Introduction
Wash hands
Introduce yourself
Confirm patient details – name / DOB
Explain the examination
Gain consent
Ask the patient to sit at 45 degrees, but ensure they are lying flat when you examine the abdomen
Adequate exposure
Chaperone ??
General inspection
Treatments: Oxygen, IV fluids, NG tube, TPN lines, Ensure drinks
Scars
Abdomen - Distended?
Patient - Stable? Pain? Discomfort?
Jaundiced?
Pallor?
Muscle wasting and cachexia?
Laid flat and not moving atall (
Vomit bowels near the bed?
Nil by mouth signs above the bed
Hands
Ask the patient to hold out their hands and hold them gently with yours
Clubbing (cirrhosis, IBD, Coeliac’s)
Leukonychia (white nails - hypoalbuminaemia in liver cirrhosis)
Koilonychia (spoon shaped nails - severe iron deficiency anaemia)
Palmar erythema (red palms - hyper dynamic circulation due to ↑oestrogen levels in liver disease/ pregnancy)
Flapping tremor - 'asterixis' (hepatic encephalopathy)
Tremor - may be due to alcohol withdrawal
Dupuytren’s contracture (familial, liver disease) , fingertip capillary glucose monitoring marks (diabetes)
Signs of IV drug use in the arms (risk factor for hepatitis)
Vital Signs: Pulse, BP, RR, Temp
Head
Sclera for jaundice (liver disease)
Conjunctival pallor (anaemia - may be due to bleeding, malabsorption)
Periorbital Xanthelasma (hyperlipidaemia in cholestasis)
Glossitis/stomatitis (iron/ B 12 deficiency anaemia) ,
Breath odour (e.g. faeculent in obstruction; ketotic in ketoacidosis; alcohol)
Kayser-Fleischer rings (excess copper deposited in the cornea peripheries - Wilson's disease)
Neck and torso:
Ask patient to sit forwards:
Neck: feel for lymphadenopathy from behind – especially Virchow's node (gastric malignancy) cervical, supraclavicular and occipital
Back inspection: spider naevi (>5 significant) , skin lesions (immunosuppression)
Ask patient to relax back:
Chest inspection : spider naevi (>5 significant) , gynaecomastia, loss of axillary hair (all due to ↑oestrogen levels in liver disease / pregnancy)
Abdomen
Inspection:
Distension (The 5F's - Fluid, Flatus, Fat, Foetus, Faeces)
Scars
Bruising (impaired clotting factor production in liver failure)
Striae (due to abnormal collagen formation - Cushing’s, EDS) (due to rapid stretching of the skin - Pregnancy, Obesity)
Spider naevi – telangiectatic lesions (swollen blood vessels) [more than 5 is abnormal and may be due to excess oestrogen caused by excessive oestrogen metabolism in chronic liver disease)
Gynaecomastria - excess oestrogen in men may cause this
Caput medusa – portal hypertension (appearance of distended and engorged superficial epigastric veins
Stoma's - important to identify these
Hernia's - some of these may be obvious just from inspection
Palpation: ask if any pain (start away from painful areas)
Superficial palpation: Tenderness, guarding (peritonitis), rebound tenderness (peritonitis) [palpate over all 9 quadrants]
Deep palpation: Masses, deep tenderness and, if relevant, Rovsing’s sign (appendicitis) and Murphy’ s sign (cholecystitis)
Organ palpation - Liver, gallbladder, spleen, kidneys
Liver: (push in on each inspiration) (hepatomegaly = metastasis/HCC, cirrhosis, hepatitis, RVF, leukaemia/ lymphoma)
Spleen: (push in on each inspiration). It can be f let better if patient rolls onto their right side with tucked legs (splenomegaly = lymphoma/ leukaemia, myelofibrosis, malaria, portal hypertension, haemolysis)
Kidney palpation
AAA palpation: press down with finger tips (one hand each side) in the horizontal plane of the umbilicus – start laterally and move medially (pulsatile mass can be normal, expansile mass is AAA)
Percussion
General percussion qualities if relevant (percussion tenderness = peritonitis; tympanic = flatus)
Liver: start from the RIF, percuss upwards and find upper and lower borders (should become dull over liver)
Spleen: percuss upward towards spleen from RIF (dull percussion note of the spleen is only heard when it is enlarged) .
Demonstrate shifting dullness (patient roll to side and percuss all way across again) ± fluid thrill (patients hand hard on abdomen mid - line and tap one side and feel other) (ascites)
Auscultation
A bruit is an abnormal blowing or swishing sound resulting from blood flowing through a narrow or partially occluded artery.
Listen for bowel sounds at ileocaecal valve in RLQ until heard, up to 1min (tinkling = obstruction; absent = paralytic ileus/ peritonitis)
Aortic /renal bruits (1cm superior and lateral to umbilicus bilaterally)
Finally
Check for ankle oedema (hypoalbuminaemia)
Lymphadenopathy (neck and supra-clavicular region)
In particular, look for Virchow's node (can be caused by abdominal and breast cancer, classically seen in gastric cancer)
To Complete Exam
Thank patient and cover them
“To complete my exam, I would examine the external herneal orifices, the external genitalia and do a digital rectal examination”
Summarise to the examiner and suggest further investigations you would do
Questions:
Give 3 GI causes of clubbing
Give 2 causes of hepatomegaly
How would you describe a mass/lump during an examination?
List 4 causes of abdominal distention
Give 3 differential diagnoses for hepatomegaly
What are spider naevi?
What is Virchow's node a sign of?
How can you demonstrate ascites?
What is a pfannenstiel incision? When might a surgeon use this?
How is IBS diagnosed?
Give 3 differences between Crohn's disease and Ulcerative Colitis?
Give 2 classic symptoms that a patient with bowel cancer may present with?
What would be the first line investigation for a patient presenting with rectal bleeding?
What is Charcot's triad?
What do tinkling bowel sounds represent?
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