Abdomen Flashcards
blanket?
expose abdomen and offer patient blanket to allow exposure only when required and if appropriate, inform patients they do not need to remove their bra)
hand and nail inspection look for these conditions
leuconychia koilonychia clubbing palmar erythema pale palmar creases spider naevi Dupytren’s contracture
end of bed inspection look for
age confusion pain obvious scars abdominal distension pallor jaundice hyperpigmentation oedema cachexia hernias
cachexia
ongoing muscle loss that is not entirely reversed with nutritional supplementation
commonly associated with underlying malignancy (e.g. pancreatic/bowel/stomach cancer) and advanced liver failure
hyperpigmentation
bronzing of the skin associated with haemochromatosis
jaundice indicates
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)
abdominal distension
may suggest the presence of ascites or underlying bowel obstruction and/or organomegaly
confusion end of bed sign
often a feature of end-stage liver disease, known as hepatic encephalopathy
age in considering pathology
younger patients more likely to have diagnoses such as inflammatory bowel disease (IBD) and older patients more likely to have chronic liver disease and malignancy
objects and equipment to look for
stoma bag surgical drains feeding tubes mobility aids vital signs fluid balance prescriptions other equipment = ECG leads, TPN, catheters
INSPECT: palms of hands for
pallor
palmar erythema
Dupuytren’s contracture
INSPECT: nails for
Koilonychia
Leukonychia
Finger clubbing
check hands for asterixis
= flapping tremor
Ask the patient to stretch their arms out in front of them
Then ask them to cock their hands backwards at the wrist joint and hold the position for 30 seconds
Observe for evidence of asterixis during this time period
causes of asterixis
hepatic encephalopathy (due to hyperammonia) uraemia secondary to renal failure CO2 retention secondary to type 2 respiratory failure
finger clubbing anatomy
loss of Schamroth’s window
loss of hyponychial angle
increased nail curvature
ask patient to breathe in during deep palpation when checking
liver and spleen
finger clubbing is likely to appear in these abdominal conditions
IBD
coeliac disease
liver cirrhosis
lymphoma of GIT
palmar erythema
= red palm
redness involving the heel of the palm that can be associated with chronic liver disease (it can also be a normal finding in pregnancy)
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)
PALPATE: hands
temp
radial pulse - rate and rhythm
Dupuytren’s contracture
Dupuytren’s contracture
thickening of palmar fascia > resulting in the development of cords of palmar fascia which eventually cause contracture deformities of the fingers and thumb
= when 1 or more fingers bend in towards palm
Dupuytren’s contracture
thickening of palmar fascia > resulting in the development of cords of palmar fascia which eventually cause contracture deformities of the fingers and thumb
= when 1 or more fingers bend in towards palm think nanna
check arms for
bruising - underlying clotting abnormalities secondary to liver disease
excoriations
needle track marks - IV drug use > viral hepatitis
excorations
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
order of exam
intro end of bed signs stuff around bed INSPECT: hands arm armpit face - eyes, mouth neck chest abdomen PALPATE abdomen - light - deep - organs = liver, spleen, kidneys, bladder and aorta PERCUSS abdomen AUSULTATE abdomen legs
check armpit for
Acanthosis nigricans
Hair loss - iron-deficiency anaemia and malnutrition
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)
INSPECT: eyes
jaundice of sclera Kayser-Fleischer rings conjunctival pallor corneal arcus xanthelasma perilimbal injection
INSPECT: face
pallor, jaundice, telangiectasia
INSPECT: mouth
Aphthous ulceration glossitis oral candidiasis angular stomatitis hyperpigmented macules
where to check for lymphadenopathy
supraclavicular, axillary and inguinal lymphadenopathy.
Virchow’s node in the left supraclavicular fossa is suggestive of gastric malignancy
left supraclavicular lymph node
Virchow’s node
= lymphatic drainage from the abdominal cavity and therefore enlargement of Virchow’s node can be one of the first clinical signs of metastatic intrabdominal malignancy (most commonly gastric cancer)
right supraclavicular lymph node
= lymphatic drainage from the thorax and therefore lymphadenopathy in this region can be associated with metastatic oesophageal cancer (as well as malignancy from other thoracic viscera)
Kayser-Fleischer rings
dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues (including the liver causing cirrhosis)
corneal arcus
a hazy white, grey or blue opaque ring located in the peripheral cornea, typically occurring in patients over the age of 60. In older patients, the condition is considered benign, however, its presence in patients under the age of 50 suggests underlying hypercholesterolaemia
xanthelasma
yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia
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
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
glossitis
smooth erythematous enlargement of the tongue associated with iron, B12 and folate deficiency (e.g. malabsorption secondary to inflammatory bowel disease)
hyperpigmented macules
pathognomonic for Peutz-Jeghers syndrome, an autosomal dominant genetic disorder that results in the development of polyps in the gastrointestinal tract
Inspect chest for
Spider naevi
Gynaecomastia
Hair loss
Quadrants of the abdomen
Top to bottom, right to left
Right hypochondrium, epigastrium, left hypochondrium
Right lumbar/flank, umbilicus region, left lumbar/flank
Right iliac fossa, suprapubic, left iliac fossa
Epigastric - stomach down to second part of duodenum, includes liver and biliary
Umbilical - down to transverse colon
INSPECT: Abdomen for
scars symmetry and shape lumps distension caput medusae striae - Cushing's, intrabdominal malignancy Cullen's sign Grey-Turner's sign peristalsis or pulsation venous distension discolouration spider naevi
palpate tips
Look at patients face whilst palpating to look for pain
Light palpation looks for soft/hard abdomen, tenderness, rebound, guarding
Rebound tenderness = in pain when you take your hands away, not so much when you initially press - when the abdominal wall, having been compressed slowly, is released rapidly and results in sudden sharp abdominal pain
Guarding = involuntary tension in the abdominal muscles that occurs on palpation associated with peritonitis
Murphy’s sign
Get patient to breathe out
Push in deep palpate right upper quadrant
Get them to breathe in
Diaphragm goes down pushes down gallbladder
If patient stops breathing in, pause breath, sign of acute cholecystitis
Guarding with breathing
spider naevi chest
skin lesions that have a central red papule with fine red lines extending radially caused by increased levels of circulating oestrogen
Commonly associated with liver cirrhosis, but can also be a normal finding in pregnancy or in women taking the COPC
If >5 are present it is more likely to be associated with pathology such as liver cirrhosis
gynaecomastia chest
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
abdominal distension 6 F’s
fat fluid flatus (gas) faeces fetus fulminant mass (severe disease)
caput medusae
engorged paraumbilical veins associated with portal hypertension (e.g. liver cirrhosis)
Inspect for hernias
ask patient to cough and observe for any protusions through the abdominal wall
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)
light palpation of abdomen
assess for tenderness, rebound tenderness, guarding, Rovsing’s sign, hernias, feel if tummy is soft or hard (bad)
Rovsing’s sign
palpation of the left iliac fossa causes pain to be experienced in the right iliac fossa
deep palpation of abdomen
if any masses identified, asses for the following:
- location
- size
- shape
- consistency - smooth/soft/hard/irregular
- mobility - attached to underlying structures?
- pulsatility - vascular
which organs to palpate for organomegaly
liver, spleen, kidneys, bladder and aorta
PERCUSS abdomen
liver
spleen
bladder
if ascites is suspected:
shifting dullness
fluid thrill
shifting dullness
Percuss from the centre of the patient’s abdomen laterally until dullness is apparent. Keeping your finger there, then ask the patient to roll onto the opposite side. Wait for at least 30 seconds in this position, before starting to percuss. If the dullness initially detected was due to fluid, this area should now be resonant and dullness will become apparent as you continue to percuss down to the centre of the abdomen
fluid thrill
Test for this by laying the flat of your left hand against the left side of the patient’s abdomen. Ask your patient to lay the flat of their hand longitudinally along the centre of their abdomen. Then tap your right hand on the right hand side of the patient’s abdomen and feel for a rippling of fluid against your left hand
next steps following examination - end pieces
examine for inguinal hernias examine external genitalia rectal exam/PR measure temp urinalysis pregnancy test stool sample
AUSCULTATE: abdomen
listen to 2 or more parts of abdomen
listen for increased, decreased or absent (have to listen for more than 3 minutes) sounds
auscultate aorta and renal arteries to identify bruits = turbulent flow:
- 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
check legs after abdomen exam for
pitting oedema - may suggest hypoalbuminaemia (liver cirrhosis)
