at metacarpophalangeal joints.
The wrist and forearm should lie in the horizontal plane and poking with fingers should be avoided.
In case of obese and muscular subjects left hand may be put over back of right hand for deeper palpation
Some subjects find it difficult to relax their abdomen,in such cases ask the subject to breathe deeply,bend there knees up and distract there
attention in other ways.

3. The sequence of examination is done as under:
Start in the left iliac region palpating lightly and work anticlockwise to end in the suprapubic region .Gently palpate each quadrant
of abdomen noting for any area of
tenderness or localized rigidity.Peritonitis produces rigidity (guarding) from reflex contraction of the muscles of abdominal wall.
Normally palpation of abdomen is painless and gives an elastic or doughy feeling.
 Repeat the examination and do deep palpation to get more information and the order of palpation of abdominal organs to:
1) Feel for the left kidney
2)Feel for the spleen
3) Feel for the right kidney
4)Feel for the liver
5)Palpate the urinary bladder
6)If a palpable swelling is present,elicit its features and feel for area of tenderness.
7) Examine the external genetalia.

4. Palpation of Left Kidney
• The subject should be relaxed with both knees and hips flexed.
• The Right Hand is placed anteriorly in the left Lumbar region while the left hand is placed posteriorly
under the costal margins. As the subject takes the deep breath ,the left hand presses forward and the
right hand presses backward,upwards and inwards and an attempt is made to feel for the kidney between
the pulps of the fingers of the two hands.
• Normally left kidney is not palpable unless enlarged or in low position.It is bimanually palpable and can
be pushed from one hand to other and this condition is known as Ballotment.

5. Palpation of Spleen:
Like left kidney spleen is normally not palpable
It is palpable only when it enlarges 2-3 times its normal size and then it is palpable below left costal
margin.Once it becomes palpable the direction of growth of spleen is downwards and towards the Right Iliac
Fossa.
Spleen can be palpated by the following three methods.
1) Classical Method: Subject lies in supine position.Start palpating from right iliac fossa towards left
hypochondrium.Edge of spleen may be felt on deep inspiration.

6. 2) Bimanual Method: Subject is put in Right lateral position , place left hand flat over lower most edge of
ribcage posterolaterally and right hand beneath costal margin well out to the left . Press medially and
downwards with your left hand and move the right hand medially step by step . If palpable the spleen will be
felt as firm,smooth ,round ,soft swelling by the right hand.
3) Hooking Method: The subject is placed in supine or right lateral position . The examiner Stands in the left side
and feels spleen by hooking his fingers over the left costal margin
Spleenomegaly is a feature of:
Malaria, Typhoid,Kala-Azar, Portal Hypertension, CML.

7. Palpation of Right Kidney:
Like Left kidney a normal right kidney is generally not palpable.
Stand on the right side of the subject,put right hand in lumbar region anteriorly and left hand posteriorly.Ask the subject
to breathe deeply.Unlike the left kidney the lower pole of right kidney may be palpablein very thin subjects.This method
is a/k/a Bimanual palpation.
Enlargement of Kidney is a feature of:
1) Wilms tumour 2)Polycystic Kidney 3)Hydronephrosis 4) Amyloidosis
Difference between Enlarged Spleen and Enlarged Kidney:
1)Spleen moves with respiration while kidney does not.
2)In spleen a notch can be felt at its lower medial border.
3)Upper border of spleen can not be reached.

8. Palpation of Liver
The subject lies in supine position with the hip and knees flexed to relax the abdominal muscles.
The examiner moves the right hand from Right iliac fossa gradually upwards until a sense of resistance is noticed.
The size of Liver must be recorded as finger breadth or in cm’s below the right costal margin.
The edge of Liver is accurately located by fingertips,it is normally sharp,firm and regular.
The surface of Liver is palpated next and it is smooth and not palpable.
The character of Liver may be:
1) Soft,smooth and tender in Heart Failure.
2) Firm and Regular in Obstructive Jaundice and Cirrhosis.
3) Hard ,irregular and nodular in advance cases of malignancies.
4) In Tricuspid regurgitation the Liver is Pulsating.
Hepatomegaly is a feature of:
a) CCF b) Amoebic Hepatitis c)Viral Hepatitis d) Hepatic Carcinoma

9. Murphy’s Sign:
This sign is present in acute cholecystitis(acute inflammation of Gall bladder)
The subject is asked to breathe deeply.At the end of inspiration there is an arrest of respiration with a gasp and a mass is palpated.
This sign is not seen in Chronic Cholecystitis.
Palpation of Urinary Bladder:
Normally it is not palpable.
In case of Retention of urine it can be palpated in the suprapubic region as a firm globular swelling with its dome reaching upto umbilicus.
Lateral border can be felt but it is not possible to feel its lower border.

10. Percussion:
Rule of percussion is same as in examination of chest.
Whole of abdomen is generally resonant(tympanic),except over liver where the note is dull.
Percussion helps to confirm the presence of enlarged liver or spleen.
Liver ,upper and lower borders of right lobe of liver can be defined accurately by percussion. Start percussion over chest anteriorly in the right
4th intercostal space where the note is resonant due to presence of lungs , then move downwards.
In the normal liver the upper border is at about the 5th intercostal where the note becomes dull, this dullness extends down to lower border
found at just below the right costal margin. Liver span is about 12-15 cm’s.
The upper limit of liver dullness is reduced in Emphysema ,Large Pneumothorax
Spleen:
Percussion over the enlarged spleen confirms the findings of palpation.
Area of splenic dullness extends. from the left costal margin to the left hypochondrium and left lumbar region

11. Clinical Significance of Percussion
Percussion of the abdomen provides the rapid confirmation of presence of free fluid (ascites) in the peritoneal cavity.
Over 1500ml of fluid must accumulate before it can be detected in physical examination.
Presence of any of the two signs Shifting Dullness or Fluid Thrill either singly or together make the diagnosis of ascites certain
a) To elicit shifting dullness stand on the right side of the patient,keeping the hand over midline start percussing laterally towards the flank,if
fluid is present the note will become dull in the flank.Now shift the patient towards the left side and allow the fluid to redistribute,now
percuss the right flank it will now become tympanic.
Similarly percuss the left flank which will be dull initially and becomes tympanic when the subject turns towards right.
b) Fluid Thrill:A less reliable method
The subject is in the supine position and keep the left hand over the left lumbar region.Ask the assistant to place ulnar border of his hand
vertically in the midline and give a tap with your right hand.A wave or pulse will be felt by the left hand.This sign can be elicited only
when a large amount of fluid is present under tension.
The purpose of the assistants hand is to dampen any impulses that may be transmitted through the fat of abdominal wall.

12. Auscultation:
Auscultation of abdomen is done for detection of bowel sounds.
To hear the bowel sounds place your stethoscope over the abdominal wall just right to the umbilicus.
Normal motality of the gut creates a characteristic gurgling sounds every 5-10 seconds.
In case of acute mechanical obstruction , bowel sounds are exaggerated and frequent loud gargles are heard known as
Borborgyni sounds.
In generalized peritonitis or paralytic ileus ,bowel sounds disappear and the abdomen is silent.

13. Examination of Hernial Sites:
Hernial sites in the groin should be seen for any swelling .If there is any swelling subject is asked to stand up
,turn the head to one side and cough.If there is impulse on coughing,it suggests Hernia.

14. Obesrvation of a Normal Abdominal Examination:
Inspection:
1) Shape of abdomen: Flat.
2) Abdominal symmetry: B/L Symmetrical.
3) State of Umbilicus: Retracted and Inverted.
4) Movement of Abdomen:Rise with inspiration and fall with expiration.
5) Visible Paplaptons:Absent.
6) Visible Peristalsis: Absent.
7) Skin of the Abdomen:Smooth ,Glossy and shiny.
8) Superficial Veins:Not seen.
9) Any Pigmentation:Absent.
10) Hernial Sites:Normal

15. Palpation:
1) Feeling: Soft and doughy.
2) Tenderness: Absent.
3) Right Kidney:Not Palpable.
4) Left Kidney: Not Palpable.
5) Liver and Gall bladder: Not Palpable.
6) Urinary Bladder: Not Palpable.
Percussion:
1) Tympanic note is present over whole abdomen except over Liver and Spleen.
2) Liver: Dull note.
3) Spleen: Dull note.

16. 4) Boundaries of Abdominal Organs:
Liver: Upper border of 5th ICS to lower border just below the right subcostal margin.
Spleen: From left lower ribs into left hypochondrium and left lumbar region.
Auscultation:
Character and intensity of Bowel sounds : Gurgling sounds present.
Any other sound heard: Nil.