Surgery Clinical Demonstration: Abdomen Flashcards
1
Q
Liver
A
- Mostly covered by rib cage
- Extends across midline
2
Q
Spleen
A
- Left 9th - 11th ribs
- Behind Mid-axillary line
- Enlargement: >=2 times before palpable, along Gardner’s line (Left 10th rib - Umbilicus - Right ASIS)
3
Q
***Bifurcation of aorta
A
Umbilicus
4
Q
McBurney’s point
A
1/3 distance from Right ASIS to Umbilicus
—> ***Appendicitis
5
Q
Subcostal line
A
Intersection point with Mid-clavicular line
—> Gallbladder
—> Cholecystitis (Murphy’s sign)
6
Q
Transpyloric plane
A
- Joining tips of **9th costal cartilage at **Linea semilunaris
- Between L1 and L2
Structures:
- Pylorus
- Gallbladder fundus
- Pancreas neck
- Kidney hila
- Origin of ***SMA
- ***Conus Medullaris
7
Q
History of GI system
A
- Pain
- SOCRATES - Mass
- site
- duration
- how discovered
- vary in size?
- associated symptoms e.g. discharge - GI tract symptoms
- N+V (Frequency, Quantity, Nature)
- Intestinal obstruction (Distension, Pain, Vomiting, Constipation)
- Appetite loss
- Weight loss
- Heartburn, Regurgitation, Bloating, Distension, Dysphagia
- Bleeding
—> **Melena (Haematin)
—> **Coffee ground vomit (Methaemoglobin)
—> Haematemesis
—> Per-rectal - Bowel disturbances
- constipation
- diarrhoea
- bowel habit change
- tenesmus
- steatorrhoea
- pale stool - Jaundice
- pale stool
- dark urine
- yellowing of skin + sclera
8
Q
Physical examination
A
- General
- Abdominal examination (Supine, Nipple to Mid-thigh)
- Inspection
- Palpation
- Percussion
- Auscultation
9
Q
General examination
A
***Head to Toe
- ***Cachexia
- ***Distress
- Hepatic encephalopathy (mental state)
- ***Tubes / drips (nasogastric, feeding tube, urethral catheter, IV drip)
- Head
- **Pallor, **Jaundice, Hyperpigmentation, Parotid gland - Mouth
- Lips
- Breath (***Fetor hepaticus, Alcohol, Halitosis (Fetor oris))
- Tongue (ulcer, cyanosis, hydration, glossitis)
- Mucosa
- Teeth, Gum - Neck
- Swelling
- LN (Virchow’s node: palpable left supraclavicular LN —> ***Troisier’s sign: Virchow’s node + Intra-abdominal malignancy)
—> LN not palpable (X not enlarged)
- Dilated veins
- JVP - Chest
- Spider angioma (blanch on compression of central arteriole)
- Gynaecomastia
- Herpes zoster - Hands
- **Palmer erythema (pregnancy / chronic liver disease / normal)
- **Clubbing
- Nail abnormalities (e.g. Koilonychia (spoon nail), **Leukonychia)
- **Dupuytren’s contracture (contracted palmar aponeurosis)
- ***Flapping tremor
- Peripheral cyanosis
- Radial pulse - Ankles
- ***edema (bilateral: heart failure vs unilateral: obstruction, DVT)
- ulcer (medial malleolus: venous hypertension, distal phalanges: peripheral vascular disease)
- pigmentation (venous hypertension / chronic liver disease) - Vital signs
- BP
- ***Pulse
- Temp - Special
- Stigmata of liver diseases
10
Q
Inspection
A
- Abdominal contour
- Flat
- Scaphoid
- Obese
- Distension (屎肥仔汽水) - Symmetry
- visible mass - Bulging
- Suprapubic: Bladder, Uterus
- Subcostal: Liver, Spleen - Normal movement with respiration / Immobile (Pain when movement due to peritonitis)
- Distended veins
- **IVC obstruction
- **Caput medusae
—> differentiate by press 2 ends and release 1 end to see bloodflow - Visible peristalsis
- Intestinal obstruction - Visible pulsation
- aneurysm - Umbilicus
- hernia
- Sister Joseph nodule - Hernia
- Incisional (diastasis recti)
- Groin (cough impulse: cough / left head up / standing) - Scar
- Fistula
- Stoma
- feeding gastrostomy
- colostomy - Pigmentation, Striae, Scratch marks
- Ecchymosis
- **Cullen’s sign —> Umbilical
- **Grey-Turner’s sign —> Flank - Ask to cough —> look for hernia / induce pain anywhere
11
Q
Palpation
A
- Sit / Kneel
- Warm hands
- Ask for pain
- Look at face
- 4 Quadrants
- Superficial —> Deep
- tenderness
- masses
- pulsation - Peritoneal signs
- tenderness
- guarding (involuntary contraction against pressure)
- rigidity (generalised contraction)
- rebound tenderness
- absent bowel sound (ileus due to diffuse peritonitis) - ***Murphy’s sign
- acute cholecystitis —> pressed on “Murphy’s point” —> inspire —> pain —> positive Murphy’s sign -
**Courvoisier’s law (sign)
- Gallbladder enlargement with Jaundice
—> likely due to obstruction by **cancer (Pancreas, Common Bile Duct, Ampulla) / ***Recurrent Pyogenic cholangitis rather than stone
—> if stone obstruct CBD, then gallbladder already fibrosed before obstruction (D石已經多到塞CBD) - Liver and Spleen
- hands move upwards towards costal margin when expiration, stop when inspiration to feel for descent —> check liver consistency
- ***Riedel’s lobe (lobus appendicularis / lobus linguiformis)
—> tongue-like extension from right lobe of liver
- Spleen
—> start from RLQ along Gardner’s line
—> right lateral position for spleen tip - Kidney
- Ballottement
- Lower pole: 5cm below Transpyloric plane
- Hilum: Transpyloric plane
- Palpating hand kept still —> feel for movement towards anterior abdominal wall - Palpable masses
- site, size, shape, surface, consistency, pulsation, tenderness, mobility on palpation / with respiration, intra-abdominal (less obvious on tensed abdominal wall by moving head up)
- Ballottement for retroperitoneal mass - Pulsation
- expansile e.g. Abdominal aortic aneurysm —> within the mass / transmitted? - Look for organomegaly in the presence of gross ascites
- Dipping technique (Flex MCP)
12
Q
Percussion
A
- Liver
- upper border
- liver span
- absence of dullness when free gas present - Spleen
- splenic dullness: **behind mid-axillary line —> dullness extending anterior to mid-axillary line —> enlargement
- enlarged spleen vs left kidney: **resonance due to overlying colon for kidney - Bladder
- suprapubic bulging
- urinary retention - Shifting dullness
- negative shifting dullness: cannot exclude ascites (>1L)
- fluid thrill
13
Q
Auscultation
A
Stethoscope Diaphragm
- Bowel sound
- Obstruction: increased / high-pitched tingling
- Ileus / Peritonitis: decreased / absent - Bruit
- Hepatomegaly
- Aorta (between xiphoid and umbilicus)
- Renal artery stenosis (Transpyloric plane) - Succussion splash / Gastric splash
- splashing sound in gastric outlet obstruction (e.g. pyloric stenosis / gastric cancer)
—> listen over epigastrium + rock patient sideways
