30-01-22 - Clinical examination of the Abdomen / GU Flashcards
Learning outcomes
- To demonstrate an understanding of the fundamentals of abdominal and genitourinary examinations
- To relate clinical signs to underlying pathology
- Use history and examination findings to help reach a diagnosis
What are the 5 steps to the Clinical examination of the Abdomen / GU?
What systems are we considering in this examination?
- 5 steps to the Clinical examination of the Abdomen / GU:
1) Introduction and explanation
2) Inspection
3) Palpation
4) Percussion
5) Auscultation - In this examination, we are considering the GI system, renal and genitourinary systems
What should we do prior to starting the examination of the Abdomen / GU?
How is the patient positioned during this examination?
- Prior to starting the examination of the Abdomen / GU, we must ask if the patient is in any pain or discomfort
- We also must position the patient appropriately:
- Comfortably supine with head resting on only 1 or 2 pillows
- We also must expose the abdomen from the xiphisternum to the pubic symphysis
General inspection.
What 2 things do we look for around the patient?
What 5 things are we looking for when looking at the patient?
What 2 things do we consider about pathological signs?
- General inspection
- 2 things we look for around the patient:
1) Sick bowls
2) Empty bottles/cans - 5 things we are looking for when looking at the patient:
1) Does the patient look well or not?
2) In pain?
3) Nutritional state; cachectic (loss of body weight, weakness) or obese?
4) Signs of liver disease e.g. bruising, spider naevi
5) Oedema (GI/GU causes = cirrhosis, pelvic mass, nephrotic syndrome, renal failure) - 2 things we consider about pathological signs:
1) What is the underlying cause?
2) How does this relate to history?
Close inspection hands and arms.
What are 4 GI causes of finger clubbing?
What is asterixis?
When does it occur?
- Close inspection hands and arms
- 4 GI causes of finger clubbing:
1) M - Malabsorption (e.g. coeliac)
2) I - Inflammatory bowel disease (UC + Crohn’s)
3) L - Lymphoma
4) C – Cirrhosis - Remember cardiovascular and respiratory causes!
- Asterixis is a coarse flapping tremor which occurs with hepatic encephalopathy
What 6 other conditions are we also looking for on the hands/skin during close inspection hands and arms?
What can we also check while checking the hands/arms?
- 6 other conditions are we also looking for on the hands/skin during close inspection hands and arms:
1) Leukonychia
* White discolouration of the nails
* Can indicate liver disease/failure
* Most common cause is trauma, so not always pathological
2) Koilonychia
* Spoon shaped nails
* Caused by iron deficiency anaemia
* Could indicate bleeding from the GI tract
3) Palmar erythema
* Reddening over the thenar and hypothenar eminences (base of thumb/pinkie)
* People with liver disease can get high oestrogen which causes this
4) Dupuytrens contracture
* Thickening of tendon in the hand, causing nodules and shortening of the tendon
* If we feel over the hand, we can feel thickened lumps
* Linked to liver disease
5) Spider naevus
* Red clump of blood vessels
* Can be found in any part of the skin
* Can be seen in liver failure
* 2 or more clumps are pathological
6) Purpura
* Non-blanching rash of the skin (rash that doesn’t fade when a person presses on it)
* Can indicate meningitis
* Can also occur in liver conditions where this abnormality in clotting factors
- While inspecting the hands/arms, we can also check the radial bulse and BP/temperature from the chart
Close inspection of face.
What 2 conditions are we looking for on close inspection of the face?
- Close inspection of face
- 2 conditions are we looking for on close inspection of the face:
1) Jaundice
* Caused by too much bilirubin in the blood, leading to the yellowed skin/sclera of the eye
* Has prehepatic, hepatic, and post-hepatic causes
* Can be itchy, which can cause scratch marks on the skin
2) Conjunctival pallor
* Can be a sign of anaemia, which could be caused by blood loss from the GI tract
What 6 structures are we looking at when inspecting the mouth?
What equipment do we need to use?
- 6 structures we are looking at when inspecting the mouth:
1) Mouth
2) Breath
3) Lips
4) Tongue
5) Teeth
6) Gums - We would need to use a tongue depressor and light
What 8 symptoms/conditions are we looking for when inspecting the mouth?
- 8 symptoms/conditions are we looking for when inspecting the mouth:
1) Stomatitis
* Pain and Inflammation of the oral mucosa
* Angular stomatitis is inflammation of the mucous membranes around the corners of the mouth
2) Glossitis
* Inflammation of the tongue.
* Associated with B12 deficiency
3) Candidiasis (oral thrush)
4) Ulcers
5) Pigmentation (Peutz- Jeghers Syndrome - v. rare)
6) Telangiectasia
* Dilated or broken blood vessels located near the surface of the skin or mucous membranes.
* They often appear as fine pink or red lines, which temporarily whiten when pressed
* Associated with liver failure
7) Dentition
* The arrangement or condition of the teeth in a particular species or individual
8) Gingivitis and “mousy” odour (fetor hepaticus)
* Common and mild form of gum disease
* Fetor hepaticus is the characteristic breath of patients with severe parenchymal liver disease
Close inspection chest and axillae.
What 3 conditions are we checking for on close inspection chest and axillae?
- Close inspection chest and axillae
- 3 conditions are we checking for on close inspection chest and axillae:
1) Spider naevi
* A cluster of minute red blood vessels visible under the skin, occurring typically during pregnancy or as a symptom of certain diseases
2) Gynaecomastia in men
* Due to high oestrogen states in liver failure
3) Both axillae for loss of axillary body hair
Close inspection of abdomen.
What 7 factors are we checking on close inspection of abdomen.
What are the 6 Fs of distension?
Describe the 9 regions of the abdomen (in picture)
- Close inspection of abdomen
- 7 factors are we checking on close inspection of abdomen:
1) Movement
2) Distension
3) Scars
4) Herniae
5) Masses
6) Striae (stretch marks)
7) Dilated veins “caput medusae” - 6 Fs of distension:
1) Fat
2) Fluid
3) Faeces
4) Flatus
5) Foetus (“5 Fs”)
6) ‘Flipping big tumour’ - 9 regions of the abdomen (in picture)
Abdominal Palpation (Superficial then deep).
Describe the 3 steps in abdominal palpation.
What 4 things are we palpating for?
- Abdominal Palpation (Superficial then deep)
- 3 steps in abdominal palpation:
1) In abdominal palpation, we kneel besides the bed so our eyes are at eye level of the abdomen
2) We ask the patient to point to any painful areas, then we start to palpate all 9 regions, starting away from painful areas and then ending with the tender point
3) We palpate superficially with one hand, then palpate deep with one hand on top of the other
- 4 things we are palpating for:
1) Tenderness (including guarding or re-bound tenderness)
2) Masses
3) Organomegaly (liver, spleen, kidneys)
4) Abdominal aorta - Watch the patients face while we do this
Palpate for liver: hepatomegaly.
What does the liver move with?
Describe the 4 steps in palpation of the liver
- The liver moves with respiration
- 4 steps in palpation of the liver:
1) Begin in right iliac fossa
2) Ask the patient to breathe in and out deeply
3) Palpate upwards to right costal margin with a copping hand position
4) Feel for liver edge as it descends on inspiration and move hand between each breath
What 5 factors do we need to describe upon palpating the liver?
What are 7 causes of hepatomegaly?
- 5 factors do we need to describe upon palpating the liver:
1) Size
2) Surface + edge (smooth/irregular)
3) Consistency (soft/hard)
4) Tenderness
5) Pulsatility? - 7 causes of hepatomegaly:
1) Hepatitis
2) Alcoholic liver disease
3) Right heart failure
4) Fatty infiltration
5) Biliary tract obstruction
6) Malignancy (metastatic / primary)
7) Haematological disorders
When is Murphy’s sign elicited?
What are 3 steps in palpating for Murphy’s sign?
What is meant by Courvoisier’s sign?
What is this likely caused by?
- Murphy’s sign is elicited in patients with acute cholecystitis
- 3 steps in palpating for Murphy’s sign:
1) Feel for gall bladder tenderness (e.g. acute cholecystitis)
2) Patient breathes in whilst you gently palpate RUQ in midclavicular line
3) On liver descent contact with inflamed gallbladder causes tenderness and sudden arrest of inspiration
- Courvoisier’s sign means the patient has Painless jaundice and a palpable gallbladder
- Likely due to extrahepatic obstruction E.g. Pancreatic cancer
- UNLIKELY to be gallstones
What does the spleen move with?
What are 5 steps for palpating for splenomegaly?
- The spleen moves with respiration
- 5 steps for palpating for splenomegaly:
1) Ask the patient to breathe in and out deeply
2) Palpate upwards to left hypochondrium
3) Feel for edge of an enlarged spleen as it descends on inspiration
4) Characteristic notch may be palpable
5) Move hand between each breath
What is the technique for renal palpation?
- To palpate the renal system, we ballot the kidneys
- This is where we put 1 hand posterior and 1 hand anterior and bounce the kidney between the hands
- You will only feel the kidneys if they are enlarged or if the patient has a very low BMI
- Remember to sit patient forwards and palpate for renal tenderness when examining back later
Where does the abdominal aorta pass through?
What is the most common area for aortic aneurysm?
What are potential symptoms?
How do we check for abdominal aorta aneurysms?
- The abdominal aorta passes through the epigastric region
- The abdomen is the most common area for aortic aneurysm
- They may be asymptomatic, and large aneurysms can rupture
- When we palpate the abdomen, we will feel an expansile mass (pulse pushes hands apart)
Percussion- ascites.
What is ascites?
What are 6 causes of ascites?
How do we percuss for ascites?
What causes shifting dullness in ascites?
What causes a fluid thrill?
- Percussion- ascites
- Ascites is an abnormal collection of fluid in peritoneal cavity
- 6 causes of ascites:
1) Hepatic cirrhosis
2) Intra-abdominal malignancy
3) Nephrotic syndrome
4) Cardiac failure
5) Pancreatitis
6) Constrictive pericarditis etc. - To percuss for ascites, we start in the midline and progress towards the flanks
- Shifting dullness in ascites is caused when the patient moves (e.g onto side), resulting in the fluid moving, causing the dullness to become even duller
- A fluid thrill can be cause by having 2 hands
Auscultation.
What 3 locations are we listening to during auscultation?
- Auscultation.
- 3 locations we are listening to during auscultation:
1) Listen for normal bowel sounds (up to 2 min)
* Listen somewhere over the abdomen
* Should be gurgling at some point within 2 minutes
* If this does not occur, the bowel is not functioning e.g due to obstruction
2) Auscultate for abdominal aortic bruits
* Turbulent blood flow due to narrowing e.g due to atherosclerosis
* Sounds like a whoosh
3) Auscultate renal arteries
* (in picture)
Back.
What are the 4 steps to examining the back?
- Back
- 4 steps to examining the back:
1) Sit patient forwards
2) Inspect back
3) Palpate for renal tenderness
* Gently pushing over kidneys from the back with a fist
4) Palpate for cervical lymph nodes
What can Cervical lymph node examination indicate?
What sequence do we palpate lymph nodes (in picture)?
- Cervical lymph node examination may indicate local disease
- May indicate more distant disease:
1) Tumours of the upper gastrointestinal tract may metastasise to the lower part of the left posterior cervical triangle
2) Virchow’s node / Troisier’s sign
- What sequence do we palpate lymph nodes (in picture)
What are 4 indications for a rectal examination?
What are 3 steps to a rectal examination?
- 4 indications for a rectal examination:
1) Rectal bleeding
2) Prostatic symptoms
3) Change in bowel habit
4) Possible spinal cord injury - 3 steps to a rectal examination:
1) Explain procedure
2) Gain informed consent
3) Offer a chaperone
What is the purpose of a speculum examination?
How is this done?
- Speculum examinations can be used for smears
- The plastic part is lubricated and inserted, and the handles are brough together to open to view of the cervical os
