• Abdominal Examination check list:

 Wash your hand

 Greeting
 Introduce yourself
 Permission to examine

 General survey :
o Body built
o Surrounding
 General exam:
o Hands
▪ Clubbing
▪ Tremors
• Fine
• Flabby
▪ Palmar erythema
▪ Dupytren contracture (diabetes, alcoholic liver diseases)
▪ Nails
o Shunt (radial or brachial)
▪ Functioning or not (presence or absence of thrill)
▪ Recent or old use (scab or scar)
▪ Complicated or not
▪ Other methods of RRT
▪ Underlying cause of renal failure
▪
o Eye
▪ Pallor
▪ Jaundice
▪ Pallor + jaundice
o Mouth
▪ Gingival hyperplasia
▪ Telangiectasia
▪ Pigmentation
o Parotid gland
o Neck veins
o Chest:
▪ Gynecomastia (tender mobile disc >2cm)
▪ Spider naevi
▪ Axilla (hair distribution & scars)
 o Lower limb edema (ask about pain while pressing and looking at the patient) then start local
inspection from the foot of the bed

Inspection:
 Distension
 Swelling
 Scars
 Dilated veins (if present look for vein below umbilicus and do milking and check direction of filling)
 Ask the patient to
o Cough
o Take a deep breath

Palpation & percussion :

1. Superficial
 Ask the patient to flatten the bed
 Kneel
 Ask about pain in any area and make that your last area to examine
 Palpate while looking to patient face in vertical S direction look for underlying fullness

2. Deep
 Start in the right iliac fossa with side of the index going up
 Ask the patient to take deep breath and wait to feel the border of the organ “hitting” your
hand
 If not felt, go again from right iliac fossa with the tip of your fingers going up a few centimeters
after each breath
 After feeling the right border of the liver confirm by light percussion from right iliac fossa
 Then heavy percussion from above to check for liver span
 Then palpate the left border of the liver with the tips of the fingers starting just above the
umbilicus till the xiphisternum

 Palpate the spleen starting from the right iliac fossa

 If not found then palpate from the left iliac fossa
 If not found turn the patient on his right lateral position, support with your left and palpate
with your right hand until you reach costal margin
 If not found then percuss the last three spaces expecting to find dullness, not splenectomized
(evident scar as well)
 If found from the beginning then percuss in the plane the spleen was found confirming
 Try to find the medial border of spleen and notch (in some patient left lobe of liver could be
confused with splenomegaly)

 Bimanual examination of the kidney on both sides

 Assess for shifting dullness

o Start above the umbilicus so to not confused with full bladder and go down under the
umbilicus (light percussion)
o Keep percussing until the note changes
o Turn the patient to his other side without removing your hand
o Wait for a few seconds then percuss the abdomen again
o If resonant note then you have demonstrated shifting dullness
Auscultation:
 If organomegaly then auscultate the organ for
rubs
▪ If hepatic bruit =perihepatitis
in Gonorrhea)
▪ If splenic bruit =splenic
infarction
 Venous hum (indicates portal htn)
 Renal bruit (2.5 cm to the side and above the
umbilicus)

Back:
 Inspect for spider naevi “upper back”
 Sacral edema ask for pain and press while looking at his face
 If renal case auscultate the basal long zones to know if he is well dialyzed or not
 Lymph nodes (superficial cervical and supraclavicular)

Finish examination by covering the patient and thank him…

How to present your case

This gentleman comfortable/ breathless at bed

Average/ over/ underbuilt

Has/ No/ peripheral stigmata of CLD “palmar erythema, spider nevi, gynecomastia, Duputryn contracture,
inverted hair distribution “

He has /NO/ clubbing , pallor, jaundice, lower limb edema

The abdomen is flat/ scaphoid / distended (mention positive inspection signs as scars, Bulge…)

Right lobe of liver is palpable (Not) ..cm below RCM with sp… cm, left lobe palpable.. Cm below xiphisternum

Sharp/ rounded border, smooth / irregular surface, firm /soft/ hard consistency, tender or not, pulsatile
or not, Brit heard over it or not

Spleen palpable (Not) … cm below left coastal margin ..rounded / sharp border , smooth surface, firm/ soft/
hard consistency non ballotable, can’t get above it, dull on percussion with dullness continuous with splenic
bed dullness, notch felt or not

Kidneys (not) bimanually palpable

Shifting dullness is positive or negative

Other masses if any describe ..site size surface share borders percussion note intra or extra peritoneal and
bruit heard or not
So my diagnosis this gentleman has

Hepatomegaly / splenomegaly /Hepatosplenomegally / shrunken liver +/- ascites

(clinical Dx )

For DD (etiology)

Complicated or not (Varices, hypersplenism , SBP, HRS)

Functional status (in liver cell failure or not = jaundice, coagulopathy,

encephalopathy)

How to put your …

Rule 1 presence of ascites or shrunken liver , venous hum, caput medussae, signs
of CLD all = CLD consider all causes

• BHF in Egypt
• Viral hepatitis
• Alcoholic
• NASH
• Others, according to the clues in general examination

Rule 2 if you have hepatomegaly / HSM or splenomegaly +

• Lymphadenopathy = lymphoproliferative disease

• Severe pallor = myeloproliferative / CLD
• Jaundice = CLD / lymphoproliferative
• Pallor and jaundice = CHA / CLD/ Lymphoproliferative

How to investigate abdominal case

Basic CBC , ESR, CRP, area and electrolytes

LFT

Confirm Dx by ultrasound +

• Evidence of hemolysis if you put CHA on top of your list “bilirubin,

haptoglobin, LDH, reticulocytes”
 • Ascitic tap if there is Ascites
• CT chest and abdomen if evidence of lymphadenopathy

Investigations of the cause

• In CLD : bilharzial Ag in stool, hepatitis serology, HBA1c, lipid profile

• In CHA : HB electropharesis, osmotic fragility, sickling test and blood film
• If lymph nodes take biopsy
• In myeloproliferative : BM biopsy

Investigations for complications

• CLD alpha fetoprote… upper git endoscopy

CHA iron study and hepatitis serology as well as hormonal as say…

Q..what are indications of diagnostic ascitic tap

Q..what are indications of upper git endoscopy

Treatment of abdomen case

• Non pharmacological
o Education and counseling
o Stop alcohol
o Vaccination against HAV, HBV
▪ If splenectomy vaccination againt:
• H.influenza /10 y
• Pneumococcal /5y
• Meningococcal /3y
o Social, psychological, financial, nutritional support
• Pharmacological
o Treatment of the cause
o Treatment of complications
▪ If ascites treatment is:
• Salt restriction
• Fluid restriction if Na < 125
 • Spironolactone up to 400mg
• Frusemide up to 160 mg
• Frequent ascitic tap
• TIPSS
• Liver transplantation
• What are indications of liver transplant
What is the single most important precaution before liver transplantation..