Abdomen

Question 1

blanket?

Answer 1

expose abdomen and offer patient blanket to allow exposure only when required and if appropriate, inform patients they do not need to remove their bra)

Question 2

hand and nail inspection look for these conditions

Answer 2

leuconychia
koilonychia
clubbing
palmar erythema
pale palmar creases
spider naevi
Dupytren’s contracture

Question 3

end of bed inspection look for

Answer 3

age
confusion
pain
obvious scars
abdominal distension
pallor
jaundice
hyperpigmentation
oedema
cachexia
hernias

Question 4

cachexia

Answer 4

ongoing muscle loss that is not entirely reversed with nutritional supplementation

commonly associated with underlying malignancy (e.g. pancreatic/bowel/stomach cancer) and advanced liver failure

Question 5

hyperpigmentation

Answer 5

bronzing of the skin associated with haemochromatosis

Question 6

jaundice indicates

Answer 6

yellowish or greenish pigmentation of the skin and whites of the eyes due to high bilirubin levels (e.g. acute hepatitis, liver cirrhosis, cholangitis, pancreatic cancer)

Question 7

abdominal distension

Answer 7

may suggest the presence of ascites or underlying bowel obstruction and/or organomegaly

Question 8

confusion end of bed sign

Answer 8

often a feature of end-stage liver disease, known as hepatic encephalopathy

Question 9

age in considering pathology

Answer 9

younger patients more likely to have diagnoses such as inflammatory bowel disease (IBD) and older patients more likely to have chronic liver disease and malignancy

Question 10

objects and equipment to look for

Answer 10

stoma bag
surgical drains
feeding tubes
mobility aids
vital signs
fluid balance
prescriptions
other equipment = ECG leads, TPN, catheters

Question 11

INSPECT: palms of hands for

Answer 11

pallor
palmar erythema
Dupuytren’s contracture

Question 12

INSPECT: nails for

Answer 12

Koilonychia
Leukonychia
Finger clubbing

Question 13

check hands for asterixis

Answer 13

= flapping tremor
Ask the patient to stretch their arms out in front of them
Then ask them to cock their hands backwards at the wrist joint and hold the position for 30 seconds
Observe for evidence of asterixis during this time period

Question 14

causes of asterixis

Answer 14

hepatic encephalopathy (due to hyperammonia)
uraemia secondary to renal failure
CO2 retention secondary to type 2 respiratory failure

Question 15

finger clubbing anatomy

Answer 15

loss of Schamroth’s window
loss of hyponychial angle
increased nail curvature

Question 16

ask patient to breathe in during deep palpation when checking

Answer 16

liver and spleen

Question 17

finger clubbing is likely to appear in these abdominal conditions

Answer 17

IBD
coeliac disease
liver cirrhosis
lymphoma of GIT

Question 18

palmar erythema

Answer 18

= red palm

redness involving the heel of the palm that can be associated with chronic liver disease (it can also be a normal finding in pregnancy)

Question 19

koilonychia

Answer 19

spoon-shaped nails, associated with iron deficiency anaemia (e.g. malabsorption in Crohn’s disease)

Question 20

leukonychia

Answer 20

whitening of the nail bed, associated with hypoalbuminaemia (e.g. end-stage liver disease, protein-losing enteropathy)

Question 21

PALPATE: hands

Answer 21

temp
radial pulse - rate and rhythm
Dupuytren’s contracture

Question 22

Dupuytren’s contracture

Answer 22

thickening of palmar fascia > resulting in the development of cords of palmar fascia which eventually cause contracture deformities of the fingers and thumb

= when 1 or more fingers bend in towards palm

Question 23

Dupuytren’s contracture

Answer 23

thickening of palmar fascia > resulting in the development of cords of palmar fascia which eventually cause contracture deformities of the fingers and thumb

= when 1 or more fingers bend in towards palm think nanna

Question 24

check arms for

Answer 24

bruising - underlying clotting abnormalities secondary to liver disease
excoriations
needle track marks - IV drug use > viral hepatitis

Question 25

excorations

Answer 25

scratch marks that may be caused by the patient trying to relieve pruritis. In the context of an abdominal examination, this may suggest underlying cholestasis

Question 26

order of exam

Answer 26

``` intro end of bed signs stuff around bed INSPECT: hands arm armpit face - eyes, mouth neck chest abdomen PALPATE abdomen - light - deep - organs = liver, spleen, kidneys, bladder and aorta PERCUSS abdomen AUSULTATE abdomen legs ```

Question 27

check armpit for

Answer 27

Acanthosis nigricans | Hair loss - iron-deficiency anaemia and malnutrition

Question 28

Acanthosis nigricans

Answer 28

darkening (hyperpigmentation) and thickening (hyperkeratosis) of the axillary skin which can be benign (most commonly in dark-skinned individuals) or associated with insulin resistance (e.g. type 2 diabetes mellitus) or gastrointestinal malignancy (most commonly stomach cancer)

Question 29

INSPECT: eyes

Answer 29

``` jaundice of sclera Kayser-Fleischer rings conjunctival pallor corneal arcus xanthelasma perilimbal injection ```

Question 30

INSPECT: face

Answer 30

pallor, jaundice, telangiectasia

Question 31

INSPECT: mouth

Answer 31

``` Aphthous ulceration glossitis oral candidiasis angular stomatitis hyperpigmented macules ```

Question 32

where to check for lymphadenopathy

Answer 32

supraclavicular, axillary and inguinal lymphadenopathy. Virchow’s node in the left supraclavicular fossa is suggestive of gastric malignancy

Question 33

left supraclavicular lymph node

Answer 33

Virchow's node = lymphatic drainage from the abdominal cavity and therefore enlargement of Virchow’s node can be one of the first clinical signs of metastatic intrabdominal malignancy (most commonly gastric cancer)

Question 34

right supraclavicular lymph node

Answer 34

= lymphatic drainage from the thorax and therefore lymphadenopathy in this region can be associated with metastatic oesophageal cancer (as well as malignancy from other thoracic viscera)

Question 35

Kayser-Fleischer rings

Answer 35

dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues (including the liver causing cirrhosis)

Question 36

corneal arcus

Answer 36

a hazy white, grey or blue opaque ring located in the peripheral cornea, typically occurring in patients over the age of 60. In older patients, the condition is considered benign, however, its presence in patients under the age of 50 suggests underlying hypercholesterolaemia

Question 37

xanthelasma

Answer 37

yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia

Question 38

perilimbal injection

Answer 38

inflammation of the area of conjunctiva adjacent to the iris. Perilimbal injection is a sign of anterior uveitis, which can be associated with inflammatory bowel disease. Other clinical features of anterior uveitis include photophobia, ocular pain and reduced visual acuity

Question 39

Aphthous ulceration

Answer 39

round or oval ulcers occurring on the mucous membranes inside the mouth. Aphthous ulcers are typically benign (e.g. due to stress or mechanical trauma), however, they can be associated with iron, B12 and folate deficiency as well as Crohn’s disease

Question 40

glossitis

Answer 40

smooth erythematous enlargement of the tongue associated with iron, B12 and folate deficiency (e.g. malabsorption secondary to inflammatory bowel disease)

Question 41

hyperpigmented macules

Answer 41

pathognomonic for Peutz-Jeghers syndrome, an autosomal dominant genetic disorder that results in the development of polyps in the gastrointestinal tract

Question 42

Inspect chest for

Answer 42

Spider naevi Gynaecomastia Hair loss

Question 43

Quadrants of the abdomen | Top to bottom, right to left

Answer 43

Right hypochondrium, epigastrium, left hypochondrium Right lumbar/flank, umbilicus region, left lumbar/flank Right iliac fossa, suprapubic, left iliac fossa Epigastric - stomach down to second part of duodenum, includes liver and biliary Umbilical - down to transverse colon

Question 44

INSPECT: Abdomen for

Answer 44

``` scars symmetry and shape lumps distension caput medusae striae - Cushing's, intrabdominal malignancy Cullen's sign Grey-Turner's sign peristalsis or pulsation venous distension discolouration spider naevi ```

Question 45

palpate tips

Answer 45

Look at patients face whilst palpating to look for pain Light palpation looks for soft/hard abdomen, tenderness, rebound, guarding Rebound tenderness = in pain when you take your hands away, not so much when you initially press - when the abdominal wall, having been compressed slowly, is released rapidly and results in sudden sharp abdominal pain Guarding = involuntary tension in the abdominal muscles that occurs on palpation associated with peritonitis

Question 46

Murphy's sign

Answer 46

Get patient to breathe out Push in deep palpate right upper quadrant Get them to breathe in Diaphragm goes down pushes down gallbladder If patient stops breathing in, pause breath, sign of acute cholecystitis Guarding with breathing

Question 47

spider naevi chest

Answer 47

skin lesions that have a central red papule with fine red lines extending radially caused by increased levels of circulating oestrogen Commonly associated with liver cirrhosis, but can also be a normal finding in pregnancy or in women taking the COPC If >5 are present it is more likely to be associated with pathology such as liver cirrhosis

Question 48

gynaecomastia chest

Answer 48

Enlargement of male breast tissue caused by increased levels of circulating oestrogen (e.g. liver cirrhosis). Other causes include medications such as digoxin and spironolactone

Question 49

abdominal distension 6 F's

Answer 49

``` fat fluid flatus (gas) faeces fetus fulminant mass (severe disease) ```

Question 50

caput medusae

Answer 50

engorged paraumbilical veins associated with portal hypertension (e.g. liver cirrhosis)

Question 51

Inspect for hernias

Answer 51

ask patient to cough and observe for any protusions through the abdominal wall

Question 52

Cullen's sign

Answer 52

bruising of the tissue surrounding the umbilicus associated with haemorrhagic pancreatitis (a late sign)

Question 53

Grey-turner's sign

Answer 53

bruising in the flanks associated with haemorrhagic pancreatitis (a late sign)

Question 54

light palpation of abdomen

Answer 54

assess for tenderness, rebound tenderness, guarding, Rovsing's sign, hernias, feel if tummy is soft or hard (bad)

Question 55

Rovsing's sign

Answer 55

palpation of the left iliac fossa causes pain to be experienced in the right iliac fossa

Question 56

deep palpation of abdomen

Answer 56

if any masses identified, asses for the following: - location - size - shape - consistency - smooth/soft/hard/irregular - mobility - attached to underlying structures? - pulsatility - vascular

Question 57

which organs to palpate for organomegaly

Answer 57

liver, spleen, kidneys, bladder and aorta

Question 58

PERCUSS abdomen

Answer 58

liver spleen bladder if ascites is suspected: shifting dullness fluid thrill

Question 59

shifting dullness

Answer 59

Percuss from the centre of the patient’s abdomen laterally until dullness is apparent. Keeping your finger there, then ask the patient to roll onto the opposite side. Wait for at least 30 seconds in this position, before starting to percuss. If the dullness initially detected was due to fluid, this area should now be resonant and dullness will become apparent as you continue to percuss down to the centre of the abdomen

Question 60

fluid thrill

Answer 60

Test for this by laying the flat of your left hand against the left side of the patient’s abdomen. Ask your patient to lay the flat of their hand longitudinally along the centre of their abdomen. Then tap your right hand on the right hand side of the patient’s abdomen and feel for a rippling of fluid against your left hand

Question 61

next steps following examination - end pieces

Answer 61

``` examine for inguinal hernias examine external genitalia rectal exam/PR measure temp urinalysis pregnancy test stool sample ```

Question 62

AUSCULTATE: abdomen

Answer 62

listen to 2 or more parts of abdomen listen for increased, decreased or absent (have to listen for more than 3 minutes) sounds auscultate aorta and renal arteries to identify bruits = turbulent flow: - aortic bruits: auscultate 1-2 cm superior to the umbilicus, a bruit here may be associated with an abdominal aortic aneurysm - renal bruits: auscultate 1-2 cm superior to the umbilicus and slightly lateral to the midline on each side. A bruit in this location may be associated with renal artery stenosis

Question 63

check legs after abdomen exam for

Answer 63

pitting oedema - may suggest hypoalbuminaemia (liver cirrhosis)