Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

OSCE Clinical Examinations > Abdominal Examination > Flashcards

Abdominal Examination Flashcards

1
Q

How do you adequately expose the patient before an abdominal exam?

A

Adequately expose the patient’s abdomen for the examination from the waist up (offer a blanket to allow exposure only when required and if appropriate, inform patients they do not need to remove their bra). Exposure of the patient’s lower legs is also helpful to assess for peripheral oedema.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Next is the end-of-the-bed examination, what clinical signs underlying pathology are you looking for?

A

Age
Confusion
Pain
Obvious scars
Abdominal distension
Pallor
Jaundice
Hyperpigmentation
Oedema
Cachexia
Hernias

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What objects or equipment on or around the patient are you looking for that might provide insight into their medical history and current clinical status?

A

Stoma bags - note the location - left or right
Surgical drains - contents?
Feeding tubes
Other medical equipment - ECG? Meds? Catheters?
Mobility aids
Vital signs
Fluid balance
Prescriptions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the next part of the abdominal exam?

A

Hands - inspection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are you looking for on the palms of the hands?

A

Pallor
Palmar erythema
Dupuytren’s contracture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are you inspecting the nails for?

A

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).

Finger clubbing - IBS, CD, LC and lymphoma of GI tract

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What other thing should you inspect for whilst assessing the hand’s section?

A

Asterixis

  • The most likely cause is hepatic encephalopathy (due to hyperammonaemia) or uremia secondary to renal failure.
    CO2 retention -> type 2 resp failure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

The next stage is palpation, what things are you doing to assess here?

A
  • Temperature
  • Radial pulse -> rate and rhythm
  • Dupuytrens contracture
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is Dupuytren’s contracture and how do you assess for it?

A

Dupuytren’s contracture involves thickening of the palmar fascia, resulting in the development of cords of palmar fascia which eventually cause contracture deformities of the fingers and thumb. There are a number of factors that have been associated with the development of Dupuytren’s contracture including genetics, excessive alcohol use, increasing age, male gender, and diabetes.

To assess Dupuytren’s contracture:

Support the patient’s hand and palpate the palm to detect bands of thickened palmar fascia that feel cord-like.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Next, you assess the arms, what are you looking for?

A
  • Bruising
  • Excoriations (relieve pruritis)
  • Needle track marks
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Whilst supporting the arm you need to assess the axillae for..

A

Acanthosis nigricans
Hair loss

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is acanthosis nigricans?

A

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).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What things are you looking for when assessing the eyes? You must ask the patient to pull down their lower eyelid and inspect for signs suggestive of GI pathology

A
  • Conjunctival pallor
  • Jaundice
  • Corneal arcus
  • Xanthelasma
  • Kayser-Fleischer rings
  • Perlimbal injection
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Next, you assess the mouth, what do you ask the patient to do and what are you looking for?

A
  • angular stomatitis
  • Glossitis
  • Oral candidiasis
  • Aphthous ulceration
  • Hyper-pigmented macules
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is next?

A

Palpate for lymphadenopathy

The left supraclavicular lymph node (known as Virchow’s node) receives 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).

The right supraclavicular lymph node receives 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).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Next is the chest, what are you looking out for in the inspection which suggestive of GI pathology?

A
  • Spider naevi
  • Gynaecomastia
  • Hair loos
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

How must you position your patient for the abdominal examination?

A

Position the patient lying flat on the bed, with their arms by their sides and legs uncrossed for abdominal inspection and subsequent palpation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

First you must inspect, what are you looking out for?

A
  • Scars
  • Abdominal distension (6 F’s)
  • Caput Medusae
  • Striae
  • Hernias
  • Cullen’s sign (bruising in umbilicus - haemorrhagic pancreatis)
  • Grey-turner’s sign (bruising in the flanks associaed with haemorrhagic pancreatiis)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Next you would inform the examiner that if there was a stoma you would..

A

Assess the following characteristics:
- Location
- Contents
- Consistency of stool
- Spout

20
Q

Whats next?

A

Palpation!
First, you must prepare by asking them to lie flat on the bed, and ask them if there are any areas of pain -> if so examine last

Kneel beside the patient to carry out palpation and observe their face throughout the examination for signs of discomfort

21
Q

You must palpate twice, what type is first?

A

Light palpation of the abdomen
Do all 9 regions

You are looking for..
- Tenderness
- Rebound tenderness
- Voluntary guarding
- Involuntary guarding/rigidity
- Rovsing’s sign -> LIF pain
- Massess

22
Q

What do you do after light palpation?

A

Palpate each of the nine abdominal regions again, this time applying greater pressure to identify any deeper masses. Warn the patient this may feel uncomfortable and ask them to let you know if they want you to stop. You should also carefully monitor the patient’s face for evidence of discomfort (as they may not vocalise this).

23
Q

If there are any masses what should you be looking for

A
  • Location
  • Size and shape
  • Consistency
  • Mobility
  • Pulsatility
24
Q

What is next? how do you do this?

A

Palpate the liver.

  1. Start in RIL at the edge of the iliac spine and use the flat edge of your hand.
  2. Ask the patient to take a deep breath and as they begin to do this palpate the abdomen, feel for a step as the lever edge passes below your hand during inspiration
  3. Repeat the process moving 1-2cm superiorly from the RIF each time towards the right costal margin.
  4. As you get close (1-2cm below it) it may become palpable in healthy individuals.
25
Q

What is next? how do you do this?

A

Palpate the liver.

  1. Start in RIL at the edge of the iliac spine and use the flat edge of your hand.
  2. Ask the patient to take a deep breath and as they begin to do this palpate the abdomen, feel for a step as the lever edge passes below your hand during inspiration
  3. Repeat the process moving 1-2cm superiorly from the RIF each time towards the right costal margin.
  4. As you get close (1-2cm below it) it may become palpable in healthy individuals.
26
Q

If you are able to identify the liver edge, assess the following characteristcs

A

Degree of extension below the costal margin: - >2cm then hepatomegaly

Consistency of the liver edge - nodular?

Tenderness - hepatitis or cholecystitis

Pulsatility - tricuspid regurg

27
Q

What should be palpated next?

A

Gallbladder - if palpable it suggests enlargement secondary to biliary bile flow obstruction

Should be attempted at the right costal margin, in the mid-clavicular line (the tip of the 9th rib). If the gallbladder is enlarged, a well-defined rounf mass that moves with respiration may be noted.

Tendernesss suggests a diagnosis of cholecystitis
Non tenderness suggests underlying pancreatic cancer

28
Q

What is murphy’s sign?

A
  1. Position your fingers at the right costal margin in the mid-clavicular line at the liver’s edge.
  2. 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”).

29
Q

What organ is palpated next?

A

The spleen. - shouldnt be able to palpate in healthy

  1. Begin in the RIF, starting at the edge of the superior iliac spine.
  2. Ask the patient to take a deep breath and as they begin to do this palpate the abdomen with your fingers aligned with the costal margin, feel for the splenic edge passes below the hand during inspiration.
  3. Repeat this process of palpation moving 1-2cm superiorly from RIF each time towards the central margin.
30
Q

What are some causes of hepatomegaly?

A

Hepatitis (infective and non-infective)
Hepatocellular carcinoma
Hepatic metastases
Wilson’s disease
Haemochromatosis
Leukaemia
Myeloma
Glandular fever
Primary biliary cirrhosis
Tricuspid regurgitation
Haemolytic anaemia

31
Q

What are some causes of splenomegaly?

A

Portal hypertension secondary to liver cirrhosis
Haemolytic anaemia
Congestive heart failure
Splenic metastases
Glandular fever

32
Q

Whats next after palpating the spleen?

A

Ballot the kidneys - in healthy not normally ballotable but maybe in those with low BMI

  1. Place your left hand on the anterior abdominal wall just below the right costal margin in the right flank.
  2. Push your fingers together, pressing upwards with your left hand and downwards with your right hand
  3. Ask the patient to take a deep breath in - feel for the lower pole of the kidney moving down between your fingers.
  4. If it is ballotable describe size and consistency.
  5. Repeat this process on the opposite size of the kidney
33
Q

What can cause enlarged kidneys?

A

Bilaterally enlarged, ballotable kidneys can occur in polycystic kidney disease or amyloidosis.

A unilaterally enlarged, ballotable kidney can be caused by a renal tumour.

34
Q

What should be palpated next?

A

The aorta.

  1. Using both hands do a deep palpation just superior to the umbilicus in the midline
  2. Note the movement of your fingers
    - In healthy your hands should begin to move superiorly with each pulsation of the aorta
    - If they move out -> expansile mass (AAA)
35
Q

What should be palpated last? What must you make sure they do before going?

A

The bladder.
As if they want to do to the toilet and warn that it may be uncomfortable and might have a sudden urge to piss themselves

The distended bladder can be palpated in the suprapubic area - most will not be palpable if passing urine regularly.

36
Q

What comes next after you have completed the palpation of the abdomen?

A

Percussion, first the liver.

Percuss in the same direction and technique as palpation and continue up until the percussion note changes from dull to resonant - upper liver border

Use this to estimate its approximate size

37
Q

After the percussion of the liver?

A

Percussion of the spleen.

Again with the same technique from RIF to left costal margin until the note changes from resonant to dull -> identify the size

38
Q

How do you percuss the bladder>

A

Percuss downwards in the midline from the umbilical region towards the pubic symphysis. A distended bladder will be dull to percussion allowing you to approximate the bladder’s upper border.

39
Q

What can percussion also identify?

A

Any ascites by identifying shifting dullness.

40
Q

How do you percuss for ascites?

A
  1. Percuss from the umbilical region to the patient’s left flank. If dullness is noted, this may suggest the presence of ascitic fluid in the flank.
  2. Whilst keeping your fingers over the area at which the percussion note became dull, ask the patient to roll onto their right side (towards you for stability).
  3. Keep the patient on their right side for 30 seconds and then repeat percussion over the same area.
  4. If ascites is present, the area that was previously dull should now be resonant (i.e. the dullness has shifted).
41
Q

What is next after the percussion of all the organs?

A

Abdominal auscultation.
Auscultate over at least two position on the abdomen to assess bowel sounds.

42
Q

What different bowel sounds might you hear?

A

Normal bowel sounds: typically described as gurgling (listen to an example in our video demonstration)

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).

43
Q

What must you also listen for?

A

Bruits

Auscultate over the aorta and renal arteries to identify vascular bruits suggestive of turbulent blood 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.

44
Q

What is the final part of the abdominal examination?

A

Legs
Assess the patients lower legs for evidence of pitting oedema which may suggest hypoalbuminaemia

45
Q

What is an example summary

A

Today I examined Mrs Smith, a 64-year-old female. On general inspection, the patient appeared comfortable at rest, with no evidence of abdominal distension or jaundice. There were no objects or medical equipment around the bed of relevance.”

“The hands had no peripheral stigmata of gastrointestinal disease and were symmetrically warm. There was no evidence of asterixis.”

“The pulse was regular at 70 beats per minute.”

“The arms did not have any evidence of bruising or excoriations and the axillae were unremarkable.”

“On inspection of the face, there were no stigmata of gastrointestinal disease.”

“There was no evidence of lymphadenopathy in the supraclavicular region.”

“Closer inspection of the chest did not reveal any stigmata of gastrointestinal disease.”

“On inspection of the abdomen, no scars, distension or hernias were noted. Abdominal palpation and percussion were unremarkable with no evidence of organomegaly. Bowels sounds were normal and no bruits were noted.”

“There was no evidence of peripheral oedema on the assessment of the legs.”

“In summary, these findings are consistent with a normal abdominal examination.”

“For completeness, I would like to perform the following further assessments and investigations.”

OSCE Clinical Examinations (6 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions