Abdominal Exam
Symptoms;
Questions.
Vomiting
How long?
Abdo Pain
How often?
Diarrhoea
How much?
Distension
Pattern?
Constipation
Associated features?
Masses
Blood PR
Jaundice +/- itch
Systemic symptoms;
(fatigue / weight loss)
GU; swellings/dysuria/etc.
[** have DD for all these**]
O/E;
1) Inspection
i) General
C H A N D L E R (while washing hands)
Signs;
tenderness
weight loss
organomegaly
ascites
signs of chronic dx
signs of deficiencies
jaundice
Systemic signs;
(NNB. growth failure)
External Supports;
NG / PEG / stoma /
TPN /
Catheter / PD dialysis
“ideally I’d like to expose from nipple to knee for a thorough examination,
but in the interest of modesty, for the moment I’ll just ask _______ to take off shirt,
& anything else I’ll leave to the end if that’s ok”
<3-4 years often happier in Mum’s arms & so sometimes have to examine upright
‘pot belly’ normal (lordosis) in infants
ii) GIT specific – skin, hair & nails good indicator of good nutrition
Hands; Clubbing (how? Stages? Sign of?)
Deficiencies; Hb, Iron,
Other; palmar erythema, xanthoma, hepatic flap
Face; scleral icterus, anaemia
Mouth; ulcers, teeth, candida, hydration
Skin; jaundice, scratches, spider naevi, NF1 signs, telangiectasia, bruises
Wasting; (malnutrition) – wt/ distribution, med arm circ, buttocks
iii) Abdomen
(were you asked to examine the abdomen or GI system?)
Scars
Shape & symmetry
Distension (kneel down to be sure, looking across abdo.)
Movement & Pulsatile masses etc
(cutaneous signs as above, + vessels etc.)
Nutritional Status
+ Spine & flanks (can do at later)
Height & Weight centile
“& as I said I’ll defer genital & perianal inspection for now” Buttocks/Thighs
Triceps Skin-fold (s/c fat stores)
MUAC (skeletal mass)
(+ medical & diet history)
Tenderness;
ask; “is there any pain?”
Guarding / Rigidity
get on Right-hand side of bed
Rebound / Rovsing’s
down on knees so at eye level
1) superficial – looking for tenderness (watch patient’s face, not abdomen)
2) deep palpation - looking for masses (don’t be afraid)
3) liver;
Measure in Mid-Clavicular Line
2) Palpation
Start in RIF
1-2cm below costal margin N in < 2yrs
Is edge tender? Smooth? Firm?
4) Spleen; start RIF, move up, notched
< 1cm tip is Normal
5) Kidneys; bimanual palpation
+/- bladder; (if distension / urinary retention etc.)
distended vessels
3) Percussion
Masses; be able to describe;
Site, size, shape,
tender,
mobility (? with resp)
Solid / cystic
Surface; smooth / nodular
Liver; dull to percussion
percuss in MCL down from above (liver can be up to nipple, 6th I/C space)
& up from RIF (? Below costal margin)
offer to use tape to measure liver span
Normal is 6-12 cm in 6-12 year olds
Ascites; shifting dullness (not fluid thrill)
Should be resonant in midline
Percuss down from umbilicus until dull
Roll child over with this point high x 30-60 sec
* this is a good opportunity to examine the back & spine; scars / spina bifida etc.*
+/- Bladder (if palpated), spleen / masses
4) Auscultation
Bowel Sounds;
Renal Bruits
5) At end;
(say “I’d complete your exam with [the following];
the examiner will likely forego this)
1) Inguinal area; rashes, hernia – [no genital exam in girls]
2) Scrotum; testes descended?
Milking testes down, Swellings
3) Penis - ?phimosis ? meatus ?ballooning
4) Lymph nodes
5) Peri-anal area; tags, fissures, fistulae
[never do PR exam]
6) In nappy – stool / urine & offer dipstick the urine