Abdo Flashcards
Confusion (abdo)
end-stage liver disease (hepatic encephalopathy)
Causes of abdominal distension
ascities
bowel obstruction
organomegaly
Jaundice
a yellowish or greenish pigmentation of the skin and whites of the eyes due to high bilirubin levels (e.g. acute hepatitis, liver cirrhosis, cholangitis, pancreatic cancer).
Hyperpigmentation
bronzing of skin
haemochromatosis
Oedema (abdo exam)
cirrhosis
Cachexia (abdo)
underlying malignancy: pancreatic/bowel/stomach
advanced liver failure
Hernias
may be visible from the end of the bed (e.g. umbilical/incisional hernia). Asking the patient to cough will usually cause hernias to become more pronounced
Medical paraphernalia of GI disease
Stoma bag(s): note the location of the stoma bag(s) as this can provide clues as to the type of stoma (e.g. colostomies are typically located in the left iliac fossa, whereas ileostomies are usually located in the right iliac fossa).
Surgical drains: note the location of the drain and the type/volume of the contents within the drain (e.g. blood, chyle, pus).
Feeding tubes: note the presence of feeding tubes (e.g. nasogastric/nasojejunal) and whether the patient is currently being fed.
Other medical equipment: ECG leads, medications, total parenteral nutrition, catheters (note volume/colour of urine) and intravenous access.
Mobility aids: items such as wheelchairs and walking aids give an indication of the patient’s current mobility status.
Vital signs: charts on which vital signs are recorded will give an indication of the patient’s current clinical status and how their physiological parameters have changed over time.
Fluid balance: fluid balance charts will give an indication of the patient’s current fluid status which may be relevant if a patient appears fluid overloaded or dehydrated.
Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications.
Gastro causes of anaemia
malignancy
GI bleed
malnutrition
Palmar erythema
a redness involving the heel of the palm that can be associated with chronic liver disease (it can also be a normal finding in pregnancy).
Dupuytren’s contracture
= thickening of palmar fascia
causes: genetics, excessive alcohol use, increasing age, male gender, diabetes
Koilonychia
spoon-shaped nails, associated with iron deficiency anaemia (e.g. malabsorption in Crohn’s disease).
Leukonychia
whitening of the nail bed, associated with hypoalbuminaemia (e.g. end-stage liver disease, protein-losing enteropathy).
Gastro causes of clubbing
IBD
Coeliac
Cirrhosis
Lymphoma
Asterixis
= flapping tremor
Causes: hepatic encephalopathy (hyperammonaemia), urea (renal failure), CO2 retention (T2RF)
Inspection of arms
Bruising: may suggest underlying clotting abnormalities secondary to liver disease (e.g. cirrhosis).
Excoriations: scratch marks that may be caused by the patient trying to relieve pruritis. In the context of an abdominal examination, this may suggest underlying cholestasis.
Needle track marks: important to note as intravenous drug use can be associated with an increased risk of viral hepatitis.
Axillae inspection
Acanthosis nigricans: darkening (hyperpigmentation) and thickening (hyperkeratosis) of the axillary skin which can be benign (most commonly in dark-skinned individuals) or associated with insulin resistance (e.g. type 2 diabetes mellitus) or gastrointestinal malignancy (most commonly stomach cancer).
Hair loss: loss of axillary hair associated with iron-deficiency anaemia and malnutrition.
Jaundice in eyes
most evident in the superior portion of the sclera (ask the patient to look downwards as you lift their upper eyelid).
Perilimbal injection
inflammation of the area of conjunctiva adjacent to the iris. Perilimbal injection is a sign of anterior uveitis, which can be associated with inflammatory bowel disease. Other clinical features of anterior uveitis include photophobia, ocular pain and reduced visual acuity.
Glossitis
smooth erythematous enlargement of the tongue associated with iron, B12 and folate deficiency (e.g. malabsorption secondary to inflammatory bowel disease).
Aphthous ulceration
round or oval ulcers occurring on the mucous membranes inside the mouth. Aphthous ulcers are typically benign (e.g. due to stress or mechanical trauma), however, they can be associated with iron, B12 and folate deficiency as well as Crohn’s disease.
Hyperpigmented macules in mouth
pathognomonic for Peutz-Jeghers syndrome, an autosomal dominant genetic disorder that results in the development of polyps in the gastrointestinal tract.
Virchow’s node
left supraclavicular lymphadenopathy
one of the first clinical signs of metastatic intrabdominal malignancy (gastric cancer) or metastatic oesophageal cancer (+ malignancy from thoracic viscera)
Spider naevi
skin lesions that have a central red papule with fine red lines extending radially caused by increased levels of circulating oestrogen. Spider naevi are commonly associated with liver cirrhosis, but can also be a normal finding in pregnancy or in women taking the combined oral contraceptive pill. If more than 5 are present it is more likely to be associated with pathology such as liver cirrhosis.
Gynaecomastia
enlargement of male breast tissue caused by increased levels of circulating oestrogen (e.g. liver cirrhosis). Other causes include medications such as digoxin and spironolactone.
Hair loss (chest)
also caused by increased levels of circulating oestrogen. General malnourishment can also result in hair loss.
Caput medusae
engorged paraumbilical veins associated with portal hypertension (e.g. liver cirrhosis).
Striae
caused by tearing during the rapid growth or overstretching of skin (e.g. ascites, intrabdominal malignancy, Cushing’s syndrome, obesity, pregnancy).
Cullen’s sign
bruising of the tissue surrounding the umbilicus associated with haemorrhagic pancreatitis (a late sign).
Grey-Turner’s sign
bruising in the flanks associated with haemorrhagic pancreatitis (a late sign).
Stomas description
Location: this can provide clues as to the type of stoma (e.g. colostomies are typically located in the left iliac fossa, ileostomies and urostomies are typically located in the right iliac fossa).
Contents: can be stool (e.g. colostomy or ileostomy) or urine (e.g. urostomy).
Consistency of stool: note if it is liquid (ileostomy) or solid (colostomy).
Spout: colostomies are flush to the skin with no spout whereas ileostomies and urostomies have a spout.
Rebound tenderness
said to be present when the abdominal wall, having been compressed slowly, is released rapidly and results in sudden sharp abdominal pain. This is a non-specific, unreliable clinical sign that can, in some cases, be associated with peritonitis (e.g. appendicitis).
Voluntary guarding
contraction of the abdominal muscles in response to pain
Involuntary guarding/rigidity
involuntary tension in the abdominal muscles that occurs on palpation associated with peritonitis (e.g. appendicitis, diverticulitis).
Rovsing’s sign
palpation of the left iliac fossa causes pain to be experienced in the right iliac fossa. This sign was historically said to be indicative of appendicitis, but it is not reliable and at best indicates peritoneal inflammation of any cause affecting the left and/or right iliac fossa
Masses on deep palpation
Location: note which of the nine abdominal regions the mass located within.
Size and shape: assess the approximate size and shape of the mass.
Consistency: assess the consistency of the mass (e.g. smooth, soft, hard, irregular).
Mobility: assess if the mass appears to be attached to superficial or underlying structures.
Pulsatility: note if the mass feels pulsatile, suggestive of vascular aetiology (e.g. abdominal aortic aneurysm).
Liver palpation
Degree of extension below the costal margin: if greater than 2 cm this suggests hepatomegaly.
Consistency of the liver edge: a nodular consistency is suggestive of cirrhosis.
Tenderness: hepatic tenderness may suggest hepatitis or cholecystitis (as you may be palpating the gallbladder)
Pulsatility: pulsatile hepatomegaly is associated with tricuspid regurgitation.
Causes of hepatomegaly
Hepatitis (infective and non-infective)
Hepatocellular carcinoma
Hepatic metastases
Wilson’s disease
Haemochromatosis
Leukaemia
Myeloma
Glandular fever
Primary biliary cirrhosis
Tricuspid regurgitation
Haemolytic anaemia
Murphy’s sign
- Position your fingers at the right costal margin in the mid-clavicular line at the liver’s edge.
- Ask the patient to take a deep breath.
If the patient suddenly stops mid-breath due to pain, this suggests the presence of cholecystitis (known as “Murphy’s sign positive”)
Causes of splenomegaly
Portal hypertension secondary to liver cirrhosis
Haemolytic anaemia
Congestive heart failure
Splenic metastases
Glandular fever
Causes of enlarged kidneys
Bilaterally enlarged, ballotable kidneys can occur in polycystic kidney disease or amyloidosis.
A unilaterally enlarged, ballotable kidney can be caused by a renal tumour.
Bowel sounds
Normal bowel sounds: typically described as gurgling
Tinkling bowel sounds: typically associated with bowel obstruction.
Absent bowel sounds: suggests ileus which is a disruption of the normal propulsive ability of the intestine due to a malfunction of peristalsis. Causes of ileus include electrolyte abnormalities and recent abdominal surgery. To be able to confidently state that a patient has ‘absent bowel sounds’ you need to auscultate for at least 3 minutes (this is unlikely to be the case in an OSCE given the time restraints).
Bruits auscultation
Aortic bruits: auscultate 1-2 cm superior to the umbilicus, a bruit here may be associated with an abdominal aortic aneurysm.
Renal bruits: auscultate 1-2 cm superior to the umbilicus and slightly lateral to the midline on each side. A bruit in this location may be associated with renal artery stenosis
Legs (abdo)
pitting edema: hypoalbuminemia (liver cirrhosis or protein-losing enteropathy)
To complete abdo exam
Take full history
?cardio/resp exam
Obs
Check hernial orifices (e.g. if there are signs of bowel obstruction).
Perform a digital rectal examination (PR) (e.g. if there is suspicion of gastrointestinal bleeding).
Perform an examination of the external genitalia (e.g. to rule out testicular torsion as a cause of referred abdominal pain or an indirect inguinal hernia).
Urine dip
