Abdominal + Hernia Examination Flashcards
Introductions
Wash hands, PPE Introductions Explanation of the exam and gain consent Adjust bed to 45 Ask patient to expose themselves from waist up -offer blanket Ask about any pain
Step 2
General inspection
What objects and equipment may you find around the bed
Prescriptions, medications, drug charts
Fluid balance charts
Vital signs
Mobility aids
Medical equipment
- ECG
- catheter
- O2
- IV access
- drains, stoma bags (check contents)
Feeding tubes
Step 2
General inspection
Clinical signs
Age
- Youth => IBD?
- Older => CLD, malignancy?
Confused?
-sign of end stage LD (hepatic encephalopathy)
Habitus
- abdominal distension? (organomegaly? Ascites from cirrhosis)
- cachexic (malignancy?)
- hernias
- scars
Complexion
- pale => anemia (CKD, malabsorption, Fe, B12, folate deficient?)
- jaundiced => (hepatitis, pancreatitis, gallstones, alcoholic?)
- hyperpigmented => haemochromatosis (excess Fe damages liver)
Step 3 Hands
Palm signs
What are you looking for
What are they signs of?
3 things
Palmar erythema (thenar, hypothenar)
- pregnant
- CLD (liver unable to metabolise estrogen => accumulation => increased blood flow)
Pallor
-anemia (Fe, B12, folate deficient, GI malabsorption)
Dupuytrens contracture
-alcoholic, diabetic
Step 3 Nails
What are you looking for
What are they signs of
2 things
Leukonychia
-hypoalbuminemia (decreased prod in liver due to cirrhosis, hepatitis/low protein absorption)
Koilonychia
-Fe deficient (malabsorption in gut, Crohns?)
What can finger clubbing tell you
Crohns
Coeliac
Cirrhosis
Cancer (GI lymphoma)
Step 3 Asterixis
What can this tell you
Hepatic encephalopathy (hyperammonemia due to poor liver metabolism)
Uremia (renal failure)
Step 3 Palpation of hands
What can you find?
What can this tell you
Temperature
-cold => poor perfusion
Radial pulse
-assess rate and rhythm
Step 4 Arm and armpits
What are you looking for
What can this tell you?
Bruising
-cirrhosis => clotting abnormalities
Excoriations
-bile blockage => itching
Needle tracks
-IVDU => HepB, C
Acanthosis nigricans (darkening, thickening) -T2D or GI malignancy (stomach)
Hairloss
-Fe deficiency anaemia, malnutrition (divert blood flow to vital areas, hair growth not stimulated)
Step 5 Face (Eyes)
What are you looking for
What can this tell you
Sclera
- Pallor => anemia (Fe deficient, malabsorption)
- Jaundice => liver cirhhosis, hepatitis pancreatic cancer, bile blocakge)
Iris
- corneal arcus in under 50s => hypercholesterolemia
- Kayser Fleischer rings => Copper deposits (abnormal processing by liver/excess can cause cirhhosis)
- perilimbal injection => anterior uveitis, accompanied with photophobia, eye pain, reduced visual acuity (linked to IBD)
Around the eyes
-xanthelasma => hypercholesterolemia
Step 5 Face (Mouth)
What are you looking for
What can this tell you
Tongue
- glossitis => malnutrition, malabsorption of Fe, folate, B12 (IBD, alcoholic)
- oral candidiasis => immunosuppresed/malnourished
Mucus membranes
- apthous ulcers => B12, folate Fe deficiency but can be benign (Crohns, malnutrition/malabsorption)
- hyperpigmented macules => Peutz Jegar (GI polyps)
Mouth corners
-angular stomatitis => malnutrition/malabsorption (Fe, B vitamin deficient)
Step 5 Face (Neck)
What are you looking for
What can this tell you
L supraclavicular fossa => GI metastases
R supraclavicular fossa => thorax metastases
Step 6 Chest inspection
What are you looking for
What can this tell you
Spider naevi (high estrogen)
- 5+ => cirhhosis
- pregnancy, HRT use
Gynecomastia (high estrogen)
- cirrhosis
- medication (digoxin, spironolactone)
Hair loss
- malnutrition
- increased estrogen
Step 6 Abdominal inspection
What are you looking for
What can this tell you
Scars
-past surgical history clues
Distension
-6Fs (fat, flatus, feces, fetus, fulminant mass, fluid)
Hernias
-ask patient to cough
Caput medusa
-portal HTN or IVCO (check direction of blood flow)
Stretch marks
- ascites, abdominal malignancy, Cushings
- obesity, pregnancy
Cullen’s sign (umbilical bruising)
-late pancreatitis
Grey Turner’s sign (flank bruising)
-late pancreatitis
Step 6 Stomas
What are you looking for
What could this tell you
Type and contents
- colostomy => LIF, solid stool,
- ileostomy => RIF, liquid stool
- urostomy => RIF, urine
Spouts
- colostomies => flush to skin, no spout
- ileostomies, urostomies => spout
Step 7 Abdominal palpation
Light palpation
What are you looking for
What can this tell you
Tenderness
-note region, think what structures are present and severity of pain
Rebound tenderness
-peritonitis (possible appendicitis)
Guarding
-appendicitis, diverticulitis
Masses
Step 7 Abdominal palpation
Deep palpation
What are you looking for
What can this tell you
Assess qualities of masses found
Location
Size, shape
Consistency - smooth, soft, hard, irregular
Mobility - attached to superficial/deep structures
Pulsatility - vascular etiology
Step 8 Liver palpation
What are you looking for
What can this tell you
1-2cm under costal margin => normal
Liver edge properties
-2cm+ => hepatomegaly
Nodular => cirrhosis
Tenderness => hepatitis, cholecystitis?
Pulsatility => tricupspid regurgitation
What are the differentials for hepatomegaly?
VITAMIN CDEF
Vascular
- tricuspid regurgitation, RV failure
- heart failure
- constrictive pericarditis
Iatrogenic/idiopathic
-statins, macrolides, amiodarone
Autoimmune
-autoimmune hepatitis
Metabolic
- haemochromatosis
- Wilson’s
- glycogen storage problems
Infective/inflammatory
-bacterial/viral hepatitis
Neoplastic
- liver metastases
- liver carcinoma
- leukemia, lymphoma
Congenital
-haemolytic anemias (thalassemia)
Functional
-biliary obstruction
Step 8 Gallbladder palpations
- how would you do this
- what signs are you looking for
R costal margin at MCL
NOT NORMALLY PALPABLE
-if palpable (well defined round mass that moves with respiration) => enlargement secondary to biliary obstruction
Murphy’s sign => pain midbreath
-cholecystitis, cholangitis?
No pain, enlarged => pancreatic cancer (esp w jaundice?), cholangiocarcinoma?
Step 8 Spleen palpation
- how would you do this
- what are you looking for
L costal margin
NOT NORMALLY PALPABLE
-if palpable => 3x its size
What are the differentials for splenomegaly
-VITAMIN CDEF
Vascular
- Portal HTN secondary to cirrhosis
- haemolytic anemia
- HF
Infective/inflammatory
-glandular fever (infects B cells => lymphoid organs swell)
Neoplastic
-splenic metastases
Step 8 Kidney balloting
- how would you do this
- what are you feeling for
R and L flanks on inspiration
NOT NORMALLY PALPABLE
-if palpable => describe it
Bilateral enlargement => PKD, amyloidosis (amyloid released by abnormal plasma cells accumulates in kidneys)
Unilateral enlargement => renal tumour
Step 9 Aorta palpation
- how would you do this
- what are you feeling for
Deep palpation superior to umbilicus at midline
-hands should move superiorly
If hands move laterally => expansile mass (AAA)
Step 9 Bladder palpation
- how would you do this
- what are you feeling for
Check when the patient last went to the bathroom
Give them an opportunity to relieve themself
Warn them that this may be uncomfortable and may make them want to pee
NOT NORMALLY PALPABLE
-Distended bladder in suprapubic area (behind pubic symphysis => urinary obstruction, retention?
Step 10 Liver percussion
- how would you do this
- what are you judging
Resonant to dull
Lower liver and upper liver border => liver size
Step 10 Spleen percussion
- how would you do this
- what are you judging
Resonant to dull
SHOULD NOT BE IDENTIFIABLE
Step 10 Bladder percussion
- how would you do this
- what are you judging
Midline from umbilical region => pubic symphysis
-distended bladder will be dull to percussion
SHOULD NOT BE IDENTIFIABLE
Step 10 Shifting dullness
- how would you do this
- what are you judging
Umbilicus => L lumbar until dullness noted
Keep your finger on the dull area, ask the patient to roll towards to (to the right) => wait for 30s
If dull region is now resonant => ascities has shifted
Step 11 Bowel sounds
- how would you do this
- what sounds are you listening for
2 areas Normal => gurgling Tinkling => bowel obstruction Absent => ileus -electrolyte abnomalities -recent abdo surgery
Step 11 Bruits
-which would you listen for
1-2cm above umbilicus => AAA
1-2cm superolateral to umbilicus => renal bruits
1-2cm superolateral on both sides => renal artery stenosis
Step 12 Legs
-what are you looking for
Peripheral edema => hypoalbuminemia
Completion of the examination
Explain to the patient that you have finished and thank them for their time
Dispose of PPE, wash hands
Summarise findings
-mention positive findings
-if nothing abnomal found in an area => no stigmata of GI disease
For completeness
- check hernial orifices
- check external genitalia
- DR exam
Hernia examination
-inspection
Patient
- pain
- obvious scars
- abdo distention - BO from incarcerated hernia?
- pallor - anemia from GI bleed?
- cachexia - malignancy
- hernia may be visible
Objects
- stoma bag - parastomal hernia, common complication of stoma formation
- surgical drains - location and contents
- mobility aids
What is a hernia
What is not a hernia
Hernia
- single, soft, reducible, painless, cough impulse
- cannot get above lump
- bowel sounds
Not a hernia
- multiple lumps (lymphadenopathy?)
- hard, nodular (malignancy)
- can get above lump (scrotal mass?)
- transillumination (hydrocele?)
- bruit (AVM?)
Hernia examination
- what would you do
- what are you looking for
Patient supine on couch
- inspect for masses
- palpate femoral pulses
- palpate inguinal LNs
Patient standing
-inspect for hernias
Inguinal
- invaginate scrotum => palpate ext inguinal ring and post wall for muscle defects
- cough impulse => indirect inguinal
- reduce hernia towards internal ring and occlude int ring, cough impulse => direct inguinal
Palpation of scrotum
-cannot get above lump => hernia
Femoral - distal lateral to pubic tubercle
Inguinal - proximal medial to pubic tubercle
