OSCE - Abdominal

Question 1

Examination - JACCO

Answer 1

• Jaundice - Yellowing of skin and sclera of eyes. Can be caused by the build-up of Bilirubin (yellow/brown - the product of red blood cell breakdown):
  
  • Gallstones
  • Alcoholic Liver Disease
  • Pancreatitis
  • Hepatitis
  • Sickle Cell
• Anaemia - Pallor in mucous membranes or dull, pale skin caused by lack of red blood cells.
• Cyanosis - Bluish discolouration of the skin due to poor circulation/inadequate oxygenation of the blood. Peripherally caused by low O₂ in the red blood cells, or problems getting oxygenated blood to the body. Cold temps. can lead to blood vessel narrowing & temporarily blue-tinged skin. Central cyanosis is more serious and can be caused by low cardiac output.
• Clubbing - Deformity of the finger or toenails associated with a number of diseases, mostly of the heart & lungs.
• Oedema - Condition characterised by an excess of watery fluid collecting in the cavities or tissues of the body. Note lower leg/ankle (?sacral?) oedema could be an indication of heart failure

Question 2

Inspection

Answer 2

• Obese/size - Abdomen flat to round in people of average weight. Protruding abdomen ? caused by 6 F’s - Fat, Foetus, Fluid, Flatus, Faeces, Flippin’ great tumour.
• Symmetry - Look for symmetry, lumps, bumps, scars, striae(stretch marks), colour. Bulge may indicated distended bladder or Hernia. Any pulsating masses? AAA?
• Swelling - Is stomach normally distended?
• Scars/Lacerations - Any surgical scars?
• Bruising
  
  • Grey Turners Sign - ecchymosis of L flank indicative of haemorrhagic pancreatitis.
  • Cullens sign - ecchymosis of periumbilical area indicative of haemorrhagic pancreatitis, ruptured intra-abdominal ectopic pregnancy.

Question 3

Auscultation

Answer 3

• Good technique
• Uses diaphragm
• Correct location
• Bowel sounds
  
  • ​Hyperactive
  • Present
  • Hypoactive
  • Absent
  • Normal range of sounds 5 - 34 per minute

Question 4

Percussion

Answer 4

• Explain to Pt
• Good technique
• Correct locations - All 4 quadrants
• Tympany or Dullness - Pass comment
• Liver span - 6 - 12cm, does the liver appear larger? Alcoholism?

Question 5

Palpation

Answer 5

• Explain to Pt
• Technique
  
  • ​Detect tenderness of organs, masses or fluid accumulation.
  • Light palpation used to assess tenderness & guarding.
  • Deep palpation used to assess for masses(NOT RECOMMENDED FOR PARAMEDICS).
• Look for response/discomfort in Pt face
• Locations - All 4 quadrants
• Note - Any guarding or rigidity

Question 6

Special tests

Answer 6

• Rovsing - Pressure on L lower quadrant causes pain in R lower quadrant, indication of acute appendicitis - said to be Rovsing+
• Psoas - With supine Pt, place pressure on R knee by hand, ask Pt to raise R thigh against resistance - increased abdo pain on flexion indicates ? irritation of Psoas muscle by inflamed Appendix.
• Obturator - Internal rotation or R leg flexed to 90º at the hip and knee - resultant tightening of the Internal Obturator muscle may cause increased abdo pain - indication of Appendicitis or peritoneal inflammation.
• Murphy’s sign - Hook L thumb or fingers of R hand under costal margin, ask Pt to breath in & out - R upper quadrant pain & tenderness suggestive of Acute Cholecystitis(obstruction of Cystic duct)/Gallbladder inflammation - said to be +Murphy’s sign
• McBurneys Point - Location on the abdomen at which ++tenderness indicates Appendicitis - between 1.5-2 inches from the anterior spinous process of the ileum, on a straight line drawn from that process to the umbilicus.
• Kehr’s sign - L shoulder pain referred from the Diaphragm, suggestive of free intraperitoneal blood from a splenic injury.

Question 7

Further Tests

Answer 7

Observations suggested by scenario

• BP?
• BM?