Abdominal + Hernia Examination Flashcards
(36 cards)
Introductions
Wash hands, PPE Introductions Explanation of the exam and gain consent Adjust bed to 45 Ask patient to expose themselves from waist up -offer blanket Ask about any pain
Step 2
General inspection
What objects and equipment may you find around the bed
Prescriptions, medications, drug charts
Fluid balance charts
Vital signs
Mobility aids
Medical equipment
- ECG
- catheter
- O2
- IV access
- drains, stoma bags (check contents)
Feeding tubes
Step 2
General inspection
Clinical signs
Age
- Youth => IBD?
- Older => CLD, malignancy?
Confused?
-sign of end stage LD (hepatic encephalopathy)
Habitus
- abdominal distension? (organomegaly? Ascites from cirrhosis)
- cachexic (malignancy?)
- hernias
- scars
Complexion
- pale => anemia (CKD, malabsorption, Fe, B12, folate deficient?)
- jaundiced => (hepatitis, pancreatitis, gallstones, alcoholic?)
- hyperpigmented => haemochromatosis (excess Fe damages liver)
Step 3 Hands
Palm signs
What are you looking for
What are they signs of?
3 things
Palmar erythema (thenar, hypothenar)
- pregnant
- CLD (liver unable to metabolise estrogen => accumulation => increased blood flow)
Pallor
-anemia (Fe, B12, folate deficient, GI malabsorption)
Dupuytrens contracture
-alcoholic, diabetic
Step 3 Nails
What are you looking for
What are they signs of
2 things
Leukonychia
-hypoalbuminemia (decreased prod in liver due to cirrhosis, hepatitis/low protein absorption)
Koilonychia
-Fe deficient (malabsorption in gut, Crohns?)
What can finger clubbing tell you
Crohns
Coeliac
Cirrhosis
Cancer (GI lymphoma)
Step 3 Asterixis
What can this tell you
Hepatic encephalopathy (hyperammonemia due to poor liver metabolism)
Uremia (renal failure)
Step 3 Palpation of hands
What can you find?
What can this tell you
Temperature
-cold => poor perfusion
Radial pulse
-assess rate and rhythm
Step 4 Arm and armpits
What are you looking for
What can this tell you?
Bruising
-cirrhosis => clotting abnormalities
Excoriations
-bile blockage => itching
Needle tracks
-IVDU => HepB, C
Acanthosis nigricans (darkening, thickening) -T2D or GI malignancy (stomach)
Hairloss
-Fe deficiency anaemia, malnutrition (divert blood flow to vital areas, hair growth not stimulated)
Step 5 Face (Eyes)
What are you looking for
What can this tell you
Sclera
- Pallor => anemia (Fe deficient, malabsorption)
- Jaundice => liver cirhhosis, hepatitis pancreatic cancer, bile blocakge)
Iris
- corneal arcus in under 50s => hypercholesterolemia
- Kayser Fleischer rings => Copper deposits (abnormal processing by liver/excess can cause cirhhosis)
- perilimbal injection => anterior uveitis, accompanied with photophobia, eye pain, reduced visual acuity (linked to IBD)
Around the eyes
-xanthelasma => hypercholesterolemia
Step 5 Face (Mouth)
What are you looking for
What can this tell you
Tongue
- glossitis => malnutrition, malabsorption of Fe, folate, B12 (IBD, alcoholic)
- oral candidiasis => immunosuppresed/malnourished
Mucus membranes
- apthous ulcers => B12, folate Fe deficiency but can be benign (Crohns, malnutrition/malabsorption)
- hyperpigmented macules => Peutz Jegar (GI polyps)
Mouth corners
-angular stomatitis => malnutrition/malabsorption (Fe, B vitamin deficient)
Step 5 Face (Neck)
What are you looking for
What can this tell you
L supraclavicular fossa => GI metastases
R supraclavicular fossa => thorax metastases
Step 6 Chest inspection
What are you looking for
What can this tell you
Spider naevi (high estrogen)
- 5+ => cirhhosis
- pregnancy, HRT use
Gynecomastia (high estrogen)
- cirrhosis
- medication (digoxin, spironolactone)
Hair loss
- malnutrition
- increased estrogen
Step 6 Abdominal inspection
What are you looking for
What can this tell you
Scars
-past surgical history clues
Distension
-6Fs (fat, flatus, feces, fetus, fulminant mass, fluid)
Hernias
-ask patient to cough
Caput medusa
-portal HTN or IVCO (check direction of blood flow)
Stretch marks
- ascites, abdominal malignancy, Cushings
- obesity, pregnancy
Cullen’s sign (umbilical bruising)
-late pancreatitis
Grey Turner’s sign (flank bruising)
-late pancreatitis
Step 6 Stomas
What are you looking for
What could this tell you
Type and contents
- colostomy => LIF, solid stool,
- ileostomy => RIF, liquid stool
- urostomy => RIF, urine
Spouts
- colostomies => flush to skin, no spout
- ileostomies, urostomies => spout
Step 7 Abdominal palpation
Light palpation
What are you looking for
What can this tell you
Tenderness
-note region, think what structures are present and severity of pain
Rebound tenderness
-peritonitis (possible appendicitis)
Guarding
-appendicitis, diverticulitis
Masses
Step 7 Abdominal palpation
Deep palpation
What are you looking for
What can this tell you
Assess qualities of masses found
Location
Size, shape
Consistency - smooth, soft, hard, irregular
Mobility - attached to superficial/deep structures
Pulsatility - vascular etiology
Step 8 Liver palpation
What are you looking for
What can this tell you
1-2cm under costal margin => normal
Liver edge properties
-2cm+ => hepatomegaly
Nodular => cirrhosis
Tenderness => hepatitis, cholecystitis?
Pulsatility => tricupspid regurgitation
What are the differentials for hepatomegaly?
VITAMIN CDEF
Vascular
- tricuspid regurgitation, RV failure
- heart failure
- constrictive pericarditis
Iatrogenic/idiopathic
-statins, macrolides, amiodarone
Autoimmune
-autoimmune hepatitis
Metabolic
- haemochromatosis
- Wilson’s
- glycogen storage problems
Infective/inflammatory
-bacterial/viral hepatitis
Neoplastic
- liver metastases
- liver carcinoma
- leukemia, lymphoma
Congenital
-haemolytic anemias (thalassemia)
Functional
-biliary obstruction
Step 8 Gallbladder palpations
- how would you do this
- what signs are you looking for
R costal margin at MCL
NOT NORMALLY PALPABLE
-if palpable (well defined round mass that moves with respiration) => enlargement secondary to biliary obstruction
Murphy’s sign => pain midbreath
-cholecystitis, cholangitis?
No pain, enlarged => pancreatic cancer (esp w jaundice?), cholangiocarcinoma?
Step 8 Spleen palpation
- how would you do this
- what are you looking for
L costal margin
NOT NORMALLY PALPABLE
-if palpable => 3x its size
What are the differentials for splenomegaly
-VITAMIN CDEF
Vascular
- Portal HTN secondary to cirrhosis
- haemolytic anemia
- HF
Infective/inflammatory
-glandular fever (infects B cells => lymphoid organs swell)
Neoplastic
-splenic metastases
Step 8 Kidney balloting
- how would you do this
- what are you feeling for
R and L flanks on inspiration
NOT NORMALLY PALPABLE
-if palpable => describe it
Bilateral enlargement => PKD, amyloidosis (amyloid released by abnormal plasma cells accumulates in kidneys)
Unilateral enlargement => renal tumour
Step 9 Aorta palpation
- how would you do this
- what are you feeling for
Deep palpation superior to umbilicus at midline
-hands should move superiorly
If hands move laterally => expansile mass (AAA)
