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Short Case > Abdomen > Flashcards

Abdomen Flashcards

1
Q

How do you differentitiate splenomegaly from a kidney?

A

The spleen has no palpable upper border (the kidney does)

The spleen moved inferomedially on inspiration (the kidney doesn’t)

The spleen has a notch (the kidney doesn’t)

There is no resonance to percussion over a splenic mass (there is over the kidney)

The spleen is not ballotatable (the kidney is)

A friction rub can sometimes be heard over the spleen

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2
Q

What is a normal liver span?

A

Normal liver span is 12cm (11-14cm)

Mildly enlarged 12-15cm

Moderately enlarged 15-20cm

Massively enlarged is >20cm

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3
Q

Spiel for nomral liver findings?

A

The liver edge was regular, smooth, soft and non-tender and measured [11-14cm]. It was not pulsatile or ptosed.

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4
Q

What is a normal liver span?

A

11 - 14 cm.

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5
Q

What size is massive hepatomegaly and what are the causes?

A

A span > 20 cm is massive hepatomegaly.

Malignancy

Hepatoma

Metastases from another primary

Myeloproliferative disorders: myelofibrosis, dysplasia, CML

Hepatic pathologies

Hepatoma

Other

Tricuspid regurgitation (pulsatile hepatomegaly)

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6
Q

What size is moderate hepatomegaly and what are the causes?

A

A span of 15 - 20 cm is moderate hepatomegaly.

Malignancy

Myeloproliferative: Myelofibrosis / myelodysplasia / CML

Liver metastases

HCC

Primary liver pathologies

NAFLD

Haemachrmatosis

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7
Q

What are the sizes of splenomegaly?

A

1-2 cm mild splenomegaly

3-7 cm moderate splenomegaly

>7cm marked splenomegaly

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8
Q

What are the sizes and causes of marked splenomegaly?

A

>7cm = marked splenomegaly

Malignancy

Myelofibrosis, CML, Myelodysplasia

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9
Q

What are the sizes and causes of moderate splenomegaly?

A

3-7 cm = moderate splenomegaly

Malignancy

Myeloproliferative disorders: myelofibrosis, dysplasia, CML, PRV

Lymphoma, CLL

Hepatic

Portal HTN (with CLD liver may be small)

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10
Q

What causes hepatosplenomegaly?

A

Cirrhosis is usually = small liver + splenomegaly

NAFLD, EtOH liver disease, haemachromatosis, HCC causes hepatosplenomegaly

or

infiltrative diseases (lymphoma, amyloid, CTDs)

or

haematological malignancies (myelofibrosis / dysplasia) causes massive hepatosplenomegaly

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11
Q

What are the signs of portal hypertension?

A

Splenomegaly

Ascites

Prominent paraumbillical veins

History of oesophageal / rectal varicies

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12
Q

What are the peripheral stigmata of EtoH related liver disease?

A

Dupuytren’s contracture

Parotidomegaly

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13
Q

What are the sizes and causes of mild splenomegaly?

A

1-2 cm = mild splenomegaly

Malignancy

Myeloproliferative disorders: myelofibrosis, dysplasia, CML, PRV, ET

Lymphoma, CLL

Hepatic

Portal HTN (with CLD liver may be small)

Other

CTDs (RA)

ITP, Thalassaemia, Sickle Cell

Sarcoid, Amyloid

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14
Q

How do you differentiate splenomegaly from a left renal mass

A

Spleen

  • Moves inferiorly and medially on inspiration
  • ​Not ballotable
  • Notch in upper margin (if moderate splenomegaly), and can’t get above
  • Dullness in Traube’s space

Renal mass

  • Moves inferiorly on inspiration
  • Ballotable
  • No notch, and can’t get above
  • No dullness in Traube’s space
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16
Q

How to present exam findings of liver pathology.

A

Broad signs of CLD

Cachexia

Clubbing

Leuchonycia

Palmar erythema / Spider naevi (count the number)

Gynaecomastia / loss of body hair

Anaemia (conjunctival pallor and pale palmar creases)

Brusing

Jaundice / scleral icterus

Signs of decompensated liver disease

Jaundice

Ascites / SBP

Hepatic encephalopathy

HCC

HRS

HPS

Or state there is no evidence of decompensation

Signs of portal HTN

Ascites

Splenomegaly

Caput medusae / enlarged paraumbilical veins

In regard to the aetioloigy of the underlyig CLD

EtOH: Dupetryn’s / Parotidomegaly / tremor / Cerebellar syndrome / Peripheral neuropathy

Hep B / C: tatoos, IVDU

PBC: xanthelasma, zanthomata

Haemochromatosis: bronze pigmentation, arthropathy and 2nd and 3rd MCPJ

CCF: tricuspid reugrigitation

Wilson’s: KF rings (only seen on slit lamp!)

Alpha 1 anti-trypsin: signs of COPD

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17
Q

Presenting renal findings on exam:

Non-ballotable kidney and signs of RRT (fistula or transplant)

Ballotable kidney with or without signs of RRT

A

Aetiology of CKD

Renovascular disease: body habitus, hypertensive

Diabetes if finger pricks / insulin pumps / lipohypertrophy from insulin

Ballotable masses (PCKD)

Vasculitis: vasculitisc skin rash

CTDs: systemic sclerosis

Treatment of CKD

AVF

Tenkhoff catheter

  • Functioning or non-functioning*
  • Infected or not infected*

Complications of CKD / Adequacy of Renal Replacement Therapy

Asterixis / Altered mental status or encephalopathic

Fluid overload / HTN

Sallow skin complecion / Pruritis / brusing

Pericardial rub

Pale conjunctivae / palmar creases anaemia

Tachypnoea to compensate for metabolic acidosis

Renal Transplant

Transplant tenderness

Complications of immunosupression:

  • stigamata of infection
  • presence of skin lesion
  • cyclosporin: gum hypertrophy,, hirsuitism, tremor
    • steroids: cushingoid*
18
Q

What to examine at the end of PCKD exam?

A

BP

Neurological exam - cerbeal aneurysms

Cardiac exam - MVP and AR

Respiratory exam - sign of fluid overload

19
Q

What else to ask for at the end of a renal abdomen exam?

A

Weight

Urinalysis - haematuria, proteinuria

Cardiac exam - MVP/AR associated with PCKD, pericardial rub

Respiratory exam - sign of fluid overload

Lower limb exam - oedema, or peripheral neuropathy associated with uraemia

20
Q

What is a normal liver span?

A

11 - 14 cm.

21
Q

What size is massive hepatomegaly and what are the causes?

A

A span > 20 cm is massive hepatomegaly.

Malignancy

Hepatoma

Metastases from another primary

Myeloproliferative disorders: myelofibrosis, dysplasia, CML

Hepatic pathologies

Hepatoma

Other

Tricuspid regurgitation (pulsatile hepatomegaly)

22
Q

What size is moderate hepatomegaly and what are the causes?

A

A span of 15 - 20 cm is moderate hepatomegaly.

Malignancy

Myeloproliferative: Myelofibrosis / myelodysplasia / CML

Liver metastases

HCC

Primary liver pathologies

NAFLD

Haemachrmatosis

23
Q

What are the sizes of splenomegaly?

A

1-2 cm mild splenomegaly

3-7 cm moderate splenomegaly

>7cm marked splenomegaly

24
Q

What are the sizes and causes of marked splenomegaly?

A

>7cm = marked splenomegaly

Malignancy

Myelofibrosis, CML, Myelodysplasia

25
Q

What are the sizes and causes of moderate splenomegaly?

A

3-7 cm = moderate splenomegaly

Malignancy

Myeloproliferative disorders: myelofibrosis, dysplasia, CML, PRV

Lymphoma, CLL

Hepatic

Portal HTN (with CLD liver may be small)

26
Q

What causes hepatosplenomegaly?

A

Cirrhosis is usually = small liver + splenomegaly

NAFLD, EtOH liver disease, haemachromatosis, HCC causes hepatosplenomegaly

or

infiltrative diseases (lymphoma, amyloid, CTDs)

or

haematological malignancies (myelofibrosis / dysplasia) causes massive hepatosplenomegaly

27
Q

What are the signs of portal hypertension?

A

Splenomegaly

Ascites

Prominent paraumbillical veins

History of oesophageal / rectal varicies

28
Q

What are the peripheral stigmata of EtoH related liver disease?

A

Dupuytren’s contracture

Parotidomegaly

29
Q

What are the sizes and causes of mild splenomegaly?

A

1-2 cm = mild splenomegaly

Malignancy

Myeloproliferative disorders: myelofibrosis, dysplasia, CML, PRV, ET

Lymphoma, CLL

Hepatic

Portal HTN (with CLD liver may be small)

Other

CTDs (RA)

ITP, Thalassaemia, Sickle Cell

Sarcoid, Amyloid

30
Q

How do you differentiate splenomegaly from a left renal mass

A

Spleen

  • Moves inferiorly and medially on inspiration
  • ​Not ballotable
  • Notch in upper margin (if moderate splenomegaly), and can’t get above
  • Dullness in Traube’s space

Renal mass

  • Moves inferiorly on inspiration
  • Ballotable
  • No notch, and can’t get above
  • No dullness in Traube’s space
32
Q

How to present exam findings of liver pathology.

A

In regard to the aetioloigy of the underlyig CLD

Dupetryn’s / Parotidomegaly

Signs of decompensated liver disease

Ascites / SBP

Hepatic encephalopathy

HCC

HRS

HPS

Or state there is no evidence of decompensation

Signs of portal HTN

Ascites

Splenomegaly

Caput medusae / enlarged paraumbilical veins

Other signs of CLD

Palmar erythema / Spider naevi

Jaundice

33
Q

How to describe an undifferentiated abdominal mass

A

Location

Size

Consistency (soft, firm)

Tender, non-tender

Move with respiration?

Pulsatile?

Associated rub or bruit?

Percussion note (resonant or dull)?

34
Q

What are the relevant positives or negatives to note in the presence of an undifferentiated abdominal mass?

A

Cachexia

Evidence of anaemia (pallor of the palmar creases, pale conjunctivae)

Presents of lymphadenopathy (especiqally left supraclavicular fossa - Vurchowv’s node)

35
Q

Relevant positives and negatives for PCKD

A

Cx of PCKD specifically

Was kidney tender?

Evidence of scars / fistula for current or previous renal replacement therapy

Gross inspection of mental status and neurologucal exam - complications of ruptured aneurysm

Evidence of nodular liver edge / hepatomegaly in keeping with hepatic involvement

No evidence of splenic cysts / splenomegaly

Complications of CKD more broadly

No evidence of anaemia - pallor palmar creases, pale conjunctivae

HT, evidence of fluid overload

Mentating normally, no asterixis / altered conscious state

No sallow skin complexion / pruritis / bruising

36
Q

What are the causes of a unilateral palpbable kidney?

A

Simple cysts

Renal carcinoma

PCKD with contralateral nephrectomy

Congeintal abscence of a kidney

Other cystic diseases: Von Hippel Lindau, Tunerous Sclerosis

37
Q
A
38
Q

Relevant positives or negatives in CLD?

A

Broad signs

  • Cachexia
  • Hepatic encephalopathy
  • Clubbing
  • Leuchonycia
  • Palmar erythema / Spider naevi (count the number)
  • Gynaecomastia / loss of body hair
  • Anaemia (conjunctival pallor and pale palmar creases)
  • Brusing
  • Jaundice / scleral icterus
  • Ascites / SBP

Evidence of PHTN?

39
Q

What features on ascitic fluid is suggestive of portal hypertension as the aetiology?

A

SAAG > 11

+ total protein < 2.5g/dL

40
Q

What feature on ascitic fluid is suggestive of SBP?

A

PMN ≥250 cells/mm3

(if much higher >20,000, think about secondary bacterial peritonitis)

Leucs > 500 cells/mm3

Picture: Slide 10 Portal HTN Lecture

Short Case (5 decks)

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