ABDOMINAL EXAMINATION

What General inspection of the patient, as for all examinations How to General appearance colour, overt sweating, anxiousness, appearing drowsy, tachypnoea (>20 breaths/min). Look for spooning of nails White spots, stripes or blotches on nails Iron deficiency anaemia; possible causes include iron intake, gut absorption, iron loss through intestinal bleeding or parasitic infection. Small spots: no pathological cause, poss. trauma Stripes: often bad. Chemotherapy, liver cirrhosis, heavy metal poisoning. Might be trauma. Totalis: hypoalbuminaemia due to insufficient protein uptake or synthesis (i.e. liver dysfunction). Portal hypertension, chronic hepatitis, in pregnancy (30% of RA sufferers; thyrotoxicosis) MAY indicate liver cirrhosis; if hxx relates, possible link with alcoholism. Cirrhosis, Crohns, ulcerative colitis, malabsorption, oesophageal cancer, laxative abuse. Associated with various hepatic encephalopathies, which is confusion or altered level of consciousness due to liver failure. Liver dysfunction can result in failure to metabolise toxins that adversely affect the brain (e.g. failure to metabolise ammonia to urea). Anaemia due to iron intake/uptake (e.g. enzyme production, inflammatory bowel diseases due to ulceration), splenic dysfunction, intestinal bleeding, RBC production (Vit B12 deficiency). Pre-hepatic breakdown of RBCs overloading liver: haemolytic conditions, malaria, repetitive impact trauma (e.g. marching). Failure to excrete conjugated bilirubin into gut: Hepatocellular: hepatitis, cirrhosis Post-hepatic: pancreatic cancer causing compression around bile duct, gall bladder stone blocking duct. Ulcerative colitis, Vit C deficiency (also, immunosuppression, trauma). Vit B deficiency, anaemia. Can indicate abdominal or thoracic malignancy or pathology. Left SC lymph node is particularly relevant for abdominal symptoms. If > 5 on the chest, may indicate liver pathology. May indicate liver pathology. Pulsation: consider aortic aneurysm. Rebound tenderness: associated with peritonitis and with UC if in the lower right quadrant. GIT-Related Indications

Hands

Koilonychia Leukonychia

Palmar erythema Dupuytrens contracture Clubbing Liver flap/asterixis

Red palms or thenar/hyperthenar eminences Look for overt contracture or hardening and th tightening of the palmar fascia proximal to 4 finger. Check for a diamond of light between nail beds when index fingers are pressed nail-to-nail. Ask patient to hold hands in dorsiflexion. If asterixis is present, the hands will flap.

Face

Conjunctiva

Look for pallor

Sclera

Look for yellowing/jaundice

Neck Chest

Buccal mucosa Glossitis Supraclavicular lymph nodes Spider naevi Gynaecomastia Appearance Palpation

Look for ulcerations Glossitis: swollen, smooth tongue. Raised lymph nodes just superior to the mid-clavicle Tiny red moles with little spidery legs coming out of them Breasts on men Look for scars, bruises, pulsations or swellings Palpate first superficially, then more deeply. Feel for masses, unusual textures. Observe the patients face

Abdomen

ABDOMINAL EXAMINATION
for pain response. Start away from the painful area! Abdominal guarding (tense, in spasm): abruptly painful abdomen, e.g. appendicitis, peptic ulcer perforation, ectopic pregnancy, diverticulitis, iliopsoas abscess. Hepatomegaly: cirrhosis, fatty liver, neoplastic, glandular fever, malaria, some forms of hepatitis. Splenomegaly: early sickle cell anaemia, RA, SLE, congestion due to portal hypertension, metabolic disorders. Either too much getting in, or not enough getting out. Unilateral: Pyelonephritis, renal vein thrombosis. Bilateral: leukaemia infiltration, associated with diabetes mellitus, multiple myeloma (due to production of kidney-harming protein). Solid, dull sounds: abdominal mass, intestinal obstruction, constipation. Hepatomegaly causes listed above. Pain: inflammation due to causes above; kidney/ureter infection. Liver cirrhosis (in 80%) of cases. Many possible rarer causes.

Specific Organs

Splenomegaly, hepatomegaly

Palpate starting diagonally opposite the organ until you feel the edge, or in the case of the spleen, until you have reached the left costal margin. The liver descends on the in breath. Place one hand beneath 12 rib/L1 and one hand on the abdomen. Palpate between the two. Not usually palpable in healthy patients, unless v thin. Percuss the abdomen, or if checking liver span percuss from upper chest on the right downwards, and from right ASIS upwards. With the patient sitting upright, strike over the 12 ribs on each side. Percuss in the midline for resonant sound. If present, percuss laterally until dullness is heard. With index finger on the resonant area and another on the dull area, ask the patient to roll onto their side facing you. Percuss from the position of the outside finger toward the midline. If resonance shifts toward the lateral aspect and dullness into the midline, excess fluid is present. Listen next to the umbilicus for bowel sounds (borborygmus). Listen for up to 30 seconds.
th

Kidneys/nephromegaly

Percussion

Abdominal mass

For renal dysfunction Shifting dullness excess peritoneal fluid/ascites

Auscultation

Bowel motility

No noise = no intestinal peristalsis! However absence of evidence is not evidence of absence. May be present with peritonitis, Ogilvie Syndrome (malignancy causing pressure on coeliac plexus, therefore sympathetic supply). Tinkling noise: intestinal obstruction e.g. adhesions, volvulus, malignancy.

Jaundice: in hepatocellular and post-hepatic jaundice, the person will appear yellow, and urine will be amber as bilirubin is conjugated. In post-hepatic jaundice stool is also pale (bilirubin cannot get into GIT). In pre-hepatic jaundice, urine and stool are a normal colour but the person is yellow.