Abdominal Exam
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Abdominal Exam
HistoryPain, Nausea/Vomit, Bleeding, Weight change, Distension (fat, fluid, foetus, faecal, flatulence), Stool/Urine
ObservationGeneral Demeanour Peripheral → central
Distress on exertions. Wind (diet?), Belching (excess swallowing –hiatus hernia?)Breath Smelly – Liver
Sweet – DiabetesFacial appearanceSkin Pruritis - JaundiceHabitus Oedema, Gynacomastia (liver-oestrogen), Obesity/cachexia
Hands Sweaty anxiety, hyperthyroidismTemp Cold + blue – peripheral cyanosis
Warm + blue – central cyanosisColour Red, erytheama – Liver, hyperthyroidism, RA, nicotine stainsdupuytren's contracture Liver, alcohol, diabetes, smokingSpider naevi Not >5 on hands+trunk above nipples.
Chronic liver disease, ↑ Oestrogen, pregnantHaemangeoma Cambell de Morgan spots, dots, “no legs” – harmless
Nails Leuconychia White nails → Liver, chronic hepatitisKoilonychia Iron deficiency, possibly blood lossBrown Kidney failureSplinter hemorrhage Small emboli under nail. Manual worker, infective endocarditisClubbing Fluctuation – ↓ nail/bed angle, ↑ nail curvature, ↑ ST bulk
Heart – Subacute bact endocarditis, Cyanotic congenital heart diseaseLung – Bronchial carcinoma, Fibrosing alveolitisGI – Cirrhosis, Ulcerative colitis, Crohn’s diseaseIdiopathic
Feet Pitting oedema press 20 sec, again higher up. R heart fail, congested vena cava, liver, kidney disorder, DVT, hypoalbuminia (osmotic pressure), low protein diet
Temp and colour As in handsFace Colour Yellow – jaundice
Silver/grey – ↑ IronPallor – ↓ Oxygenated Hb in skinBlue – CyanosisMalar flush – rosy cheeks
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Eyes Sclera Yellow – jaundiceBlue – Osteogenesis imperpectaCorneal arcus – Silvery whit line (>50), in young – hyperlipedemia
Conjunctiva Pale – AnemiaBlue – cyanosisBleeding capillaries – ↑ NSAID, hypertension
Around orbit Xanthelasma – yellow blisters, hyperlipedemia, poss liver dysfunctionMouth Ulcers Virus, HIV, rheumatological conditions
Angular stomatitis Crack at corners, don’t heal well – Anemia, malabsorbtion, ↓ iron/folic A, Vit BTongue Colour Big beefy smooth red sore – Glossitis, ↓ iron/folic A, Vit B
Pale – AnemiaBrown/dry – Mouth breathers, dehydrated , smokersBlue – central cyanosisCreamy curd like – Candida Albicus (Corticosteroids med)
Sub-lingual Engorged sublingual veins – Portal hypertensionChest Gynacomastia ↑ Oestrogen, liver dysfunction (↓ breakdown)
Spider Naevi Not >5 on hands+trunk above nipples. Chronic liver disease, ↑ Oestrogen, pregnant
Abdomen Scars Surgery – appendicectomy, C-section, Cholysystectomy (R subcostal), Liver (B subcostal-mercedes-Benz scar)Herniation – umbilical, femoral, inguinal-in/direct
Striae pink – normaldark – Cushing’s syndrome
Bruised umbilicus Hemorrhage, pancreatitisDistension look horizontally, stomach or pulsating aorta?Varicose veins Longitudinal. IVC obstructionCaput medusa Portal hypertensionEngorged superficial veins around umbilicus – IVC obstruction portal hypertension
AuscultationBorborygma Normal – Bowel sounds every 5-10 sec
Absent – paralysis, peritonitisHigh pitch – ↑ gasAudible sounds – bowel obstruction, dysmotility
Bruit Renal – (2-3 cm above and lat to umbilicus) Stenosis, hypertension in youngFemoral – (between ASIS, pubic tubercle) ↓inguinal lig, Stenosis, aortic/iliac/femoral aneurismLiver – (Below R nipple, ribs 5→10) Carcinoma, alcohol hepatitis
Rub Liver – if creak → inflamed capsuleSpleen – (L rib 9→11 in midline) → inflamed capsule
PalpationSupraclavicular lymph node (L drains abdomen)
Large palpable, soft InfectionShotty Remains of old infection
Firm/rubbery/irregular Malignant diseaseEach quadrant General lumps, masses
Rebound tenderness Peritoneal irritation
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Liver Downward displacement Hyperinflated lung (percuss to check)Reidel’ lobe Lower lobe normal, especially in womenHepamegaly (enlarged)+ smooth+ irregular
Right heart failure, malignant, hepatitisFatty liver. ↑ alcoholCirrhosis, Tumour
Atrophy (small) Cirrhosis, hepatitisSpleen(L axillary line, rib 9 → 11)
Splenomegaly Portal hypertension, hemolytic anemia, virus, glandular feverSplenectomy (absent) previous trauma, Hodgin’s disease
Gallbladder Murphy’s point R mid cost marginMurphys sign Press + inhale → pain or catch breathCholecystitis Inflamed from stones, cancer in pancreatic head
Appendix Mc Burney’s point 2/3 from ASIS → umbilicus. Pain → Appendicitis (pain start at umbilicus)Rovsing’s sign Press L iliac fossa → pain R fossa = Acute appendicitisIliopsoas sign Active resist psoas → pain, inflammation = Retroiliac or Perinephic abscess
Kidney(Upper poles: L rib 11, R rib 12. Lower poles: 3-4cm sup iliac crest)
Atrophy Most common. infection, trauma
Enlarged Hydronephritis (blocked), polysystic kidney
Pulses Aorta Palpate between xiphisternum and umbilicusAneurysm – pulsating, expanding at lat border of rectus abdominis
Femoral Between ASIS/pubic tubercle, below inguinal lig (get consent first!)Radiofemoral delay If weaker femoral → aortic aneurysm or coarctaction (narrow)
PercussionLiver Below R nipple, Ribs 5 → 10
From resonant → dullSpleen L axillary line, Ribs 9 → 11Peritoneum Ascites Fluid in peroteneal cavity (↓ albumin, osmotic pressure)Signs and SymptomsPain Time ↑ pain on empty stomach or at night → peptic ulcers
↑ pain after fatty diet, epigastric pain → gallbladderType Visceral pain → Deep at midline, diffuse, referred pain, sympathetic nerves from T5-L2
Perotineal pain → Localised painColicky pain → From hollow structures (intestine) short (sec-min) intermittent pain. If colicky pain suddenly become chronic – poss mesenteric infarct
Location Epigastric area – ForegutUmbilical – midgutSupra pubic – hind gut
Nausea Medication, pregnancy, upper GI (+vomiting)Vomiting With nausea Upper GI
With blood – Oesophagus or gutGreen (bile) – obstruct in deudenum past bile duct
Without nausea Poss ↑ intra cranial pressureFlatulence lactase deficiency, intestinal malabsorbtion
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Fluctuating distension(↑ day, ↓ night)
With pain IBS, pregnancyWithout pain ovarian pathology
Diarrhoea Acute drugs (anti biotic), infectionChronic IBS, hyperthyroid, cancer inflammationType Osmotic – ↓ H20 absorption in colon, drugs, motility disorders
Secretory – mucosal inflammation, viral/bacterial, ulcerative colitis, Crohn’s diseaseStools Pale Biliary obstruction (lack of pigment)
Pale + greasy Fat malabsorbtionBlack tarry Melaena, upper GI bleedingGrey/black Oral iron or bismuth therapyFresh blood Rectal/anal/large colon bleedingMixed with pus ulcerative colitis, dysenteryWatery with grain Cholera (odorless “rice water”)
Jaundice Prehepatic (haemolytic) Stool + urine normal colourHepatocellular Stool – normal
Urine – darkObstructive Stool – pale
Urine – dark + pruritusDisordersIBS Abdominal pain, change of bowel habits and stool consistency, chronic, no rectal bleeding or weight loss.
Pt more sensitive to dairy, wheat, fat, caffeine.Liver disease Hepatomegaly, jaundice, ascites, Circulatory changes (palmar erythema, spider naevi), Endocrine (↑oestogen, ↓libido,
breast size ↓women- ↑men, ↓hair, irregular menses) Haemorrhage tendency (bruise, purpura, menorrhagia), Portal hypertension, Hepatic encephalopathy; pigmentation, clubbing, leuconychia, low grade fever
Cirrhosis Damage of liver structure, scars, nodules, poss from hypertensionPrimary biliary cirrhosis
Auto immune. >50 women. Granular inflammation destroy intra lobular bile ducts, unexplained pruritis
Anastomoses 3 types: Oesophagus, umbilicus, anusPortal hypertension → round Carina, Caput medusa, haemorroids
Hepatitis Inflammation. Symptoms: Arthralgia, jaundice, pyrexia, fatigue, diarrhea, pigmentationHep A – Faecal → oral. Self-limiting. No TTTHep B – Blood, body fluid, sex. Chronic infection rare. Anti virus TTTHep C – Blood, body fluid 80% get chronic infection → cirrhosis, liver failHep D – Only in Hep B patient → cirrhosis , live failureHep E – Oral contact with faces. No TTT. Self limiting