abdo exam.pptx - confidentiality: protecting and providing information
TRANSCRIPT
Rashad Jurangpathy (4th year)
THE ABDOMINAL EXAMINATION
BASICS!!
1. INTRODUCTION & CONSENT
2. INSPECTION
3. PALPATION
4. PERCUSSION
5. AUSCULTATION
6. CLOSE
Introduction• Introduce yourself• Explain – what’s involved / how long• Consent• Exposure• Wash hands• Position• WIPE
• ‘Good morning/afternoon Mr/Mrs, my name is Rashad Jurangpathy and I am a 3rd year medical student. Is it ok if I quickly examine your tummy? This will involve me inspecting your tummy, having a quick feel and listen to it, as well as looking at your hands and your face. It will only take about 10 minutes of your time. Is that ok? For this examination, I’d like you to undress from waist upwards – you can do so behind the curtains whilst I go and wash my hands. Tell me when you’re ready. (Tell examiner, ideally I’d like the patient exposed from nipples to knee, but will not ask in this case, to preserve the dignity of the patient)’
BASICS!!
1. INTRODUCTION & CONSENT
2. INSPECTION
3. PALPATION
4. PERCUSSION
5. AUSCULTATION
6. CLOSE
End of bed examination / ‘outside-in’
Around the bed
• Medication / lines / PCA• Monitors• Fluids• Catheter bags
Patient itself
• Comfortable?• Well?• Nutritional state / unfinished food• Quick inspection of abdomen
• Distension• Stoma bags• Obvious masses• Pulsatile masses• Scars
• Any obvious signs?
Hands
Hands
• Warmth & perfusion• Clubbing• Leuconychia• Koilonychia
• Palmo Palmar erythemao Dupuytren’s contracture – ‘thickening + shortening of
palmar fascia, resulting in flexion deformities of 4 and 5
• Pulse• Asterixis (30 seconds)
• BP
Causes of clubbing
GI Causes (4 C’s):1. IBD (esp. Crohn’s)
2. Cirrhosis
3. GI lymphoma
4. Malabsorption disease, e.g. coeliac
Resp Causes:1. Lung cancer2. Chronic lung suppurative disease:
a) CFb) Empyemac) Bronchiectasis
3. Fibrosing alveolitis4. Mesothelioma
Cardiac Causes:1. Congenital cyanotic heart disease2. Endocarditis3. Atrial myxoma
Signs of chronic liver diseaseCOMPENSATED SYMPTOMS• Parotid enlargement• Spider naevi• Gynaecomastia• Clubbing, dupuytren’s contracture, xanthomas• Scratch marks• Testicular atrophy• Purpura
GENERAL SYMPTOMS• Jaundice• Loss of body hair
DECOMPENSATED SYMPTOMS• Encephalopathy, asterixis, fetor hepaticus, drowsy• Ascites• Capud medusae• Oedema
Causes of palmar erythema
Hyperdynamic states:• Pregnancy• Polycythaemia• Cirrhosis• Thyrotoxicosis
Face• Eyes
– Jaundice– Conjunctival pallor– Kayser-fleischer rings
• Face– Malar flush
• Mouth– STICK TONGUE OUT: Hydration status / Glossitis (smooth, red, sore tongue) –
iron, folate or b12 def.– TONGUE TO ROOF OF MOUTH: jaundice / central cyanosis– SHOW TEETH: dental caries / irregular dentition– GUMS: gingivitis / scurvy (soft & haemorrhagic)– Ulcers– Angular stomatitis (cheilitis) – iron def.– Abnormal pigmentation:
• Peutz-Jeghers• Telangiectasia
– Hallitosis / Fetor
Face
Neck, Chest & Abdomen• Palpate for Virchow’s node• Inspect chest for:
– Spider Naevi: >6 = abnormal; along course of SVC; can be blanched when pressed in middle and will then refill
– Gynaecomastia– Loss of hair
• Inspect abdomen more closely now – make sure to check flanks closely:• Distension – size/shape/symmetry – 5F’S: fluid (ascites), foetus, faeces, fat, flatus• Stoma bags• Obvious masses• Pulsatile masses• Scars• Spider naevi• Purpura• Caput medusae• Grey Turner’s & Cullen’s signs• Scratch marks• Striae• Bruising• Hernias – including umbilical, incisional & para-stomal
Neck, Chest & Abdomen
Spider naevi
Caput medusae
Cullen’s sign
Grey-turner’s sign
A- Ileostomy – End ileostomy – UC sufferers who have a
proctocolectomy
B – Loop colostomy – Colon Ca palliation
C – End colostomy – Hartmann’s procedure for
diverticular disease – sigmoid region excised, proximal region brought to surface with rectum
conserved
R hemicolectomy – Crohn’s (removal of affected ileum + proximal colon) – Crohn’s predominantly affects terminal ileum leading to stricturing + episodic SBO
Lanz scar (appendicectomy)
McBurney’s scar (appendicectomy)
Liver transplant
Open cholecystectomy
Rarely used – R hemicolectomy
Hysterectomy / cystectomy
L loin/lumbar incision – nephrectomy / renal transplant (hockey stick scar)
Midline scars – laparotomy / AAA repair / bowel resection
Vertical groin incision – embolectomy in femoral artery
Rooftop + thoracotomy - oesophagectomy
Rooftop incision (mercedes benz scar without the top
vertical line) – liver transplant / upper GI /
pancreas
BASICS!!
1. INTRODUCTION & CONSENT
2. INSPECTION
3. PALPATION
4. PERCUSSION
5. AUSCULTATION
6. CLOSE
Palpation• Always start off by asking: ‘Where is the pain?’• Always start palpation away from site of pain• Get to level of abdomen – either kneel down or raise bed• Always look at patient’s face whilst palpating• Start with LIGHT palpation (1 hand), and then DEEP palpation (2 hands)• Palpate all the 9 segments• LIGHT palpation:
– Check for tenderness (+ rebound tenderness) / guarding / rigidity– If tender on light palpation, ask pt. it ok to press deeper– Rebound tenderness indicates if parietal peritoneum is inflamed (peritonitis) – in exam, say
that you would test for rebound tenderness
• DEEP palpation:– Feel for any masses: site, size, shape, mobility, consistency, pulsation, bruit
• For any mass/lump/bump, try and assess the following:– Site– Size– Shape– Colour– Consistency– Surface– Temperature– Tenderness– Translucency– Mobility– Pulsation– Fluctuation– Reducibility– Edge– Regional lymph nodes– Perhaps auscultate as well
Palpation for organomegalyPalpation of liver:• RIF & upwards to RUQ; move up 2cm at a time• Push in on inspiration to feel lower border• Normal liver size – M: 10-12cm / F: 8-10cm• To assess accurately for hepatomegaly, need to percuss for upper and lower borders
(liver is dull, lung is resonant)– Normal upper border: 5th ICS
• If can feel liver border, need to assess:– Size, surface, edge, consistency (craggy – hepatocellular cancer), tender, pulsatile (tricuspid
regurgitation)– Is it smooth generalised enlargement? Knobbly generalised enlargement? Localised swellings?
Palpation of spleen:• RIF & upwards diagonally to LUQ• Spleen situated against diaphragm, in area of rib IX-X - Can only feel spleen if
enlarged• Ways to differentiate it from enlarged kidney:
– Cannot get above it (ribs in the way)– Moves on inspiration (towards RIF)– Overlying percussion note is dull– May have a palpable notch on medial side
Palpation for organomegaly
Palpation of kidneys:• Bimanual (balloting) – keep top hand steady on abdomen, and use bottom
hand to push up• Left higher than right
– Lt superior pole: rib XI– Rt superior pole: rib XII– Lower poles around level of disc between LIII and LIV
• Check for any difference in the kidneys; if palpable, check for size, surface, consistency
Palpation cont.
Palpate for AAA:• AAA = pulsatile & expansile• If present, don’t press too hard
Check for ascites if distension visible1. Shifting dullness2. Fluid thrill
Check hernial orifices- Ask them to cough
BASICS!!
1. INTRODUCTION & CONSENT
2. INSPECTION
3. PALPATION
4. PERCUSSION
5. AUSCULTATION
6. CLOSE
Percussion
Percussion of liver and spleen – do after palpating each organ
BASICS!!
1. INTRODUCTION & CONSENT
2. INSPECTION
3. PALPATION
4. PERCUSSION
5. AUSCULTATION
6. CLOSE
Auscultation
Listen for bowel sounds:• Active, absent, tinkling• Listen for 2 minutes at one area before concluding absence• Listen at 3 areas• Absent BS = paralytic ileus or peritonitis• Tinkling BS = bowel obstruction (BS are also more frequent)
Listen for bruits:• Aortic bruits (atheroma or aneurysm) – above umbilicus• Renal artery bruits (renal artery stenosis) - 2.5cm above and lateral to umbilicus
BASICS!!
1. INTRODUCTION & CONSENT
2. INSPECTION
3. PALPATION
4. PERCUSSION
5. AUSCULTATION
6. CLOSE
Conclusion
Thank patient, ask if he has any questions, tell him he can redress now and then WASH HANDS
Present the examination
To complete my examination, I would:1. Check the external genitalia
2. Perform a DRE
3. Dipstick the urine
4. Check the hernial orifices (if not done already)
EXAMPLE ABDOMINAL EXAMINATION
Next week
‘ECG & Abdo X-rays’With
Isma Qureshi (4th year) &
Adeel Iqbal (5th year)
Wednesday 28th October, Drewe LT, 2pm
Final Reminders
• Remember to purchase MM membership for priority for MM OSCE
• All slides are available online