Abdominal Examination Flashcards
what level of exposure of the child should you have of the child during the examination
nipple to knee (but in an older child this is not necessary)
what are you looking for on general inspection?
are they well or unwell- GCS
increased facial or body hair (ciclosporin side effect)
skin rashes (dermatitis herpetiformis, perioral freckling (Peutz Jeghers), telangiectasia (Osler Weber Rendu)
Pigmentation- cafe au last with NF1 also associated with GI stroll tumours
dysmorphic features- course features of mucopolysaccharidoses
nutritional status- thriving or not thriving
nutritional support (NG tube, TPN, gastrotomy tube (peg), button
peritoneal dialysis catheter
urinary catheter (spina bifida)
older child in nappies
race ( afro Caribbean sickle cell, asian thalessaemia, and Chinese hepatitis B)
what are you looking at on the hands: finger clubbing
cystic fibrosis, chrons disease and ulcerative colitis, liver disease
Other than clubbing what else are you looking for on hand examination
anemia (nailbed pallor and palmer crease)
koilonychia (due to iron deficiency look also for smooth tongue and angular stomatitis)
leuconychia (cirrhosis)
xanthoma (hypercholeserolaemia- tendon deposits, tuberous xanthomas at elbow)
palmer erythema (chronic liver disease)
flapping tremor
What are you looking at on inspection of the face?
jaundice (looking specifically at the sclera)
cyanosis (hepatopulmonary syndrome) or facial plethora (chronic liver disease)
spider naevi or telangiectasia (Osler Weber Rendu syndrome or ataxic telangiectasia)
what are you looking at when examining the mouth
pigmentation (Peutz Jeghers Syndrome)
ulceration (aphthous ulcers- chrons, ulcerative colitis, coeliac, behcets disease)
dental caries
gum hypertrophy (myeloid leucemia and drugs like ciclosporin and phenytoin)
Macroglossia
what are the causes of macroglossia
- hypothyroidism
- Beckwith- Wiedemann Syndrome
- Mucopolysaccharidoses
- Pompe Glycogen Storage Disease
- Amyloid
on general inspection of the abdomen what are you looking for
distension
skin
scars
striae
stomas
genital area
hernia or scrotal swellings
what are the 5 Fs of distension
fat
faeces
flatus (air swallowing, malabsorption- coeliac disease, intestinal obstruction)
fluid (ascites: nephrotic syndrome, chronic liver disease)
Fetus
what scars are you looking for?
renal angle scars
liver biopsy scars
laparoscopic surgery
what is William Harvey’s method?
press on the veins with two fingers
pull fingers apart
lift one finger does vein fill?
what does William Harvey’s method help with?
it assesses the blood flow from the blood in the veins
how to tell if the striae is a caput medusae
veins drain away from the umbilicus due to portal vein obstruction. Then look for other signs of liver disease (liver failure is a specific end stage problem.
how to tell if the striae is from superior vena cava obstruction
blood flows inferiorly in the superficial abdominal veins (look for this in children with central lines- rare complication)
how do you know if it is inferior vena cava obstruction
blood flows superiorly in the superficial abdominal veins (obstruction is unlikely in exams)
what are you looking for when looking at a stoma?
ileostomy vs colostomy
mucous fistula
caecostomy tube for integrate enemas in some children with chronic constipation
what are you looking for on the genital exam
ambiguous, undescended testis
what are the different types of hernia
umbilical: common in healthy afro Caribbeans below the age of 5, Down syndrome, hypothyroidism, and mucopolysaccaridoses
inguinal hernia
hydrocele
what are you looking at on examination of the skin
scratch marks
bruising
rash
pigmentation
nappy area
what causes scratch marks on the skin
obstructive jaundice
lichenification
excoriation
erythema
visible pruritis
what causes bruising in patients
liver dysfunction
haematological disease
what kind of rash are you looking for
dermatitis herpetiformis in coeliac disease
what causes depigmentation
vitiligo
what causes hyperpigmentation
cafe au lait patches
incontinentia pigmentosa (stage 3 cutaneous lesions associated with dystrophic changes of the hair, nails and teeth
what causes hypopigmentation
incontinentia pigmentosa (stage 5)
- permanent linear hypopigmented streaks particularly on the legs
associated with alopecia
on palpation what areas are important
neck (feeling for lymphadenopathy)
gentle and deep palpation of the abdomen
feel for the liver, spleen, kidneys
how do you palpate
you lie your hand flat and feel by flexing at the metacarphalangeal joints
how do you feel for the liver
flex the fingers at the metacarpophalengeal joint using the forefingers parallel to the costal margin. begin in the right iliac fossa and work up towards the costal margin. children frequency have a palpable liver edge up t o 2 cm.
how to further assess hepatomegaly
position: measure the liver edge below the costal margin in the midclavicular line with a tape measure
texture: smooth or nodule, firm or soft
tenderness
pulsatile (hepatic AV malformation)
expansile (tricuspid incompetence)
percussion don’t forget to define the upper border of the liver to exclude hyperinflation of the liver edge
how do you feel for the spleen
palpate from the right iliac fossa with the left hand splitting the lower edge of the rib age posteriorly
if there is difficulty lie the child on her right side and palpate with the child taking big breaths
the spleen tip may be palpable in normal neonates
measure the sleep from the costal margin in the midclavicular line
percuss the border of the spleen
how do you palpate the kidneys
bimanual palpation
push up with the left hand in the renal angle and feel the kidney anteriorly with the right hand.
ballot the kidneys between the hands
if a mass is found how do you describe it
site size shape
consistency
mobility
whether tender
whether pulsatile
percussion
does it alter after bowel or bladder movement
what are you percussing for
organomegaly, mass, fluid
when to percuss for ascites
if there is hepatomegaly
if any signs of liver disease
if the abdomen appears distended
if there is oedema elsewhere
when would you listen for renal bruits
if the child has neurofibromatosis or is hypertensive
how do you determine if the scrotal swelling is a hernia vs hydrocele?
hernia transmits cough impulse, the testis can be palpated separately. A hydrocele I can get above it, and it transilluminates.
