Examination of the Abdomen

The examination of the abdomen in the elderly can pose special challenges. The patient’s dignity should be foremost while conducting this examination. Draping the groin and the sheath is recommended. The patient might not be able to lie flat on account of kyphoscoliosis or congestive heart failure, or the patient may be wheelchair bound.

The general appearance as well as the rest of the examination can provide a multitude of clues. Organ enlargement might be visible to the naked eye. Ascites is suggested by fullness in the flanks. Examination for hernias is best done by asking the patient to raise the head off the bed. Midline, incisional, and groin hernias are common in the elderly. Be cognizant of heparin or insulin injection sites with associated ecchymosis and erythema. A bruise around the umbilicus (Cullen’s) or in the femoral area (Grey Turner) signifies a retroperitoneal bleed.

Auscultation of the abdomen is done with the diaphragm the stethoscope. It is best done just lateral to the umbilicus. High-pitched bowel sounds can indicate an ileus or a small bowel obstruction. Abdominal palpation is performed with one’s hands and inquiring about any tender areas that are either avoided or examined at the end of the session. Liver edge is best palpated with the ulnar edge of the hand. Gentle pressure is applied downward as the patient breathes in. A mass in the left or the right lower quadrant should be followed up to exclude the possibility of inflammatory bowel disease, diverticulitis, or colon cancer. Spleen is palpated by asking the patient to roll on to the right side. The hand is placed along the left costal margin and the patient is asked to exhale the soft and hard to palpate. Abdominal ascites can be clinically apparent. Shifting dullness continues to be a very helpful sign. Percussion is started in the midline and the pleximeter (hnger on the abdomen) is slowly moved to the flank. Percussion is stopped where the dullness is appreciated and the patient is asked to roll over to the other side. Percussion is recommenced after about 30 seconds. The return of a tympanitic note signifies free fluid, which gravitates to the dependent area of the abdomen.

Rectal Exam

The patient has to be informed that they will experience a sensation of pressure. The first part of the anal reflex is contraction. After about 5 seconds, the sphincter relaxes and the fingers can then be advanced into the anal orifice. Once the finger is inserted, each quadrant is examined, starting at the 12 o’clock position. The prostate gland is felt anteriorly and its size symmetry, nodularity, and consistency are noted.

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