WCS07 Examination Of The Abdomen Flashcards
General examination
- Signs of relevance
- LN
- pallor - Stigmata of liver disease
- Jaundice (uncommon)
- Spider angioma
- Telangiectasia
- **Palmar erythema
- **Finger clubbing
- **Dupuytren’s contracture
- **Leukonychia
- ***Flapping tremor
- Fetor hepaticus
- Gynaecomastia
- Ankle pigmentation +/- Leg ulcers
- Fluid retention
- Easy bruising, Purpura (bleeding under SC tissue, do not disappear after pressing)
- Hepatic encephalopathy
Spider angioma
- dilated ***central arteriole spreading outwards
- face, oral, nasal mucous membrane
- ***SVC drainage area
- rarely below nipple
—> Normal (<3 on face)
—> Cirrhosis
—> Hepatitis
—> RA
—> Pregnancy
Telangiectasia
- dilated ***capillary
- paper money skin
- same significance as spider angioma
—> Scleroderma
Palmar erythema
- Chronic liver disorder
- RA
- Pregnancy
- Thyrotoxicosis
- Chronic febrile illness
- Chronic leukaemia
Finger clubbing
- Deposition of SC tissue under nail
- press on junction between nail and nail bed
4 stages
- Grade 1: floating sensation / fluctuation / softening of nail bed
- Grade 2: loss of angle between proximal nail fold (nailbed) and nail plate (nail) ∵ ↑ SC tissue
- Grade 3: increased longitudinal curvature of nail
- Grade 4: drumstick appear of fingertips
—> Cyanotic congenital heart disease
—> Infective endocarditis
—> Lung cancer
—> Chronic suppurative lung conditions (e.g. bronchiectasis, empyema) (X TB)
(—> ILD (self notes))
—> Liver conditions (Cirrhosis, Liver abscess)
—> GI (Crohn’s, UC)
記: 2 cardiac causes, 2 respi causes, 2 GI causes
Dupuytren’s contracture
- contracted palmar aponeurosis
- affect 4th + 5th tendon first
—> Normal
—> Cirrhosis (esp. ***Alcohol-related)
—> DM
—> Systemic fibrosclerosing syndromes
Leukonychia
- different from cyanosis (can still see crescent)
- cannot see crescent
- ***Hypoalbuminaemia
Flapping tremor
- severe hepatocellular decompensation
- ***Hepatic encephalopathy
Fetor hepaticus
Probably intestinal origin
—> severe hepatocellular decompensation
—> extensive collateral circulation —> portal-systemic shunt to lungs
Gynaecomastia
- Alcoholic cirrhosis
- Puberty
Ankle pigmentation +/- Leg ulcers
Associated with hypersplenism
—> regress after splenectomy
Hepatic encephalopathy
Confused, slurred speech
—> Drowsy, inappropriate behaviour
—> Stuporous, obeying simple commands
—> Coma
—> Deep coma, no spontaneous movement
Obstructive Jaundice
- Greenish jaundice
- Xanthelesma (Cholesterol crystal)
- Xanthoma (Cholesterol crystal) —> extensor surfaces, knee
- Scratch marks (deposition of bile salt —> pruritis)
Inspection
End of bed
- Shape
- Normal / Scaphoid / Distended (屎肥仔汽水) - Symmetry
- Mass / Swelling
- Dilated veins
- IVC obstruction
- Portal hypertension (i.e. Caput medusae) (由肚臍散出去)
—> observe direction of flow below umbilicus - Scars
- Striae
- acute abdominal distension with SC bleeding e.g. Ascites, Pregnancy
- white vs purple (Cushing’s syndrome) - Pigmentation
- pregnancy
- Addison’s disease - Movement
- Thoraco-abdominal respiration
- Epigastric pulsation e.g. thin patients, transmitted pulsation
- Visible peristalsis in intestinal obstruction - Umbilicus
- normal, depressed in fat abdomen
- bulging / everted with increased ***intraabdominal pressure e.g. Ascites (horizontal slit vs pregnancy: vertical slit) - Visible peristalsis
- Intestinal obstruction - Visible pulsation
- aneurysm - Hernia
- Incisional (diastasis recti)
- Groin (cough impulse: cough / lift head up / standing) - Ecchymosis / Bruising
- Cullen’s sign —> Umbilical
- Grey-Turner’s sign —> Flank
Palpation
Sit down
Ask for pain
- 9 areas
- feel for tenderness
- feel for mass
- ***Peritoneal signs
—> Tenderness
—> Guarding (involuntary contraction against pressure)
—> Rigidity (generalised contraction)
—> Rebound tenderness
—> Absent bowel sound (ileus due to diffuse peritonitis) - Liver
- Spleen
- Kidneys
Liver
- Palpation
- hand avoid rectus muscle
- hand parallel to liver lower border
- extend hand to cover left lobe (normally cannot feel due to rectus muscle)
- deep breath
- normal liver maybe palpable on inspiration or it can be pushed down by thoracic abnormalities e.g. emphysema - Percussion
- finger parallel to liver dullness
- resonant to dull
- move perpendicularly
- percuss above costal margin
- epigastrium for ***left lobe
- upper border: from above downwards - Liver span
- measure at Mid Clavicular Line
- upper border: 5th ICS
- lower border: Costal margin, Mid Clavicular Line
- span: 10cm - Edge
- sharp / rounded - Surface
- smooth / nodular (small nodules usually cannot feel, only large nodule: HCC)
- **Smooth: Fatty liver, alcoholic cirrhosis, primary biliary cholangitis
- **Nodular: Polycystic kidney and liver disease
- ***Large nodules: HCC - Consistency
- soft / firm / hard
- ***Hard: Cancer - Tenderness
- Bruit
- vascular tumour (e.g. HCC) —> heard all over
- alcoholic hepatitis —> heard all over
- compression of aorta —> turn patient to right side and bruit less prominent
Spleen
- Palpation
- deep breath
- fingers parallel to Gardner’s line (umbilicus to left anterior axillary fold) - Hooking
- right lateral position
- renal angle (lateral border of erector spinae + lowermost rib) - Percussion
- finger perpendicular to Gardner’s line
- percuss above costal margin
- spleen is dull (∵ anterior structure) - Dipping (for Ascites)
- dip hand to push down spleen and then allow it to float upwards again
- dip on lateral side also
Kidney
- Palpation
- Renal angle
- deep breath
- feel something —> bimanual palpation
- right kidney lower than left - Percussion
- partially resonant (∵ overlaid by small intestines + colon)
Distinguish between enlarged spleen vs left kidney
1.
Spleen: Anterior
Kidney: Retroperitoneal (∴ bimanually palpable)
2.
Spleen: No subcostal gap
Kidney: Subcostal gap present
3.
Spleen: Dull
Kidney: Always partially resonant (∵ overlaid by intestine)
4.
Spleen (>10cm): Notches along medial border
Kidney: No notches
5.
Both move up and down with respiration
Other mass
- Site
- Size
- Shape
- Localisation
- abdominal wall: lift head to make mass more prominent
- intraperitoneal vs retroperitoneal: less prominent, turn patient to right side, intraperitoneal organ drops and easier to feel - Movement (with respiration / by itself)
- Tenderness
- Consistency
- Pulsation
Ascites
- From resonant to dull
- Fingers: **parallel but **move perpendicularly to line of dullness
- Right lateral position —> new line of dullness —> shifting dullness (previously dull area now resonant)
- not sensitive, require >=1L of fluid - Fluid thrill
- flick on one side and feel for transmitted thrill on other side
- much less sensitive
Auscultation
- Bowel sounds
- Hyperactive:
—> After meal
—> ***Intestinal obstruction
- Hypoactive:
—> **Peritonitis
—> after surgical operation —> **Adynamic ileus
- Liver bruit
- Splenic rub
- Renal bruit (Renal artery stenosis):
- midway between xiphisternum and umbilicus
- lateral to rectus muscle - Succussion splash of stomach
- pyloric stenosis
