---

Medicine Posting - Abdomen Case Proforma

Complete Clinical Proforma with Significance, Definitions & Images

---

PART I: HISTORY TAKING

A. Biodata

---

B. Chief Complaints

• e.g., Pain abdomen - 2 weeks
• Abdominal distension - 1 week
• Jaundice - 3 days

---

C. History of Presenting Illness (HOPI)

---

D. Past History

• Similar complaints
• Previous surgeries (note scar type)
• Peptic ulcer disease, tuberculosis, hepatitis, diabetes, hypertension
• Blood transfusions (hepatitis B/C risk)

---

E. Personal History

• Diet (vegetarian/non-vegetarian)
• Alcohol intake - quantity, duration (cirrhosis, pancreatitis)
• Smoking (peptic ulcer, malignancy)
• Drug history - NSAIDs (GI bleed), steroids
• Travel history (amoebiasis, hydatid disease)

---

F. Family History

• Malignancy, inflammatory bowel disease, polyposis syndromes

---

G. Menstrual / Obstetric History (females)

• LMP, parity - to rule out ectopic pregnancy, ovarian pathology

---

PART II: GENERAL PHYSICAL EXAMINATION

"The nonabdominal examination should assess nutritional status and any signs of systemic conditions that may cause GI symptoms." - Goldman-Cecil Medicine

---

PART III: SYSTEMIC / LOCAL EXAMINATION OF THE ABDOMEN

Definition of Abdomen: The cavity bounded above by the diaphragm, below by the pelvic inlet (and pelvic floor functionally), anterolaterally by the abdominal wall muscles, and posteriorly by the vertebral column and posterior abdominal wall muscles. For clinical purposes, it extends from the level of the nipples above to the saphenous openings below.

Surface Divisions

| Right Hypochondrium | Epigastrium    | Left Hypochondrium |
|---------------------|----------------|--------------------|
| Right Lumbar        | Umbilical      | Left Lumbar        |
| Right Iliac Fossa   | Hypogastrium   | Left Iliac Fossa   |

---

STEP 1: INSPECTION

"It cannot be overemphasised how rewarding it is to spend time on inspection. Examination should be carried out in good light (preferably daylight) looking first from the side, then tangentially and finally from either end of the bed." - S. Das, Manual on Clinical Surgery

1. Skin and Subcutaneous Tissue

2. Superficial Veins (Caput Medusae)

3. Umbilicus

4. Contour of Abdomen

Obesity vs Ascites on inspection: In obesity, umbilicus is deeply inverted; in ascites, umbilicus shows varying degrees of eversion. - S. Das

5. Respiratory Movement

• Normally abdominal movement is seen with respiration
• Absent respiratory movement = peritonitis (board-like rigidity, patient "splints" the abdomen)

---

STEP 2: AUSCULTATION

Perform BEFORE palpation to avoid altering bowel sounds artificially.

---

STEP 3: PERCUSSION

General Percussion

Liver Percussion

• Upper border: percuss down from 2nd intercostal space in right midclavicular line - normal at 5th intercostal space
• Lower border: percuss upward from right iliac fossa - normally at right costal margin
• Normal liver span: 6-12 cm in midclavicular line

Splenic Percussion

• Traube's space (left 6th-10th ribs, midaxillary line): normally tympanic (due to stomach)
• Dullness in Traube's space = splenomegaly
• Nixon's method: percuss from left midaxillary line downward
• Dullness >8 cm = splenomegaly

Ascites Detection

• Definition: The demonstration of peritoneal fluid by percussing the flanks with the patient supine (dull), then rolling the patient to one side - the dullness shifts to the dependent flank.
• Method: Percuss from umbilicus toward flank until dullness is detected. Keep finger at that point. Ask patient to roll toward you - reassess in 30 seconds. If note changes from dull to resonant = shifting dullness positive.
• Significance: Positive when >500 mL of free fluid in peritoneal cavity. Distinguishes ascites (shifts) from ovarian cyst (central dullness, does not shift).

• Method: Ask assistant to place edge of hand firmly at midline. Examiner places one hand on one flank and flicks/taps the other flank - an impulse conducted across fluid is felt.
• Significance: Positive only with large quantities of ascites (>1.5 L). Less reliable than shifting dullness; false positive in obese patients (the assistant's hand prevents fat transmission).

Renal vs Splenic Swelling - Percussion Differentiation

---

STEP 4: PALPATION

Preliminary

• Warm hands, short nails, patient relaxed with knees slightly flexed
• Begin away from the site of pain
• Watch patient's face throughout for signs of pain

Light Palpation (Superficial)

• Purpose: detect tenderness, guarding, superficial masses

Deep Palpation - Organ Assessment

• Start from right iliac fossa, use radial border of index finger or flat of hand, press during expiration, feel during inspiration
• A palpable liver edge is present in: hepatomegaly, Riedel's lobe (normal variant), pushed down by emphysema

• Start from right iliac fossa, move toward left costal margin
• Cannot palpate between spleen and costal margin (no notch palpable in early enlargement)
• Ask patient to roll to right lateral position if not felt in supine

• Mild (<3 cm below costal margin): Typhoid, SBE, hepatitis, early portal hypertension
• Moderate (3-8 cm): Malaria, haemolytic anaemia, lymphoma
• Massive (>8 cm / to umbilicus or beyond): Kala-azar, CML, myelofibrosis, Gaucher's disease

• One hand behind flank, other on anterior abdominal wall
• Ballot (flick) from behind - kidney is felt anteriorly
• Ballottement = kidney is felt returning to posterior hand after being displaced
• Normal kidneys usually not palpable (except in thin adults, right kidney slightly lower)

• Felt below tip of 9th costal cartilage in right midclavicular line (Courvoisier's sign area)
• Courvoisier's Law: A palpable, non-tender gallbladder in the presence of jaundice is unlikely to be due to gallstones (stones cause fibrosis and non-distensible gallbladder); suggests malignant obstruction of the common bile duct (pancreatic head carcinoma)

• Normally palpable in thin patients midline above umbilicus
• Expansile pulsation = Aortic aneurysm (pulsates outward in all directions)
• Transmitted pulsation = Overlying mass transmits pulsation from aorta

---

PART IV: SPECIAL / FOCUSED EXAMINATIONS

---

PART V: PROVISIONAL DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS

1. History + HOPI
2. General examination findings
3. Systematic abdominal examination

---

PART VI: INVESTIGATIONS REQUIRED

• SAAG ≥1.1 g/dL = Portal hypertension (cirrhosis, CCF, Budd-Chiari)
• SAAG <1.1 g/dL = Non-portal (TB peritonitis, malignancy, nephrotic syndrome)

---

QUICK REFERENCE: KEY CLINICAL SIGNS SUMMARY

---