1
Q
What is the general order of carrying out an abdo exam? (16)
A
- WIPPEE
- Obs around bed
- General appearance
- Hands and nails
- Arms (asterixis, tremor)
- Pulse
- Resp rate
- Face
- Eyes
- Mouth
- Lymph nodes
- Abdo inspection
- Abdo palpation
- Abdo percussion
- Abdo auscultation
- Legs and ankles
2
Q
What is the position of an abdo exam?
A
Initially at 45°, totally flat later in examination
3
Q
What level of exposure does a patient need in an abdo exam?
A
Whole upper torso (from bottom of sternum to symphysis pubis)
4
Q
What observations can be made around the bed of an abdo patient? (10)
A
- Oxygen masks
- GTN spray/meds
- Walking aids
- Drip stand
- Nasogastric tube
- Snacks/nil by mouth/high cal drinks
- Stoma bag
- Asictis tap/drain
- Sick bowel
- Surgical drain
- Catheter
5
Q
What objects around the bed of an abdo patient should be checked? And what for?
A
- Stoma - check the site and bag, any poo?
- Sick bowel - check vomit?
6
Q
What could a nasogastric tube be for in an abdo patient? (2)
A
- Suck out vomit
- Give food
7
Q
What observations can be made about an abdo patient’s general appearance? (7)
A
- Comfortable/in pain?
- Unwell? Nausea?
- Cachetic? High/low BMI? Well nourished?
- Jaundice?
- Pale?
- Tattoos
- Drug use
- Vital signs
8
Q
Why look for tattoos/drug use in an abdo patient?
A
Needles are a risk factor for hepatitus
9
Q
When is it appropriate to check vital signs in an abdo patient? (2)
A
- Suspicion of infection
- Acutely unwell
10
Q
What should be looked for in the hands of an abdo patient? (7)
A
- Clubbing
- Leukonychia
- Koilonychia
- Palmar erythema
- Tar staining
- Dupurytren’s contracture
- Capillary refill time
11
Q
What is leukonychia?
A
White nail bed
12
Q
What is leukonychia most commonly caused by? And what 2 conditions could this indicate?
A
Hypoalbuminemia
- Liver failure/cirrocis
- Enteropathy (GI disease)
13
Q
What is kolionychia?
A
Spoon nails
14
Q
What causes kolionychia? (3)
A
- Chronic iron deficiency
(hyochronic pale RBC anaemia) - Autoimmune diseases e.g lupus
- Genetic
15
Q
What are the abdo causes of clubbing?
A
- Inflammatory bowel disease
- Cirrhosis
- Coeliac disease
16
Q
What could cause palmar erythema? (2)
A
- Liver disease
- Pregnancy
17
Q
What could cause Dupuytren’s contracture relevant to an abdo exam? (2)
A
- Increased alcohol usage
- Liver cirrhosis
18
Q
What are the less common causes of leukonychia? (7)
A
- Tramua
- Poisoning/drugs
- Kidney disease
- Heart failure
- Diabetes
- Hyperthyroidism
- Zinc deficiency
19
Q
What are the less common causes of palmar erythema? (3)
A
- Polychthaemia
- Thryotoxcosis
- Sarcoidosis
20
Q
What are the abdo causes of asterixis? (3)
A
- Hepatic encephalopathy (no liver toxin removal = build up of toxins = brain damage)
- Uraemia (renal failure)
- CO2 retention
21
Q
What can tremor in the arms indicate relevant to an abdo exam?
A
Alcohol withdrawal
22
Q
What should be looked for in the arms relevant to an abdo exam? (4)
A
- Bruising
- Scratch marks (excoriations)
- Track marks
- Tremor
23
Q
What does bruising indicate relevant to an abdo exam?
A
Coagulation disorder due to liver failure
24
Q
What do scratch marks indicate relevant to an abdo exam?
A
Pruritus (itch) - early sign of jaundice
25
What do track marks indicate relevant to an abdo exam?
IV drug use - risk for hep B and C
26
What should be checked for in the face relevant to an abdo exam?
Pallor
27
What should be for in the eyes relevant to an abdo exam? (4)
- Jaundice
- Conjunctival pallor
- Kayser-Fleischer rings
- Xanthelasma
28
How should the eyes be checked for jaundice?
Patient looks down and retracts upper eyelid to expose sclera - yellow?
29
What is yellow sclera known as?
Scleral icterus
30
What are kayser fleischer rings?
Copper deposits in iris best seen with a slit lamp
31
What disease to kayser fleischer rings indicate?
Wilson's disease (hepatolenticular degeneration = liver can't filter out copper)
32
What can be seen in the mouth relevant to an ado exam?
- Ulcers
- Angular stomatitis
- Glossitis
- Dry mucus membranes
- Caudidal infection
33
What are rare things that can be seen in the mouth relevant to an abdo exam?
- Telangectasia
- Brown lip discolourisation
- Purpura (burst capillary vessels in lips)
34
What is telangectasia?
Later
35
Later
Later
36
Later
Later
37
Later
Later
38
What is angular stomatitis?
Bilateral fissures in corners of mouth
39
What is angular stomatitis caused by? (3)
- Thiamine deficiency
- B12 deficiency
- Iron deficiency
40
What is glossitis caused by? (3)
- Folate deficiency
- B12 deficiency
- Iron deficiency
41
What is glossitis? (3)
Red swollen tongue
42
What abdo diseases cause ulcers in the mouth? (3)
- Crohn's
- IBD
- Coeliac disease
43
What lymph nodes should particularly be examined in the neck for an abdo exam? And where are they? (8)
- Infraclavicular
- Supraclavicular
- Submental
- Submanidbular (length of jaw
- Cervical (z shaped along neck - deep to sternocleidomastoid, shallow to scalene) - anterior cervical/posterior cervical
- Preauricular
- Postauricular
- Occipital
- Axillary
44
What does lymphadenopathy in the cervical/axillary lymph nodes indicate? (2)
- Infection
| - Malignancy
45
What node is found in the supraclaviclar area that suggests gastric malignancy?
Virchow's node
46
Where is Virchow's node found?
Left superclavicular fossa
47
What is checked in a lymph exam? (4)
- >2cm = Infection/malignancy
- Soft? Rubbery? Hard?
- Tender vs non tender
- Mobile/fixed?
48
What kind of lymph node would suggest malignancy? (4)
- Enlarged
- Hard
- Fixed
- Irregular
49
What should be inspected for in the chest relevant to an abdo exam?
- Spider naevi
- Campell de Morgan spots
- Petechial haemorrages
- Gynaecomastia (men)
- Hair loss
50
What are spider naevi?
Central red spot with reddish extensions when naevus compresed
51
What can spider naevi be significant for? (2)
- >5 = chronic liver disease
| - Pregnancy: excess oestrogen
52
What are Campbell de Morgan spots?
Benign 1-3 cm cherry red papules
53
What are petechial haemorrages and what do they indicate?
- Tiny circular non raised patches of spots (like a rash)
| - Indicate straining e.g chronic coughing
54
What is gynaecomastia?
Enlargement of breast gland in men
55
What can gynaecomastia be caused by? (3)
- Alcohol
- Liver cirrhosis
- Medications
56
What medications cause gynaecomastia? (2)
- Digoxin
| - Spironolactone
57
What are the reasons for hair loss on the chest? (3)
- Malnourishment
- Iron deficiency
- Anaemia
58
What position should the patient be in for an abdo inspection? (3)
- Lie flat
- Relax hands at sides
- Abdo muscles relaxed
59
What should be inspected for in the abdomen? (9)
- Pain
- Abdominal distension
- Scars
- Excoriation (stretch marks)
- Striae (stretch marks)
- Caput medisae
- Pulsation
- Stoma
- Masses
60
What scars should be inspected for in the abdomen? (3)
- Midline scars
- RIF
- Right subcostal
61
What are midline scars caused by?
Lapartomy
62
What is a right iliac fossa scar (RIF) caused by?
Appendectomy
63
What is a right subcostal scar caused by?
Cholecystectomy
64
What can a central pulsatile expansile mass indicate?
Abdominal aortic aneurysm (AAA)
65
What are caput medusae?
Engorged paraumbilical veins
66
What are caput medusae a sign of?
Portal hypertension
67
What are striae? And the two colours?
Stretch marks
Reddish/pink: new
White/silverish: chronic
68
What do exocriations indicate? (2)
- Cholestatsis
| - Severe itching
69
What are the reasons for abdominal distension? (5Fs)
- Fluid (ascities)
- Fat (obesity)
- Faeces (constipation)
- Flatus
- Foetus (pregnancy)
70
What do masses on abdominal inspection indicate? (2)
- Organomegaly
| - Malignancy
71
What are the 2 places stomas can be found?
- Left iliac fossa (LIF)
| - Right iliac fossa (RIF)
72
What is the type of stoma found at the left iliac fossa (LIF)?
Colostomy
73
What is the type of stoma found at the right iliac fossa (LIF)? (2)
- Ileostomy
| - Urostomy (urine containing)
74
How to prepare patient for palpation? (4)
- Ask about areas of pain
- Examine these last
- Kneel = level with patient, eye level
- Observe patient's face for signs of discomfort
75
What 9 regions of the abdomen that should palpated?
- Right hypochondriac
- Epigastric
- Left hypochondriac
- Right lumbar
- Umblical
- Left lumbar
- Right iliac
- Suprapubic
- Left iliac
76
What should be assessed in light palpation of the abdomen? (4)
- Tenderness
- Rebound tenderness
- Guarding
- Masses
77
What is tenderness in abdominal palpation? And what should be noted? (2)
Pain
- Areas involved
- Pain severity
78
What is rebound tenderness? And what does it indicate? (2)
- Pain worsened on releasing the pressure
| - Peritonitis
79
What is guarding? And what are the two types? (2)
- Involuntary tension in abdominal muscles
| - Localised vs generalised
80
What is guarding caused by? (2)
- Inflammation of peritoneum = peritonitus
| - If localised = local infection e.g appendicitis/ diverticulitis
81
What is assessed in deep palpation?
- Masses
82
What should be assessed in abdominal masses? (6)
- Site
- Size
- Region
- Consistency (smooth/soft/hard/irregular)
- Mobile? (attached to tissues)
- Pulsatile (vascular)
83
What organs should be palpated for in the abdomen? (5)
- Liver
- Gallbladder
- Spleen
- Aorta
- Bladder
84
How should the hand be used in palpating organs?
Flat edge of hand with radial side of R index finger
85
How do you palpate the liver? (4)
- Begin in right iliac fossa
- Press hand into abdomen and palpate up to costal margin
- Feel for liver edge as patient breathes in
86
What should be noted about the liver edge?
- Degree of extension below costal margin
- Smooth/regular consistency?
- Tenderness (hepatitus)?
- Pulsatility
87
What does a pulsatile liver edge indicate?
Tricuspid regurgitation
88
Where should the liver be palpated?
1cm below ribcage
89
What can cause a liver to be pushed down?
Hyperextended chest
90
How should the gallbladder be palpated?
Right costal margin, mid claviular line (9th rib)
91
Is the gallbladder usually palpable?
No
92
What does an enlarged gallbladder indicate?
Obstruction to biliary flow/infection (cholecystitus)
93
What does an enlarged gallbladder feel like?
Rounded mass moving with respiration
94
What does a positive Murphy's sign indicate?
Cholecystits
95
Describe how to perform Murphy's sign (5)
- Patient takes deep breath
- Gallbladder pushed down into hand
- Patient sudden pain=stops inspiring
- Not in left side of abdomen
96
At what size does the spleen become palpable?
x3 normal size
97
Describe how to palpate the spleen (4)
- Start in right iliac fossa
- Left costal margin
- Right hand into abdomen as patient takes deep breath
- Move to left hypochondrium
98
Should the spleen be palpable?
No
99
How should the kidneys be palpated? (8)
- Bimanual palpation
- Place left hand behind patients back at right flank
- Place right hand below right costal margin
- Press R hand fingers deep into abdomen
- At same time press upwards with L hand
- Patient takes deep breath
- Ballot kidneys up and down
- Feel lower pole of kidney moving inferiorly in inspiration
100
How should the bladder be palpated? (2)
- Left hand palpate down from umbilicus
| - To pubic symphisis
101
Should the bladder be palpable? And what does this indicate?
No, if it is = urinary retention
102
Describe palpating the abdominal aorta (4)
- Place hands either side of aortic pulsation
- Above umbilicus
- If outward movement = expansile = AAA
- If upwards movement = pulsatile
103
What should be assessed in percussion? (4)
- Liver
- Spleen
- Bladder
- Shifting dullness
104
How should the bladder be percussed?
Suprapubic region percussed
105
What is the difference between bladder and bowel percussion sounds? (2)
- Bladder=dull
| - Bowel=resonant
106
Where should the liver border be percussed and the note change from resonant to dull?
5th rib to costal margin
107
What does shifting dullness assess?
Ascities
108
How is shifting dullness assessed? (7)
- Percuss from centre of abdomen to flank
- Until dullness
- Keep finger on spot
- Roll to opposite side
- Keep patient there 30 secs
- Repeat percussion in same spot
- If dull now resonant = fluid = resonant
109
What should be ausculated in the abdomen? (2)
- Bowel sounds
| - Bruits
110
How are bowel sounds ausculated?
10 secs on left of umbilicus
111
What do normal bowel sounds sound like?
Gurgling
112
Give examples of abnormal bowel sounds and what they mean? (2)
- Tinkling: bowel obstruction
| - Absent: ileus/peritonitus
113
What 2 bruits should be ausculated for in an abdo exam?
- Aortic
| - Renal
114
Where are aortic bruits ausculated? And what is checked for?
Just above umblicus - AAA
115
Where are renal bruits ausculated? And what is checked for?
- Just above umblicus, lateral to midline
| - Renal artery stenosis
116
What should be checked for in the legs/feet in an abdo exam? (4)
- Ischaemia
- Pitting oedema - how far up?
- Venous disease: ulcers, brown pigmentation, dilation
- Erythema nodosum
117
What is erythema nodosum? And what is it caused by? (2)
- Tender red patches/nodules seen on both shins
| - Inflammation: panniculitus
118
What is erythema nodosum associated with?
IBD
119
What further exams can be done after an abdo exam? (5)
- Check hernial orifices if signs of obstruction
- Examine external genitalia if appropriate
- Digital rectal exam (PR) if upper GI bleed
- Urine dip
- Pregnancy test
Clinical
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