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Year 3 - Examinations > Abdominal > Flashcards

Abdominal Flashcards

1
Q

Describe the introduction

A
  • Introduce yourself and ask permission
  • Ensure patient is warm
  • Expose abdomen between nipples and knees
  • Keep genital area covered unless asked to examine these areas
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2
Q

Describe the inspection of the hands

A

Look for

  • Clubbing
  • Pitting of the nail
  • Palmar erythema
  • Leukonychia
  • Dupuytrens contracture
  • Examine pulse for its character and volume
  • Presence of tachycardia
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3
Q

How can hydration be assessed using the hand?

A
  • State of hydration can be assessed by examining the skin turgor
  • In the well hydrated patient the skin will relax quickly and completely. If the patient is more dehydrated the skin will be more flaccid
  • Dehydration can also be seen by a dry tongue, and in extreme cases sunken eyes and cheeks
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4
Q

What is leukonychia?

A
  • Opaque white nails

- A marker of chronic liver disease and other conditions where serum albumin is low, such as nephrotic syndrome

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5
Q

What is clubbing?

A
  • Loss of the normal angle between the nail and the nail bed
  • Fluctuation of the nail bed
  • Increased longitudinal curvature of the nail
  • Swelling of the pulp of the finger
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6
Q

What is dupuytrens contracture?

A
  • Painless thickening of the palmar aponeurosis which produces gradual lesions, initially of the little and ring fingers
  • Overlying skin is puckered and does not move when the finger is flexed
  • Dupuytrens contracture is commonly seen in conjecture with alcoholic cirrhosis
  • Surgical correction is possible
  • Normal in pregnant women due to high oestrogen
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7
Q

What is koilonychia?

A
  • Occurs in longstanding iron deficiency - nails become brittle, then flat, and ultimately become spoon shaped
  • Occurs due to GI bleed/ chrons
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8
Q

What is palmar erythema?

A
  • Reddening of the palms

- Sign of chronic liver disease

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9
Q

What are spinder naevi?

A
  • Telagestatic arterioles in the skin with radiating capillary branches
  • Occur in chronic liver disease in the distribution of the superior vena cava
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10
Q

How can anaemia be identified?

A
  • Examine the conjunctivae

- Appears pale

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11
Q

What is gynaecomastia and what are its causes?

A
  • Abnormal enlargement of the breast due to increased circulating oestrogens
  • If due to liver failure it is also associated with a loss of or female distribution of body hair
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12
Q

How is hepatic encephalopathy investigated?

A
  • Mini mental test
  • Date today
  • Date of birth
  • Name of the reigning monarch
  • Date of WW1
  • Recognise 2 people or objects
  • Count backwards from 20
  • Recall an address
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13
Q

List the signs of chronic liver disease

A
  • Clubbing
  • Confusion
  • Dupuytrens contracture
  • Gynaecomastia
  • Jaundice
  • Leukonchia
  • Palmar erythema
  • Spider naevi
  • Smell of breath
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14
Q

What is assessed in the mouth?

A
  • The state of the tongue (dryness or moisture)
  • Furring of the tongue
  • Glossitis (related to mineral deficiency - iron, folate, B12)
  • Examine the palate for jaundice
  • Corners of the mouth for angular stomatitis (can be associated with IDA)
  • Look for ulcers (associated with iron/folate/B12 deficiency or Chrons)
  • Extra pigmentation
  • Telangiectasia
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15
Q

What can be identified from patients breath

A
  • Alcohol smell
  • Fetor hepaticus (sickly - liver failure)
  • Sweetness (pear drops - ketoacidosis)
  • Halitosis (malodorous breath) may be due to food wedged in the teeth
  • Could be due to carious teeth, gingivitis, stomatitis, atrophic rhinitis, tumours of the nasal passage and pulmonary suppuration
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16
Q

What can be assessed in tongue examination?

A
  • Smooth or clean looking from diffuse atrophy of the papillae, due to iron or B12 deficiency
  • A dry tongue or furring due to dehydration
  • May be enlarged in acromegaly, myxoedema and amyloidosis
  • Can be small or spastic in motor neurone disease
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17
Q

What is gingivitis?

A

Inflammation of the gums, associated with gum hyperplasia

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18
Q

What is angular stomatitis

A
  • Painful inflamed cracks at the corner of the mouth which can be infected with candida albicans
  • May be caused by deficiency of iron or riboflavin but more commonly by ill fitting dentures which allows dripping of saliva
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19
Q

What is virchows node?

A
  • An eponymously named lymph node located in the left supraclavicular fossa, indicative of intra-abdominal (particularly gastric) malignancy
  • First described by Virchow who noticed it in himself and diagnosed his own cancer
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20
Q

Describe examination of virchows node

A
  • Supraclavicular fossae
  • Posterior cervical chain (behind sternocleidomastoid)
  • Anterior cervical chain (anterior to sternocleidomastiod)
  • Submandibular
  • Submental
  • Both sides
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21
Q

How is the patient positioned?

A
  • Lie patient flat
  • Lay patients arms side by side
  • Ensure you have clean warm hands and nails that are cut short
  • Expose abdomen
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22
Q

Describe inspection of the abdomen

A
  • Rate and pattern of respiration
  • Inspect abdomen for scars, swelling, skin, distribution of body hair, any nodules and abnormal movement, visible peristalsis, herniae, and swollen veins
  • Describe findings using zones of the abdomen (9 regions)
23
Q

List causes of abdominal distension

A
  • Accumulation of fluid in the peritoneal cavity, often associated with liver cell failure and portal hypertension. May result from a primary or secondary malignancy
  • Fat
  • Foetus
  • Faeces
  • Flatus
  • Fibroids)
  • Demonstrated by testing for shifting dullness
24
Q

How is jaundice examined?

A
  • Yellow colour of skin and mucous membranes caused by increased levels of bilirubin in the blood
  • Upper limit of normal serum bilirubin is 17micmol/l, jaundice apparent at 35micmol/l
  • Best noted in the sclera and underside of the tongue
  • Look for scratch marks on the skin indicating pruritus
25
Q

When are hernias more apparent?

A
  • Incisional or epigastric more apparent if the patient raises their head of their legs off the bed
  • Cough impulse
26
Q

Define stoma and list the different types

A
  • An abnormal opening of bowel lumen to the anterior abdominal wall, created by surgery to allow luminal contents to pass to the exterior
  • Sigmoid colostomy, urostomy, ileostomy
27
Q

Describe examination of the stoma

A
  • Ask patient and nursing staff if you cna remove the bad. Be careful not to spill the content of the bad
  • Look if faeces (colostomy or ileostomy) or if urine (urostomy)
  • Solid content more suggestive of colonostomy
  • Loose more suggestive of illeostomy
  • Look at the skin of stoma for signs of irritation (erythema, blistering)
  • If flush against the skin it is colostomy, if stoma protrudes to form a spout ileostomy
  • Single or double lumen (bridge in early post operative days if defunctioning loop colostomy)
  • Place digit of finger inside lumen, if it constricts tightly or does not admit finger tip it is stenosis
  • Inspect perineum for presence or absense of anus
  • Look for extra intestinal manifestations of condition
28
Q

List stoma complications

A
  • Skin irritation marked parastomal erythema
  • Is the stoma away from the abdominal wall, can you see lumen, can you see presence of stoma
  • Prolapse
  • Double stoma
  • Parastomal herniation
29
Q

List different surgical scars

A
  • Kochers (gall bladder removal - parrallel to subcostal margin)
  • Upper midline
  • Paramedian
  • Lowe midline
  • Grid iron
  • Lanz (right iliac fossa, appendectomy)
  • Rooftop
  • Loin
  • Pfannestiel (c-section)
  • Rutherford morrison right/left iliac fossa (renal transplant)
30
Q

Describe abdominal palpation

A
  • Use flat of hand
  • Look at signs of pain
  • Light palpation for tenderness
  • Deep for masses
  • Examine kidney, spleen, liver and abdominal aorta
31
Q

Describe palpation of the kidneys

A
  • Put the left hand in the renal angle posteriorly and the right in the anterior abdominal wall
  • Ballot the kidney between the two hands - it will move with respiration
  • Will only be felt if enlarged
32
Q

Describe examination of the spleen

A
  • Start in right iliac fossa moving up towards the left costal margin
  • Spleen descends with respiration, get the patient to take deep breaths as you palpate
  • Spleen can be differentiated from a kidney by the splenic notch
33
Q

Describe examination of the liver

A
  • Start in the right iliac fossa, using the side of hand to feel for a liver edge
  • Liver descends with respiration so ask the patient t breath in deeply
  • If enlarged the liver will be felt brushing against your fingers
34
Q

Describe examination of the abdominal aorta

A
  • Feel for an expansile pulsatile mass in the epigastrum

- If felt try to assess its size (fingers of each hand on either side to identify boundaries)

35
Q

Describe abdominal percussion

A
  • Percuss extent of solid organs or of a mass lesion undetected by palpation
  • Elicit the presence or absence of peritoneal irritation
  • Place hand over tender areas and ask patients to take deep breaths. Gradually increase pressure and indent peritoneum. Suddenly release the hand which causes sudden movement of the peritoneum (rebound tenderness)
36
Q

Describe assessment of shifting dullness

A
  • Percuss centrally and move laterally towards dull area
  • Ask patient to roll away while keeping hand in position
  • Dull area will now be resonant
  • Ask patient to roll back, percuss again and this will be dull as fluid settles back
  • Ascites can also be tested by fluid thrill (patient places one hand in the centre vertically to block fat, place one hand in flank, flick abdominal wall and you will feel fluid thrill)
37
Q

Describe the process of abdominal ausciltation

A
  • Use a stethoscope
  • Listen for a full minute before saying they are absent
  • May be possible to hear bowel sounds from the foot of the bed
  • This is called borborygmus
  • In obstruction bowel sounds are high pitched and tinkling
  • For bruits, place left of umbilicus for left renal arteries and right of umbilicus for right renal artery. Centre of abdomen for the aorta. Localisation is difficult.
  • Listen to femoral arteries for bruits
  • Listen over lump for presence or absence of bowel sounds
38
Q

How is abdominal examination concluded?

A
  • Genital examination
  • Dipstick urine
  • Rectal exam
  • Thank the patient
39
Q

List what is looked for in general inspection of the patients abdomen

A
  • General appearance
  • Anaemia
  • Jaundice
  • Abdominal distension
  • Bruising
  • Stoma bag
  • Caput medusa (portal hypertension)
  • Pulsations
  • Cullens (umbilicus bruising) and grey-turners sign (loin bruising) - haemorrhagic pancreatitis
  • Striae
40
Q

List what is looked for on the bedisde

A
  • Feeding tubes
  • Nil by mouth
  • TPN
  • Catheter
41
Q

What causes finger clubbing?

A
  • IBD
  • Lymphoma
  • Liver cirrhosis
  • Coeliac
  • Oesophogeal cancer
42
Q

List abdominal causes of hand flapping (asterixis)

A
  • Liver failure
  • Renal failure (ureamia)
  • Respiratory failure (CO2 retention)
43
Q

What is assed for in the arms?

A
  • Arteriovenous fistula
  • Blood pressure and pulses
  • In the axilla
  • Acanthosis nigricans (can be benign, due to insulin resistance or GI malignancy)
  • Bruising/petichiae (liver disease)
  • Excoriation marks (cholestasis)
  • Hair loss (iron deficiency anaemia or malnutrition)
44
Q

How are AV fistulas examined?

A
  • Palpate for thrill
  • Auscultate for a bruit
  • Wrist is radio cephalic
  • Antecubital fossa is brachiocephalic/ brachiobasilic
45
Q

Describe neck examination

A
  • JVP (fluid status)

- Lymphadenopathy (Vircows node)

46
Q

Describe examination of the eyes

A
  • Start with eyes
  • Pull down eyelids (anaemia - usually iron deficiency)
  • Jaundice
  • Raised yellowish cholesterol deposits (caused by primary biliary cholangitis)
  • Corneal arcus (normal in older patients, indicative of high cholesterol. Whitish ring due to phosphate deposition)
47
Q

What causes spider naevi?

A
  • Excess oestrogen in chronic liver disease

- Also seen in pregnancy

48
Q

What do you look for in chest examination?

A
  • Scars
  • Spider navei (COCP, chronic liver disease, pregnancy)
  • Abnormal hair distribution (chronic liver disease)
49
Q

What do you look for in light palpation?

A
  • Tenderness (and rebound tenderness, if release of the hand causes pain)
  • Guarding
  • Abdominal mass
  • Start away from site of pain
  • Watch the patients face
50
Q

Describe percussion of the liver

A
  • Percuss from right iliac region upwards until dull

- Percuss from right 4th ICS down to find upper border (where it goes dull)

51
Q

Describe percussion fo the spleen

A

From right iliac region across to left upper quadrant to find lower border

52
Q

What do you check for in the legs?

A
  • Pitting oedema

- Caused by low albumin in liver failure, kidney failure

53
Q

What is seen in wilsons disease?

A
  • High copper
  • Brown ring around iris (kayser fleischer ring)
  • Tiredness

Year 3 - Examinations (6 decks)

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