After introducing yourself what things can you comment on from the end of the bed
Drips, oxygen, catheter, drains, vomit bowl
body habits, well/unwell, pain, fever jaundice
In the peripheries what things can you comment in regards to the patients nails and what could it indicate
- clubbing - IBD or cirrhosis
- leuconychia (whitening of the nails due to albumin) - malnutrition, malabsorption chronic liver disease, nephrotic syndrome
- Koiilonychia (spooning of the nails)- iron deficiency
in the peripheries what things can you comment on in regards to the hands and what could it indicate
- Xanthomata-( raised yellow lesions on tendons) - hyperlipidaemia
- Dupuytrens contracture (thickening or contracture of the palmar fascia)- alcoholic liver disease
- palmar erythema- chronic liver disease or non-abdoo related
in the peripheries what things can you comment on in then wrist and arms and what could this indicate
- comment on the pulse (do they have an AV fistula)
- Flapping tremor- encepatholopathy due to liver failure
- Bruising as chronic liver disease may affect clotting
- Scratch marks due to raised urea ?
- Track marks or tattoos (from IVDU)
in the peripheries what things can you comment on in the eyes ad what could this indicate
- Yellowing of the sclera- jaundice
- conjuntiva pallor- anaemia
- corneal arcus (yellow ring overlying the iris) - hyperlipidaemia
- Xanthelasma- hyperlipidaemia
in the peripheries what things can you comment on in the mouth and what could this indicate
- Angular stomatitis & glossitis (reddening and inflammation at the sides of the mouth & swelling of the tongue) - iron, folate, B12 deficiency
- Ulcers - coeliac, inflammatory bowel disease, iron deficiency
- Factor hepaticas (musty, sweet breath) - liver failure
in the peripheries what things can you comment on the chest and what does this indicate
- Virchow node (left supraclavicular node) - gastric cancer
- Gynaecomastia (in males) - alcoholic liver disease, drugs; there are several but include DISCO (digoxin, isoniazid, spironolactone, cimetidine, oestrogen)
- more than 5 spider naevi - liver disease
What are the common drugs that can cause gynecomastia in males (DISCO)
- digoxin - glycoside
- Isoniazid- bacteriostatic to treat TB
- spironolactone- steroid drug to treat hypertension and hypertension
- Cimetidinie - antihistamine to treat stomach acidity and peptic ulcers
- Oestrogen
what 6 F’s can cause distention of the abdomen (stomach expansion)
Fat Fluid Flatus Faeces Foetus Fucking big mass
what things can you comment on when inspecting the abdomen and what could this indicate
- distention- 6F’s (fat, fluid, flatus, faeces, foetus, fucking big mass)
- everted umbilicus with distention ( ascites)
- Distended abdominal veins - portal hypertension
- Hernias
- Scars and stomas
When palpating the 9 areas of the abdomen what does rebound tenderness and guarding mean
rebound tenderness - pain when you release
guarding- involuntary tension of the abdo muscles
How do you palpate for the liver and what can cause an enlarged liver
Start in RIF (right iliac fossa) and move upwards to the right costal margin
- “take a deep breath in and out, feel for liver edge on inspiration”
- enlarged liver caused by: infective, neoplastic, cirrhotic, metabolic, toxins
How do you palpate for the spleen
start in the RIF (right iliac fossa) to the left costal margin
- my be able to feel notch on inferior edge of the spleen to differentiate it from other masses
- roll pt onto right hand side to ballot the spleen
how do you palpate the kidney
ballot the kidney
- one hand behind back below lower ribs and other hand over upper quadrant
- push hands together on expiration
when palpating what sign indicates cholecystitis and in what quadrant would this pain be felt
Murphys sign
- pain on deep palpation in the right upper quadrant only
How would you palpate for an abdominal aortic aneurysm
Expandable pulsatile mass above the umbilicus, usually enlarges to the left
- note that in slim individuals this is often felt but is not abnormal
When percussing, which organs are you wanting to percuss
liver (same as palpation)
spleen (same as palpation)
Bladder (in suprapubic area)
Shifting dullness if ascites suspected
when percussing the bladder what is the difference is sound between the bladder and a distended bowel
bladder : dull
distended bowel: resonant
describe how you would carry out a shifting dullness test if you suspect ascites
- percuss from midline to left flank
- leave finger at first point of dullness
- roll patient onto right side and leave for 30 seconds
- if previous dull area is now tympanic then ascites is present due to fluid shift with gravity
what things would you auscultate for in the abdomen
bowel sounds
renal bruit
liver bruit
what conditions could cause the following sounds when auscultating the bowel sounds;
- low pitched intermittent gurgling
- tinkling/high pitched
- loud, low pitched (borborygmus)
- absent after listening for 2 mins at least
- low pitched intermittent gurgling : normal
- tinkling/high pitched: partial or total obstruction
- loud, low pitched (borborygmus): diarrhoea or abnormal peristalsis
- absent after listening for 2 mins at least : peritonitis or paralytic ileum
Abdominal pain on palpation:
What could pain in the right hypochondriac area indicate (RH)
Gall stones
stomach ulcer
pancreatitis
Abdominal pain on palpation:
What could pain in the epigastrium area indicate
stomach ulcer heartburn pancreatitis gallstones epigastrium hernia
Abdominal pain on palpation:
What could pain in the left hypochondria area indicate (LH)
stomach ulcer
duodenal ulcer
biliary colic
pancreattis
