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OSCE examinations > Abdominal + Hernia Examination > Flashcards

Abdominal + Hernia Examination Flashcards

1
Q

Introductions

A 
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
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2
Q

Step 2
General inspection
What objects and equipment may you find around the bed

A

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

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3
Q

Step 2
General inspection
Clinical signs

A

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)
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4
Q

Step 3 Hands
Palm signs
What are you looking for
What are they signs of?

3 things

A

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

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5
Q

Step 3 Nails
What are you looking for
What are they signs of

2 things

A

Leukonychia
-hypoalbuminemia (decreased prod in liver due to cirrhosis, hepatitis/low protein absorption)

Koilonychia
-Fe deficient (malabsorption in gut, Crohns?)

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6
Q

What can finger clubbing tell you

A

Crohns
Coeliac
Cirrhosis
Cancer (GI lymphoma)

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7
Q

Step 3 Asterixis

What can this tell you

A

Hepatic encephalopathy (hyperammonemia due to poor liver metabolism)
Uremia (renal failure)

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8
Q

Step 3 Palpation of hands
What can you find?
What can this tell you

A

Temperature
-cold => poor perfusion

Radial pulse
-assess rate and rhythm

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9
Q

Step 4 Arm and armpits
What are you looking for
What can this tell you?

A

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)

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10
Q

Step 5 Face (Eyes)
What are you looking for
What can this tell you

A

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

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11
Q

Step 5 Face (Mouth)
What are you looking for
What can this tell you

A

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)

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12
Q

Step 5 Face (Neck)
What are you looking for
What can this tell you

A

L supraclavicular fossa => GI metastases

R supraclavicular fossa => thorax metastases

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13
Q

Step 6 Chest inspection
What are you looking for
What can this tell you

A

Spider naevi (high estrogen)
- 5+ => cirhhosis
- pregnancy, HRT use

Gynecomastia (high estrogen)
- cirrhosis
- medication (digoxin, spironolactone)

Hair loss
- malnutrition
- increased estrogen

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14
Q

Step 6 Abdominal inspection
What are you looking for
What can this tell you

A

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

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15
Q

Step 6 Stomas
What are you looking for
What could this tell you

A

Type and contents
- colostomy => LIF, solid stool,
- ileostomy => RIF, liquid stool
- urostomy => RIF, urine

Spouts
- colostomies => flush to skin, no spout
- ileostomies, urostomies => spout

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16
Q

Step 7 Abdominal palpation
Light palpation
What are you looking for
What can this tell you

A

Tenderness
-note region, think what structures are present and severity of pain

Rebound tenderness
-peritonitis (possible appendicitis)

Guarding
-appendicitis, diverticulitis

Masses

17
Q

Step 7 Abdominal palpation
Deep palpation
What are you looking for
What can this tell you

A

Assess qualities of masses found

Location

Size, shape

Consistency - smooth, soft, hard, irregular

Mobility - attached to superficial/deep structures

Pulsatility - vascular etiology

18
Q

Step 8 Liver palpation
What are you looking for
What can this tell you

A

1-2cm under costal margin => normal

Liver edge properties
-2cm+ => hepatomegaly

Nodular => cirrhosis

Tenderness => hepatitis, cholecystitis?

Pulsatility => tricupspid regurgitation

19
Q

What are the differentials for hepatomegaly?

VITAMIN CDEF

A

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

20
Q

Step 8 Gallbladder palpations

  • how would you do this
  • what signs are you looking for
A

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?

21
Q

Step 8 Spleen palpation

  • how would you do this
  • what are you looking for
A

L costal margin
NOT NORMALLY PALPABLE
-if palpable => 3x its size

22
Q

What are the differentials for splenomegaly

-VITAMIN CDEF

A

Vascular
- Portal HTN secondary to cirrhosis
- haemolytic anemia
- HF

Infective/inflammatory
-glandular fever (infects B cells => lymphoid organs swell)

Neoplastic
-splenic metastases

23
Q

Step 8 Kidney balloting

  • how would you do this
  • what are you feeling for
A

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

24
Q

Step 9 Aorta palpation

  • how would you do this
  • what are you feeling for
A

Deep palpation superior to umbilicus at midline
-hands should move superiorly

If hands move laterally => expansile mass (AAA)

25
Q

Step 9 Bladder palpation

  • how would you do this
  • what are you feeling for
A

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?

26
Q

Step 10 Liver percussion

  • how would you do this
  • what are you judging
A

Resonant to dull

Lower liver and upper liver border => liver size

27
Q

Step 10 Spleen percussion

  • how would you do this
  • what are you judging
A

Resonant to dull

SHOULD NOT BE IDENTIFIABLE

28
Q

Step 10 Bladder percussion

  • how would you do this
  • what are you judging
A

Midline from umbilical region => pubic symphysis
-distended bladder will be dull to percussion

SHOULD NOT BE IDENTIFIABLE

29
Q

Step 10 Shifting dullness

  • how would you do this
  • what are you judging
A

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

30
Q

Step 11 Bowel sounds

  • how would you do this
  • what sounds are you listening for
A 
2 areas
Normal => gurgling
Tinkling => bowel obstruction
Absent => ileus
-electrolyte abnomalities
-recent abdo surgery
31
Q

Step 11 Bruits

-which would you listen for

A

1-2cm above umbilicus => AAA
1-2cm superolateral to umbilicus => renal bruits

1-2cm superolateral on both sides => renal artery stenosis

32
Q

Step 12 Legs

-what are you looking for

A

Peripheral edema => hypoalbuminemia

33
Q

Completion of the examination

A

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

34
Q

Hernia examination

-inspection

A

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

35
Q

What is a hernia

What is not a hernia

A

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?)

36
Q

Hernia examination

  • what would you do
  • what are you looking for
A

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

OSCE examinations (142 decks)

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