Abdominal Exam Flashcards
What should you look for at the end of the bed?
- Nutritional supplements
- Nasogastric tube
- Stoma bag
- Catheter bag
- NBM status
- Obvious anaemia
- Jaundice
- Tattoos
- Distention or Scars
- Cachexia or obesity
What should you ask the patient about?
Any pain, tattoos or bruises
Why should you ask the patient to lift their head or cough?
Shows divercation of the recti and any hernias
What should you look for on the dorsal surface of the hand?
- Clubbing
- Koilonychia
- Leuconychia
What GI disorders can clubbing be a sign of?
- Inflammatory bowel disease
- Liver cirrhosis
- Coeliac disease
- Primary biliary cirrhosis
- Oesophageal achalasia
What is leuconychia and what is it a sign of?
Leuconychia are white and opaque nails
It is caused by chronic liver disease and low serum albumin conditions (e.g. nephrotic syndrome)
What is koilonychia and what is it a sign of?
Nails become thin and brittle, flatten and ultimately become spoon shaped
Caused by iron deficiency
What should you look for on the palmar surface of the hand?
- Palmar erythema
- Dupytren’s contracture
What causes palmar erythema?
- Pregnancy
- Idiopathic
- Thyrotoxicosis
- Polycythaemia
- Connective tissue disorders e.g. SLE
What is Dupuytren’s contracture what is it a sign of and how do you confirm a patient has it?
Thickening of palmar aponeurosis caused by:
- Alcohol dependence
- Epilepsy
- Diabetes
- Idiopathic
Results in a bending of one or more fingers towards the palm.
Extend the digit and feel for tightness of tendon
How to test for liver function using the hands?
Assess liver flap (30 seconds to say for sure)- Cerebral dysfunction in metabolic encephalopathy
What should you assess in the wrist and arm?
Radial pulse rate and volume and blood pressure
What should you look for in the eyes?
- Conjunctival icterus- Jaundice
- Conjunctival pallor- Anaemia
- Corneal arcus
- Xanthelasma
- Kayser- fleischer rings (Brown-green crescents at 6 and 12 o’clock)
- i. Wilson’s disease– Autosomal recessive genetic disorder in which copper accumulates in liver, basal ganglia and eyes
What should you look for in the mouth?
- Angular stomatitis- inflammation around corners of mouth
- Scurvy
- Apthous ulcers
- Buccal pigmentation
- Telangiectasia- swollen blood vessels
- Atrophic Glossitis- smooth glossy tongue
What is angular stomatitis and what does it suggest?
Inflammatory condition affecting the corners of the mouth suggesting Iron deficiency
What is scurvy and how may it present in the mouth?
Vitamin C deficiency causing soft haemorrhagic gums
What GI diseases cause apthous ulcers?
- Inflammatory bowel disease
- Coeliac Disease
- Immunocompromised
What is buccal pigmentation a sign of?
- Cachexia
- Malabsorption syndrome
- Haemochromatosis
- Peutz-Jeghers syndrome– Autosomal dominant condition where multiple hamartogenous polyps with low malignant potential affect gastrointestinal tract
Identify and explain what to look for on the tongue when performing a GI exam?
- Hydration status–dry or furring in fever/ dehydration
- Smooth clean looking tongue (loss of papillae)
- Iron/ Vitamin B12 deficiency
- Hallitosis- malodorous breath due to decomposing debris or carious teeth
- Fetor hepaticus– alcoholic/ sweet smell of ketones
What should you inspect for on the neck?
- Lymphadenopathy
- Virchow’s node (Left supraclavicular fossa)
- Intra-abdominal malignancy e.g. gastric
- Acanthosis Nigricans
- Raised JVP
What signs should you look for on the chest?
- Spider naevi (press them)
- Gynaecomastia
- Scars
- Abnormal hair distribution
What is spider naevi and what does it suggest?
They are visible arterioles with radiating capillary branches in the skin which disappear when you press them and refill from the centre. More than 5 are significant.
They are caused by chronic liver disease.
What are some causes of gynaecomastia?
Benign enlargement of male breast tissue associated with conditions which alter the oesradiol-testosterone ratio
- Physiological – puberty/ senility
- Kleinfelter’s syndrome
- Cirrhosis
- Drugs e.g. spironolactone, digoxin
- Testicular tumour, orchidectomy
- Endocrinopathy e.g. hyper/hypothyroidism
What is Greys sign?
Bruising of the flanks indicating retroperitoneal haemorrhage
What is Cullens sign?
Oedema and bruising of subcutaneous fatty tissue around umbilicus caused by enzymes tracking down falciform ligament
Commonly associated with severe acute pancreatitis
What are the general signs should be observed on the patients abdomen?
- Scars – describe site, length, likely indication
- Striae- stretch marks
- Distension – bowel obstruction
- Stomas – site, spouted/ flush, bag contents
- Caput Medusa- A sign of severe portal hypertension with porto-systemic shunting through umbilical veins
- Grey turner’s sign- associated with severe acute pancreatitis
- Cullen’s sign- associated with acute pancreatitis
What should you ask before beginning palpation?
Are you in any pain or discomfort?
What are the signs of chronic liver disease?
- Signs of chronic liver disease
- Caput medusa
- Scratch marks
- Body hair loss
- Bruising
- Testicular atrophy
- Needle marks
- Tattoos
- Ascites
- Cirrhosis
- Carcinomatosis
- CCF
What are the stages of general abdominal palpation
Ask patient if they have any pain
Palpate beginning away from the pain using the flat of the hand while looking at the patients face
Light palpation to assess for areas of tenderness and guarding
Deep palpation to assess organomegaly or masses in 9 quadrants
Assess for rebound and percussion tenderness
Assess epigastric area for AAA – Pulsatile and expansile?
How should you palpate for the liver?
Start in RIF using side of your hand to feel for a liver edge
Ask patient to fully expire and rest hand on area
Ask patient to inspire deeply and palpate deeply on inspiration
Move hand as patient expires deeply
Percuss the liver along the same line
Note the number of fingers below costal margin
What are some causes of hepatomegaly?
- Cirrhosis (e.g. Alcoholic)
- Carcinoma (primary or metastatic)
- CCF
- Infectious (HBV, HCV)
- Immune (PBC, PSC, AIH)
- Infiltrative (Amyloid, myeloproliferative disorder)
How should you palpate for the spleen?
Start in RIF moving up towards left costal margin (diagonally)
Ask patient to expire fully and rest hand on abdomen
Palpate deeply on inspiration
Percuss along the same line
What are some causes of splenomegaly?
Massive splenomegaly (>8cm)
- Myeloproliferative disorders (CML, MF)
- Tropical infections (Malaria, kala-azar)
Moderate (4-8cm)
- Myelo/ lymphoproliferative disorders
- Infiltration (amyloidosis)
Tip (<4cm)
- Myelo/lymphoproliferative disorder
- Portal hypertension
- Infections (EBV, IE, HBV/ HCV)
How should you palpate the kidneys?
Bimanual technique to ballot kidneys
What are some causes of unilateral renal enlargment?
- PCKD
- Renal cell carcinoma
- Simple cysts
- Hydronephrosis
What are some causes of bilateral renal enlargment
- PCKD
- Bilateral RCC (5%)
- Bilateral hydronephrosis
- Tuberous sclerosis
- Amyloidosis
How to assess for shifting dullness (in a patient with suspected ascites)?
Percuss the abdomen from umbilicus laterally until the percussion note becomes dull
Hold your finger at the point where the note changes
Ask the patient to roll towards you and wait for 30 seconds keeping your hand in the same position
Percuss in the same area again. Is the percussion note still dull? If not this represents shifting dullness i.e. ascetic fluid moving in the abdomen
Where should you auscultate and why?
Listen for bowel sounds for 1 minutes or until they are heard- bowel obstructions sounds like a tinkling tap
Listen for abdominal bruits indicating stenosis
Aorta
Renal arteries
Iliac arteries
Where should you inspect for oedema?
Sacrum and ankle (leg)
What further examinations should be requested to close an abdominal examination?
To examine the external genitalia
To examine the hernia orifices
To perform a digital rectal examination
Urine dipstick
