Abdominal Flashcards
Describe abdo Introduction?
Introduce, wash hands and PPE, explain, consent, bed at 45 degrees, expose abdomen and lower legs, ask patient if theyre in any pain
What are the clinical signs in abdo general inspection?
Age
Confusion for hepatic encepathlopathy
Pain
Scars
Abdo distension: ascites, organomegaly, bowel obstruction
Pallor: anaemia
Jaundice: acute hepatitis, cirrhosis, cholangitis, pancreatic cancer
Hyperpigmentation: due to haemochromotosis
Oedema (pedal or ascites): often due to coirrhosis
Cachexia: associated with malignancy e.g. pancreatic, bowel/stomach cancer and advanced liver failure
hernias: umbilical/incisional
What objects are you looking for?
Stoma bags, surgical drains and contents e.g. blood, chyle, pus. Feeding tubes, ecg leadsm medications, TPN, catheters + IV access, mobility aids, vital signs, fluid balance, prescriptions
WHAT ARE YOU LOOKING FOR ON THE PALMS?
pALLOR: FOR ANAEMIA E.G. MALIGNANCY, gi BLEEDING, MALNUTRITION
pALMAR ERYTHERMA : normal in pregnancy but chronic liver disease
Dupuytrens contracture
What nail signs are you looking for?
Koilonychia: spoon shaped = iron deficiency anaemia e.g. malabsoprtion in Crohns)
Leukonychia: whitening of nail bed with hypoalbuminaemia e.g. end liver failure adn protein losing enteropathy
Clubbing: IBD, coeliac, cirrhpsos, lymohoma of GI tract
Final Hand test?
Asterixis: stretch arms out with hands back and fingers spread and hold for 30 secs. Evidence of hepatic encepahalopathy due to hyperammonaemia ) or uraemia secondary to renal failure. aslo type 3 resp failure
What are you palpating for on the hands?
Temperature for poor peripheral perfusion
Radial pulse: for rate and rhythm
Dupuytrens cintracture: thickening of palmar fascia therfore paplate for thickened bands and curved 4/5th fingers
Causes of Dupuytrens contracture?
Various but genetics, increasing age, alcohol abuse, male and Diabetes
What are you inspecting for on the arms?
Bruising (shows clotting abnormalities due to liver disease e.g. cirrhosis)
Excoriations due to pruritis from jaundice = cholestasis
Needle tract marks: IV drugs use with increased risk of viral hepatitis
Erytherma Nodosum from Crohns/ UC/sarcoidosis/TB
What are you looking for in axillae?
Acanthosis nigricans: hyperpigmentation and hyperkeratosis from T2DM or GI malignancy 9commonly gastric cancer)
Hair loss due to iron-deficiency anaemia or malnutrition
What features of the eyes are you looking for?
Conjunctival pallor: anamia
Jaundice
Corneal arcus: hypercholesterolanaemia
Xanthelasma :’’
Keyser-fleischer rings: wilsons disease and copper deposits e.g. liver causing cirrhosis
Perilimbal inhection: inflammation of conjunctiva next to iris. Sign of anterior uveitis associated with IBD
Clinical features of anterior uveitis?
perilimbal injection, photophobia, ocular pain and reduced visual acuity
What features of the mouth are you inspecting for?
Angular stomatitis: Inflammatory condition caused by malabsoprtion and anaemia e.g. GI malignancy
GLossitis: smooth erythermatous enlargment of tongue by B12, iron, folate deficiency e.g. IBD malabsoprtion
Oral candiaiasis: immunosuppression
Apthous ulceration: Iron, b12 folate deficiency and crohns
Hyperpigmented macules: peutz-jeghers syndrome
What are we looking for in the neck>
Lymphadenopathy and particularly Virchows node in left supraclavicular fossa which in indicative of metastatic intrabdominal malignancy e.g. gastric cancer.
What are we inspecting for on the chest?
Spider naevi: normal in pregnancy or COCP but can be cirrhosis
Gynaecomastia: liver cirrhosis or medications like digoxin and spironolactone
Hair loss undernourishment and greater circulating oestrogens
What are we inspecting on the abdomen?
Scars, abdo distension (6F’s),
caput medusae (portal hypertension e.g. liver cirrhosis)
Striae (ascite, cushings, malignancy, obesity, pregnancy)
Hernias
Cullens sign: brusing of tissue around umbilicus associated with haemorrhagic pancreatitis
Grey-turners sign: bruising around the flanks associated with haemorrhagic pancreatitis
What features of stoma as we looking at?
Location, contents, stool consistency and spout
How to palpate abdo?
Ensure patient lying flat and not in pain, ask to let you know about discomfort
What light palpation should you do?
all 9 regions looking for tenderness, rebound tenderness (non-specific but can be associated with peritonitis). Guarding e.g. appendicitis and diverticulitis. Rovsings sign: LIF to RIF pain shows peritonitis. Masses
What should you look for in deep palpation masses?
Location, size and shape, consistency (smooth, hard, irregular, soft). Mobility and if atached to deepere structures. Pulsatility (looking for AAA)
Features of liver palpation?
Degree of extension beneath costal margin (>2cm = hepatomegaly)
Liver edge consistency (nodular = cirrhosis)
tenderness (suggests hepatitis or cholecystitis)
Pulsatility (pulsatile hepatomegaly associated with tricuspid regurgitation)
Hepatomegaly causes?
Congestive Cardiac Failure tricuspid regurgitation Hepatitis (inf + non-inf) Heaptocellular carcinoma Hepatic metastases Wilsons disease haemochromatosis leukaemia myeloma Glandular fever Primary biliary cirrhosis Haemolytic anaemia
Where to palpate the gallbladde?
Right costal margin, in MCL (tip of 9th rib). should be a well defined round mass thta moves with respiration
Gallbladder indications?
Painful enlarged = cholecystitis
Painless enlarged = pancreatic cancer, biliary tree cancer with Jaundice and no fevercancer (with no fever)
What is murphys sign?
Palpation of gallbladder during inspiration. If in pain, then positive and likely cholecystitis
Causes of splenomegaly?
Portal hypertension secondary to liver cirrhosis haemolytic anaemia Congestive heart failure splenic metastases glandular fever
Causes of enlarged kidensy?
Bilaterally enlarged ballotable kidneys is in polycystic kidney disease or amyloidosis.
Unilateral = renal tumour
How to assess shifting dullness?
percussion for presence of ascites. Percuss till area of dullness located. Then keep fingers on area and ask patient to roll onto their side, wait 30 secs and then percuss area again. If ascites present, area will not be resonant
What abdo auscultation?
At least two positions:
Normal bowel sounds
Tinkling bowel sounds: typically bowel obstruction
Absent bowel sounds: suggest ileus. at least 3 mins ausculatation for absent bowel sounds
Also bruits
Ileus causes?
Electrolyte abnormalities and recent abdo surgery
What bruits where?
Aortic bruits: 1-2cm superior to umbilicus. Here could show AAA
Renal Bruit: 1-2cm superior to umbilicus and lateral to midline. shows renal artery stenosis
What other examinations?
Lower leg exam for pitting oedema from hypoalbuminaemia e.g. cirrhosis or protein-losing enteropathy. Sacral oedema check
What further investigations?
- Check hernial orifices (if rsigns of bowel obstruction)
- perform DRE (if GI bleed suspicion)
- External genitalia examination (rule out testicular torsion as cause of referred abdo pain or an indirect inguinal hernia)
Budd-chiari syndrome?
Congenital or due to venous thrombosis of the hepatic vein causing painful liver enlargement. COCP RF
