Abdominal Examination

Question 1

what level of exposure of the child should you have of the child during the examination

Answer 1

nipple to knee (but in an older child this is not necessary)

Question 2

what are you looking for on general inspection?

Answer 2

are they well or unwell- GCS
increased facial or body hair (ciclosporin side effect)
skin rashes (dermatitis herpetiformis, perioral freckling (Peutz Jeghers), telangiectasia (Osler Weber Rendu)
Pigmentation- cafe au last with NF1 also associated with GI stroll tumours
dysmorphic features- course features of mucopolysaccharidoses
nutritional status- thriving or not thriving
nutritional support (NG tube, TPN, gastrotomy tube (peg), button
peritoneal dialysis catheter
urinary catheter (spina bifida)
older child in nappies
race ( afro Caribbean sickle cell, asian thalessaemia, and Chinese hepatitis B)

Question 3

what are you looking at on the hands: finger clubbing

Answer 3

cystic fibrosis, chrons disease and ulcerative colitis, liver disease

Question 4

Other than clubbing what else are you looking for on hand examination

Answer 4

anemia (nailbed pallor and palmer crease)
koilonychia (due to iron deficiency look also for smooth tongue and angular stomatitis)
leuconychia (cirrhosis)
xanthoma (hypercholeserolaemia- tendon deposits, tuberous xanthomas at elbow)
palmer erythema (chronic liver disease)
flapping tremor

Question 5

What are you looking at on inspection of the face?

Answer 5

jaundice (looking specifically at the sclera)
cyanosis (hepatopulmonary syndrome) or facial plethora (chronic liver disease)
spider naevi or telangiectasia (Osler Weber Rendu syndrome or ataxic telangiectasia)

Question 6

what are you looking at when examining the mouth

Answer 6

pigmentation (Peutz Jeghers Syndrome)
ulceration (aphthous ulcers- chrons, ulcerative colitis, coeliac, behcets disease)
dental caries
gum hypertrophy (myeloid leucemia and drugs like ciclosporin and phenytoin)
Macroglossia

Question 7

what are the causes of macroglossia

Answer 7

1. hypothyroidism
2. Beckwith- Wiedemann Syndrome
3. Mucopolysaccharidoses
4. Pompe Glycogen Storage Disease
5. Amyloid

Question 8

on general inspection of the abdomen what are you looking for

Answer 8

distension
skin
scars
striae
stomas
genital area
hernia or scrotal swellings

Question 9

what are the 5 Fs of distension

Answer 9

fat
faeces
flatus (air swallowing, malabsorption- coeliac disease, intestinal obstruction)
fluid (ascites: nephrotic syndrome, chronic liver disease)
Fetus

Question 10

what scars are you looking for?

Answer 10

renal angle scars
liver biopsy scars
laparoscopic surgery

Question 11

what is William Harvey’s method?

Answer 11

press on the veins with two fingers
pull fingers apart
lift one finger does vein fill?

Question 12

what does William Harvey’s method help with?

Answer 12

it assesses the blood flow from the blood in the veins

Question 13

how to tell if the striae is a caput medusae

Answer 13

veins drain away from the umbilicus due to portal vein obstruction. Then look for other signs of liver disease (liver failure is a specific end stage problem.

Question 15

how to tell if the striae is from superior vena cava obstruction

Answer 15

blood flows inferiorly in the superficial abdominal veins (look for this in children with central lines- rare complication)

Question 16

how do you know if it is inferior vena cava obstruction

Answer 16

blood flows superiorly in the superficial abdominal veins (obstruction is unlikely in exams)

Question 17

what are you looking for when looking at a stoma?

Answer 17

ileostomy vs colostomy
mucous fistula
caecostomy tube for integrate enemas in some children with chronic constipation

Question 18

what are you looking for on the genital exam

Answer 18

ambiguous, undescended testis

Question 19

what are the different types of hernia

Answer 19

umbilical: common in healthy afro Caribbeans below the age of 5, Down syndrome, hypothyroidism, and mucopolysaccaridoses
inguinal hernia
hydrocele

Question 19

what are you looking at on examination of the skin

Answer 19

scratch marks
bruising
rash
pigmentation
nappy area

Question 20

what causes scratch marks on the skin

Answer 20

obstructive jaundice
lichenification
excoriation
erythema
visible pruritis

Question 21

what causes bruising in patients

Answer 21

liver dysfunction
haematological disease

Question 22

what kind of rash are you looking for

Answer 22

dermatitis herpetiformis in coeliac disease

Question 23

what causes depigmentation

Answer 23

vitiligo

Question 24

what causes hyperpigmentation

Answer 24

cafe au lait patches incontinentia pigmentosa (stage 3 cutaneous lesions associated with dystrophic changes of the hair, nails and teeth

Question 25

what causes hypopigmentation

Answer 25

incontinentia pigmentosa (stage 5) - permanent linear hypopigmented streaks particularly on the legs associated with alopecia

Question 26

on palpation what areas are important

Answer 26

neck (feeling for lymphadenopathy) gentle and deep palpation of the abdomen feel for the liver, spleen, kidneys

Question 27

how do you palpate

Answer 27

you lie your hand flat and feel by flexing at the metacarphalangeal joints

Question 28

how do you feel for the liver

Answer 28

flex the fingers at the metacarpophalengeal joint using the forefingers parallel to the costal margin. begin in the right iliac fossa and work up towards the costal margin. children frequency have a palpable liver edge up t o 2 cm.

Question 29

how to further assess hepatomegaly

Answer 29

position: measure the liver edge below the costal margin in the midclavicular line with a tape measure texture: smooth or nodule, firm or soft tenderness pulsatile (hepatic AV malformation) expansile (tricuspid incompetence) percussion don't forget to define the upper border of the liver to exclude hyperinflation of the liver edge

Question 30

how do you feel for the spleen

Answer 30

palpate from the right iliac fossa with the left hand splitting the lower edge of the rib age posteriorly if there is difficulty lie the child on her right side and palpate with the child taking big breaths the spleen tip may be palpable in normal neonates measure the sleep from the costal margin in the midclavicular line percuss the border of the spleen

Question 31

how do you palpate the kidneys

Answer 31

bimanual palpation push up with the left hand in the renal angle and feel the kidney anteriorly with the right hand. ballot the kidneys between the hands

Question 32

if a mass is found how do you describe it

Answer 32

site size shape consistency mobility whether tender whether pulsatile percussion does it alter after bowel or bladder movement

Question 33

what are you percussing for

Answer 33

organomegaly, mass, fluid

Question 34

when to percuss for ascites

Answer 34

if there is hepatomegaly if any signs of liver disease if the abdomen appears distended if there is oedema elsewhere

Question 35

when would you listen for renal bruits

Answer 35

if the child has neurofibromatosis or is hypertensive

Question 36

how do you determine if the scrotal swelling is a hernia vs hydrocele?

Answer 36

hernia transmits cough impulse, the testis can be palpated separately. A hydrocele I can get above it, and it transilluminates.