Abdominal PE Flashcards
Acute Abdomen Examination
Peripheral signs: signs of dehydration and blood loss
Upper abdominal cases: jaundice
Cullen’s sign, Grey Turner’s sign
Paradoxical movement of abdomen: mass / peritonitis
Palpation: guarding, rigidity, rebound
Rectal Exam: DRE - 360 degree palpation, blood on finger
Upper abdominal pain: mini respi and CVS exam
Lower abdominal pain: hernia, pelvic exam scrotal exam
Special tests as appropriate
RUQ Pain Examination
4o year old man presents to your GP/ED complaining of RUQ abdominal pain.
General appearance: pallor, jaundice, scratch marks
Signs of dehydration, blood loss
Abdomen: paradoxical movement of the abdomen, palpation for hepatomegaly
Murphy’s sign (cholecystitis)
Respiratory: auscultate for bronchial sounds and crepitations (lower lobe pneumonia, consolidation)
LUQ Pain Examination
Case 2: 22 y/o man brought to the ED after a blunt trauma to his abdomen. He was riding a bicycle & tried to avoid a collision with a car. He is now complaining of pain in the left upper quadrant (spleen, kidney, respiratory). Primary survey has been done.
Task:
1. Explain physical examination to the medical student
2. Explain what you are looking for and why
Cullen’s sign, Grey turner, paradoxical movement of abdomen
Superficial palpation: mass (spleen hematoma)
Ballote the kidney
Palpate the spleen
Renal angle tenderness
Respiratory exam: inspect for bruises, redness, swelling, step deformity, asymmetric chest movement
palpate for rib tenderness
auscultate for absent breathing sounds
Office test: urine dipstick for blood in urine
RLQ Pain Examination
24 year old lady who has presented to you complaining of RLQ abdominal pain.
Task:
1. Explain physical examination to the medical student
Pelvic examination for females
Scrotal examination for males
Appendicitis special tests
LLQ Pain Examination
Your next patient is a 55 year old man who presents to the ED complaining of LLQ abdominal pain.
Task:
1. Explain your physical examination to the medical student
Peripheral signs: dehydration & blood loss
Abdominal exam
DRE
Inguinal exam: hernia
Scrotal exam
Chronic Liver Disease Examination
Your next patient is a 47 year old man who has been drinking alcohol for many years. He drinks 10 glasses of wine each night.
LFT deranges: AST high, ALT high
Tasks:
1. Explain your examination steps to the patient
2. Explain your PE in detail to examiner, mentioning for most relevant findings
Peripheral signs of CLD:
GA: jaundice, cachexia, LOC
Hands: leukonychia, clubbing, palmar erythema, Dupuytren’s contracture, asterixis
Arms: petechiae, scratch marks, proximal myopathy
Face: jaundice, xanthelasma, parotid enlargement, glossitis, angular stomatitis
Chest: gynecomastia, spider nevi
Abdominal exam:
caput medusa
hepatomegaly: palpation for liver edge, percussion for upper border
splenomegaly
Test for shifting dullness, fluid thrill/wave
Auscultate for liver bruits
check for hemorrhoids, testicular atrophy
Urinary Retention Examination
60 year old man came to the ED diagnosed with urinary retention.
Tasks:
1. Explain physical examination to the medical student
2. Explain what you are looking for
Differentials:
1. Outflow obstructions: BPH, Prostate cancer, Pelvic masses
2. Infections: acute prostatitis, genital herpes
3. Trauma
4. Neurologic impairment: spinal cord injuries, epidural abscess, diabetic neuropathy, stroke
Key areas of examination:
- Abdominal examination focusing on KUB
- Rectal examination: masses, fecal impaction, rectal sphincter tone
- Pelvic exam/scrotal exam
- Neurologic evaluation focusing on tone, power, reflexes, sensory
Key points:
- Prostate in DRE
- Neuro/scrotal examination
Abdominal Examination
- visible mass in suprapubic area
- paradoxical movement of the abdomen on inspiration
- palpation for a suprapubic mass
- ballottement of the kidneys
-percussion of bladder
Rectal examination
- prostate examination on DRE
- anal tone
Scrotal examination
- rash, discharge, trauma
Pelvic examination
- rash, discharge, tenderness on cervix, uterus for irregularities, adnexal masses
Spine & Neuro examination
- trauma signs
- lower limb exam: tone, power, sensory, reflexes
Pyelonephritis Examination
Your next patient is a 60 year old man who has presented to the ED complaining of abdominal pain and dysuria. You have diagnosed him with pyelonephritis. He is a known case of BPH and diabetes. He had stopped metformin due to his illness. Temp: 39 degrees
Task:
1. Explain your physical examination to the medical student
KUB abdominal examination
Level of consciousness
Kussmaul breathing
Dehydration and sepsis features
- CRT, skin turgor, pulse volume, tachcardia, sunken eyes, dry lips and mucosa
Acute abdomen palpation: guarding, rigidity, rebound tenderness
Ballot the kidneys
Palpate suprapubic area to check bladder for tenderness
Renal angle tenderness
Macroscopic Hematuria Examination
Your next patient is a 60 year old man who has presented to the ED with macroscopic hematuria.
Task:
1. Explain your PE to the medical student
General appearance: LOC, pallor
Hands: CRT, pale palmar crease, cold extremities, pulse volume & tachycardia
Abd inspection: visible masses, distention, Cullen & grey turner’s sign, paradoxical movement of the abdomen
Abd palpation: palpate bladder for tenderness, masses, distention
Ballot the kidneys
Percuss the bladder (simple way)
Rectal exam: feel for prostate
Renal angle tenderness
Scrotal exam: inspect for trauma signs, bleeding from meatus
BPH Examination
General KUB abdominal examination
Rectal examination
- explain steps, position, chaperone
Inspection: strain for fecal incontinence
Digital exam: 360 degree then anterior wall for prostate
- size
- consistency
- nodularity
- median sulcus
- tenderness of prostate
-squeeze fingers for anal tone
- remove finger and check for blood
- perianal sensation (anal wink)
Rectal Examination
- Explain steps
- Offer chaperone
- Give privacy to undress and cloth to cover himself
- Position(Standing on right side of patient)
○ Left lateral position
○ Bend knees into his chest
- External hemorrhoids, thrombosed hemorrhoid
- Prolapse internal hemorrhoids (above the dentate line)
- Rectal prolapse (circumferential folds of red mucosa)
- Fistula: look for opening of tract (Crohn’s disease)
- Anal carcinoma - irregular fungating mass
- Bleeding, pus (perianal abscess)
- Skin tags
- Anal fissures: small crack in the anal mucosa
- Ask patient to strain - features of incontinence (sphincter tone)
- Anal wink (prostate cancer): stroke a cotton wool on all 4 quadrants of the anus. Normally you see a brisk anal contraction with intact sacral nerveII. Digital Examination
- Wear gloves and lubricate tip of finger
- Place finger over the anus
- Ask patient to breathe in to distract him then insert finger
- “If patient has severe pain, most likely anal fissure, will not continue”
- Slowly increase pressure until sphincter relaxes and advance finger into the rectum
- Rotate finger clockwise to feel the anterior, left lateral, posterior, right lateral wall
- Advance finger as high as possible
- If you feel any soft lesion, it may suggestive of polyps or carcinoma
- Ask patient to strain and push your finger out (check anal tone)
- Once you withdraw your finger, look for bright blood, melena, pus, mucus
Scrotal Examination
Your next patient is a 28 year old man who comes to your concerned of a scrotal lump
Tasks:
1. Explain scrotal examination to the medical student
2. Explain your special tests
Inspect the scrotum while standing
Elevate the scrotum to see the skin underneath
Penis: retract the foreskin and inspect the mucosal surface underneath
Ask patient to cough to look for bulging mass (hernia)
Palpation of testes:
- Lumps: size, site, feel for upper border, consistency
Hernia: cannot get above the mass, (+) cough test
Varicocele: bag of worms
Hydrocele: fluctuant mass, difficult to feel testes
Cancer: lump sticking to testes, hard and stony
Epidydymoorchitis: large tender testes, thick and tender epididymis
Special Tests:
- Transillumination
- Lymph nodes: scrotal (inguinal), testicular (paraaortic)
- Phren’s sign: elevate the scrotum; (+) pain: testicular torsion, (-) pain: epididymoorchitis
- Cremasteric reflex: absent in testicular torsion
Inguinal Hernia Examination
Patient comes with a right-sided inguinal lump and he has already been diagnosed with inguinal hernia.
Task:
1. Explain PE to medical student with anatomical landmarks
Anatomical Landmarks:
- inguinal ligament
- inguinal canal
- 2 rings: superficial and deep
- 2 types: direct and indirect
Inspection:
- standing position
- cough test
- 3-finger technique
Palpation:
size, consistency, mobility, reducibility, tenderness
Transillumination
Scrotal examination
Inguinal Lymphadenopathy Examination
Your next patient is a 40 year old man who presents to you complaining of an inguinal lump. He has done an ultrasound which has confirmed an enlarged lymph node.
Task:
1. Explain PE to the medical student and mention what specific points you are looking for on examination
2 Differentials: generalized lymphadenopathy (lymphoma), localized lymphadenopathy (scrotum, lower limb)
Check temperature
GA: cachexia, pallor, jaundice, scratch marks, rash
All lymph nodes:
- Epitrochlear
- Axillary
- Cervical
- Inguinal
Lymph node characteristics: size, consistency, mobility, tenderness, overlying skin
Bone tenderness
Splenomegaly palpation and percussion (Castel method)
Scrotal and lower limb examination
