Necrobiosis lipoidica is a necrotising skin condition that usually occurs in patients with

diabetes but can also be associated with Rheumatoid Arthritis. In the former case it may be
called necrobiosis lipoidica diabeticorum. NLD occurs in approximately 0.3% of the diabetic
population, with the majority of sufferers being women. The severity or control of diabetes in
an individual does not affect who will or will not get NLD. Better maintenance of diabetes
after being diagnosed with NLD will not

Abdominal examination

Applied anatomy:
Symptoms of gastrointestinal disease:
• Esophageal symptoms 206
• Nausea, vomiting, and vomitus 208
• Abdominal pain 210
• Bowel habit 212
• Jaundice and pruritus 216
• Abdominal swelling 217
• Urinary and prostate symptoms 218
• Appetite and weight 220
• The rest of the history 221
Outline examination 223
Hand and upper limb 224
Face and chest 226
Inspection of abdomen 229
Auscultation 231
Palpation 232
Palpating the abdominal organs 233
Percussion 239
Rectal examination 241
Hernialorifices243
Important presenting patterns 246
The elderly patient 252

Bony Landmarks.

Above:

Chief bony markings are the xiphoid process, the lower six costal cartilages,
and the anterior ends of the lower six ribs.

The junction between the body of the sternum and the xiphoid process is
on the level of the 10 thoracic vertebra.
 Below:

The main landmarks are the symphysis pubis and the pubic crest and
tubercle, the anterior superior iliac spine, and the iliac crest.

The umbilicus is at the level of the fibrocartilage between the3thand 4th

lumbar vertebræ.

Surface Lines.—For convenience of description of the viscera and of reference to morbid    5

conditions of the contained parts, the abdomen is divided into nine regions, by imaginary
planes, two horizontal and two sagittal, the edges of the planes being indicated by lines
drawn on the surface of the body (Fig. 1220). In the older method the upper, or subcostal,
horizontal line encircles the body at the level of the lowest points of the tenth costal
cartilages; the lower, or intertubercular, is a line carried through the highest points of the
iliac crests seen from the front, i. e., through the tubercles on the iliac crests about 5 cm.
behind the anterior superior spines. An alternative method is that of Addison, who adopts
the following lines:
  (1) An upper transverse, the transpyloric, halfway between the jugular notch and the    6

upper border of the symphysis pubis; this indicates the margin of the transpyloric plane,
which in most cases cuts through the pylorus, the tips of the ninth costal cartilages and the
lower border of the first lumbar vertebra; (2) a lower transverse line midway between the
upper transverse and the upper border of the symphysis pubis; this is termed
thetranstubercular, since it practically corresponds to that passing through the iliac
tubercles; behind, its plane cuts the body of the fifth lumbar vertebra.
  By means of these horizontal planes the abdomen is divided into three zones named from
above, the subcostal, umbilical, and hypogastric zones. Each of these is further
subdivided into three regions by the two sagittal planes, which are indicated on the surface
by a right and a left lateral line drawn vertically through points halfway between the
anterior superior iliac spines and the middle line. The middle region of the upper zone is
called the epigastric, and the two lateral regions the right and left hypochondriac.The
central region of the middle zone is the umbilical, and the two lateral regions
theright and left lumbar. The middle region of the lower zone is
the hypogastric or pubic,and the lateral are the right and left iliac or inguinal. The
middle regions, viz.,epigastric, umbilical, and pubic, can each be divided into right and
left portions by the middle line. In the following description of the viscera the regions
marked out by Addison’s lines are those referred to.

The abdomen is divided into nine regions by intersection of imaginary planes,

two horizontal and two sagittal.

(1) upper transverse line (transpyloric):

It is locatedhalfway between the suprasternal notch and the upper border of
the symphysis pubis(roughly a hand's breadth below the xiphoid process) at
the level of first lumbar vertebra.
(2) Lower transverse line(transtubercular):
It passes through theupper border (highest points)of iliac crests at the level of
the fifth lumbar vertebra.
Local abdominal examination

INSPECTION;
 From the end of the bed for asymmetry or distension.
 From bedside while sitting or kneeling for the movement with
respiration, peristalsis, epigastric pulsation (hold breathe).
 From up while standing for distension, mass, scars, dilated veins,
umbilicus
 Ask the patient to raise his head and to cough for divarication of
recti and impulse in the hernia orifices respectively.

Umbilicus inspection:
 Position i.e. normally midway between xiphisternum and SP
 Shape i.e. normally tucked in
 abnormalities
1. Hernia .i.e. PUH (bulged out)
2. Caput medusae
3. Discharge .i.e. bloody, urine, stool
4. Polyp
5. Granuloma
6. Hemangiomas
7. Cysts i.e. dermoid or inclusion

PALPATION;
 Superficial tenderness, superficial masses
 Deep tenderness, deep masses
 Organs liver, spleen, kidneys

9 areas of the abdomen

General examination:

 General assessment of body Size.

• Face
• Hands
• Arms
• Axillae
• Chest.

1- General assessment of body Size.

measurements of height, weight, body proportions, skin fold thickness, mid–
upper arm circumference, and muscle bulk.
Height is the length from the plantar surface of the foot to the crown of the
head. 
Weight is the total weight of the body.
Body proportions include the trunk to limb ratio and the arm span. The trunk,
or "upper segment," is represented by the distance from the symphysis pubis
to the crown of the head. The "lower segment" is the distance from the
symphysis pubis to the plantar surface of the foot and represents the "limb"

contribution to total height.

are equal and remain so in adults. The arm span is the distance between the
tips of the middle fingers with the arms fully extended. In adults the arm span
should equal the height.
2- Face examination:
a) Lips.
b) Teeth.
c) Gum.
 d) Tongue.
e) Buccal mucosa.
f) Palate, tonsils and pharynx.
g) Breath.

Tongue:
The oral tongue is moist and pink with neither localized nor diffuse
discoloration or ulceration. Filiform, fungiform, and circumvallate papillae are
visible. There is normally a very thin "coat."

Palate, tonsils and pharynx:

Technique:
The tongue depressor is placed in the junction between the anterior two-thirds
and the posterior one-third of the tongue. Then, the tongue is firmly depressed.
Note the presence or absence of the tonsils, their size and bulging of one side
(indicative of a peritonsillar abscess). 

The patient should be lying flatwitha single pillow under his head, arms lying at the
sides.
The abdomen should be exposed from the bottom of the sternumto the symphysis
pubis.
Do not expose the genitalia until needed.
It is standard practice to start with the hands andwork proximally—this establishes a
physical rapport before you examinemore sensitive areas.
Looking at the patient from the end of the bed, assess their general health
and look for any obvious abnormalities described in b Chapter 3 before
moving closer. Look especially for the following:
•High or low body mass
•The state of hydration
•Fever
•Distress
•Pain
•Muscle wasting
•Peripheral edema
•Jaundice
•Anemia

The abdominal cavity is the largest hollow space in the body. It is bound cranially
by the xiphoid process of the sternum and the costal cartilages of ribs 7-10;
caudally, by the anterior ilium and the pubic bone of the pelvis; anteriorly, by the
abdominal wall musculature; and posteriorly, by the L1-L5 vertebrae.

The anatomic planes of the abdominal wall are made up of multiple muscular
and fascial layers that interdigitate and unite to form a sturdy, protective
musculofascial layer that protects the visceral organs and provides strength and
stability to the body's trunk.

The abdominal wall is composed of 5 paired muscles: 2 vertical muscles (the

rectus abdominis and the pyramidalis) and 3 layered, flat muscles (the external
abdominal oblique, the internal abdominal oblique, and the
transversusabdominis muscles). These muscles and their fascial attachments
interdigitate and unite to form a sturdy, protective musculofascial layer that
gives strength and support to the anterolateral abdominal wall.Local
examination
Patient supine on examination table with arms at side or folded across chest.

The major components of the abdominal exam include:

observation, auscultation, percussion, and palpation.
Look around bedside for treatments or adjuncts – sick bowls /feeding tubes /stoma
bags /drains
Patients appearance – in pain? / agitated? / confused?
Observation chart –  note abnormalities – e.g. pyrexia / hypotension / tachycardia etc
Body habitus – healthy / obese/ low BMI /  cachectic
Scars – midline scars (laparotomy) / RIF (appendectomy) / right
subcostal (cholecystectomy)
Jaundice – indicates likely liver disease – cirrhosis / hepatitis 
Anaemia – obvious pallor suggests significant anaemia – e.g. GI bleeding
Abdominal distention – ascites / bowel distension / large masses
Masses – may suggest malignancy / organomegaly
Dressings – may be covering wound sites – infection / bleeding
Tattoos / needle track marks – have increased suspicion for blood borne viruses (e.g.
Hepatitis B/C)
Excoriations – suggestive of pruritus – iron deficiency anaemia / cholestasis 

Hands
Clubbing – can be a result of inflammatory bowel disease / cirrhosis / coeliac disease
Koilonychia – spooning of the nails – chronic iron deficiency 
Leukonychia – whitened nail bed – hypoalbuminemia – liver failure / enteropathy 
Palmar erythema – reddening of palms – thenar /hypothenar eminences – liver disease /
pregnancy

Dupuytren’s contracture:

o Thickening of palmar fascia

o Associated with alcohol excess

o If patient has chronic liver disease, this may suggest alcohol is the cause

 
Hepatic flap:

o Ask patient to stretch out arms, with hands dorsiflexed& fingers stretched out

o Ask to hold their hands in that position for 15 seconds

o The hands will flap (flex/extend at the wrist) in an irregular fashion if positive

o This sign can indicate either encephalopathy (due to liver failure) / uraemia / CO2 retention

Arms
Bruising – may suggest abnormal coagulation (↑PT) due to liver failure
Petechiae – suggestive of thrombocytopenia – often platelets <20
Excoriations – iron deficiency anaemia / cholestasis 
Track marks – intravenous drug use – higher risk for hepatitis B/C

Axillae
Lymphadenopathy – may suggest metastatic malignancy / lymphoma 
Hair loss – malnourishment / iron deficiency anaemia
Acanthosisnigricans (darkened pigmentation)– can be indicative of malignancy in the
GI tract

Eyes
Ask patient to lower one of their eyelids with their finger. Inspect for the signs below.

Jaundice – often first noted in the sclera – e.g. haemolysis, hepatitis, decompensated
cirrhosis, biliary obstruction (gallstone, malignancy)
Anaemia – conjunctival pallor suggests significant anaemia 
Xanthelasma – raised yellow deposits surrounding eyes – PBC/ hyperlipidaemia 

Mouth
Angular stomatitis – inflamed red areas at the corners of the mouth – iron/B12
deficiency
Oral candidiasis – white slough noted on oral mucous membranes – iron deficiency /
immunodeficiency
Mouth ulcers – Crohn’s disease / coeliac disease
Tongue (glossitis)  – smooth swelling of the tongue with associated erythema
– iron/B12/folate deficiency 
Neck
Cervical lymph nodes – lymphadenopathy may indicate infection / metastatic
malignancy
Virchow’s node – left supraclavicular fossa – suggestive of gastric malignancy

Chest
Spider naevi – central red spot with reddish extensions  (>5 significant) – chronic liver
disease  
Gynaecomastia – overdevelopment of male mammary glands
(pseudofeminisation) – liver cirrhosis / digoxin/ spironolactone
Hair loss – pseudofeminisation/  malnourishment / iron deficiency anaemia

Close inspection of abdomen

Position the patient laying flat, with their arms by their side & legs uncrossed
Scars – midline scars (laparotomy) / RIF (appendectomy) / right
subcostal (cholecystectomy)
Masses – assess size, position, consistency, mobility – lipoma / malignancy /
organomegaly

Pulsation – a central pulsatile &expansile mass may indicate an abdominal aortic
aneurysm (AAA)
Cullen’s sign – bruising surrounding umbilicus – retroperitoneal bleed
(pancreatitis/ruptured AAA)
Grey-Turner’s sign – bruising in the flanks – retroperitoneal bleed (pancreatitis/ruptured
AAA)

Abdominal distension
– fluid (ascites) / fat (obesity) / faeces (constipation) / flatus / fetus (pregnancy)
Striae – either reddish/pink (new) or white/silverish (chronic) – abdominal distension 
Caput medusae – engorged paraumbilical veins – portal hypertension
Stomas – Colostomy (LIF) / Ileostomy (RIF) / Urostomy (RIF, contains urine)

Palpation
Ask about the presence of any areas of pain (examine these last).

Crouch down and palpate the abdomen with your eye line at the same level as the
patient’s.

Look at patients face throughout the examination for signs of discomfort.

Light palpation
Assess each of the four quadrants for the following…

Tenderness – note the areas involved and the severity of the pain

Rebound tenderness – pain is worsened on releasing the pressure – peritonitis
Guarding – involuntary tension in the abdominal muscles – assess if localised or
general 
Masses – large / superficial masses may be noted on light palpation

Deep palpation 
Assess each of the four quadrants again, but with greater pressure on palpation

If any masses are noted, assess:

o Location – which quadrant?

o Size

o Shape

o Consistency – smooth / soft / hard / irregular

o Mobility – is it attached to superficial / underlying tissues?

o Pulsatility – a pulsatile mass suggests vascular aetiology – aneurysm

Liver
1. Start palpation in the right iliac fossa

2. Press your right hand into the abdomen as you ask the patient to take a deep
breath

3. Feel for a step, as the liver edge passess below your hand

4. If you don’t feel anything, repeat the process with your hand 1-2 cm higher 

If you feel the liver edge, note the following:

o Degree of extension below the costal margin

o Consistency of the liver edge (smooth/irregular)

o Tenderness – suggestive of hepatitis 

o Pulsatility – a pulsatile enlarged liver can be caused by tricuspid regurgitation

Gallbladder
The gallbladder is not usually palpable when healthy

An enlarged gallbladder suggests obstruction to biliary flow /

infection (cholecystitis)

Perform palpation at the right costal margin, mid-clavicular line (9th rib tip)

If enlarged, a round mass, moving with respiration may be palpated – note any
tenderness

Murphys sign:

o Place your hand in the area noted above

o Ask the patient to take a deep breath

o As the gallbladder is pushed down into your hand they may suddenly develop pain & stop
inspiring

o This is a positive Murphy’s sign, which is suggestive of cholecystitis

Spleen
The spleen is not usually palpable, therefore if you feel it, it’s at least 3x it’s normal size!

1.  Start in right iliac fossa – as massive splenomegaly can extend this far!

2. Align your fingers in the same direction as the left costal margin

3. Press your right hand into the abdomen as you ask the patient to take a deep
breath

4. Feel for a step, as the splenic edge passess under your hand (a notch may be
noted) – note position

5. If you don’t feel anything, repeat process with your hand 1-2 cm closer to the
LUQ
Kidneys
1. Place your left hand behind the patients back at the right flank

2. Place your right hand just below the right costal margin in the right flank

3. Press your right hands fingers deep into the abdomen

4. At the same time press upwards with your left hand

5. Ask the patient to take a deep breath

6. You may feel the lower pole of the kidney moving inferiorly during inspiration 

7. Repeat this process on the opposite side to assess the left kidney

Aorta
1. Palpate using fingers from both hands

2. Palpate just above the umbilicus at the border of the aortic pulsation

3. Note the movement of your fingers:

o Upward movement = pulsatile

o Outward movement = expansile (suggestive of AAA)

Bladder
An empty bladder will not be palpable (pelvic)
However an enlarged full bladder can be felt arising from behind the pubic
symphysis
This may suggest a diagnosis of urinary retention 

Percussion
Abdominal organs
Liver – percuss up from RIF then down from right side of chest to determine the size of
the liver
Spleen – percuss up from RIF moving towards the LUQ to assess for splenomegaly
Bladder – percuss suprapubic region – differentiating suprapubic masses (bladder
(dull) / bowel (resonant))
Shifting dullness

1. Percuss from the centre of the abdomen to the flank until dullness is noted
2. Keep your finger on the spot at which the percussion note became dull
3. Ask patient to roll onto the opposite side to which you have detected the dullness
4. Keep the patient on their side for 30 seconds
5. Repeat your percussion in the same spot
6. If fluid was present (ascites) then the area that was previously dull should now be
resonant
7. If the flank is now resonant, percuss back to the midline, which if ascites is present, will
now be dull (i.e. the dullness has shifted)

Auscultation
Bowel sounds
Normal – gurgling
Abnormal –  e.g. “tinkling” (bowel obstruction)
Absent – ileus / peritonitis

Bruits
Aortic bruits – auscultate just above the umbilicus –  AAA
Thank patient
Wash hands
Summarise findings

Say you would carry out the following if appropriate…

Check hernial orifices – e.g. if there’s signs of obstruction
Perform a digital rectal examination (PR) – e.g. if there’s a suggestion of UGIB
Perform an examination of the external genitalia

“If appropriate, I would examine the hernial orifices, perform a PR or examine the

external genitalia“

Renal  bruits – auscultate just above the umbilicus, slightly lateral to the midline
 How to
differentiate between liver, spleen and kidney

Liver Spleen Kidney

Dull Dull Resonant

Does not move with

Moves with respiration Moves with respiration respiration
 Notch Ballotable

Cannot get above it Cannot get above it Can get above it

Left hypochondrium
Right hypochondrium