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Short case

GI system
3 possibilities:
1. GI cases: CLD with portal ht/hepatomegaly/hepatosplenomegaly
2. Haematological cases: splenomegaly +/- hepatomegaly & lymph eg. Hematological
malignancy/Thalassemia/leukemia/pernicious anemia?
3. Renal cases: PCKD/bilateral hydronephrosis (stands alone or due to PCKD as well) ballotable
kidney/transplanted kidney
Liver causes evident by hepatomegaly
-malignancy
-hepatic congestion eg hepatic vein thrombosis (budd-chiari)/right heart failure
-infection eg malaria/hepatitis/infectious mononucleosis (glandular fever)
-hematological eg leukemia/lymphoma/sickle cell/hemolytic anemia/myeloproliferative disorder
(myelofibrosis)
-anotomical eg. Ridels lobe
Start with general inspection at the end of the bed; expose abdomen
-patient lying/well/comfortable/not in distress
Hand:
Koilonychias (iron deficiency anemia)
Leukonychia (hypoalbuminimia due to nephrotic syndrome, liver?)
Brown nails (CKD)
Clubbing ddx: IBD/cirrhosis/lymphoma/celiac disease
Palmar pallor (anemia)
Palmar erythema (liver?)
AV fistula scar at upper arm
-feel for thrill (functioning)
-in and out needle mark on each scar (fistula in use of dialysis)
Bruises (related to liver- easy bleeding)
Asterixis/liver flap (hepatic encephalopathy/respi/renal failure)
Pulse
Eye:
Conjunctival pallor
Scleral icterus
Xanthelasma
Mouth:
Glossitis
Angular stomatitis
Mouth ulcer
Hydrated
Central cyanosis?

Chest:
Spider naevi (liver)
Gynacomastia (liver)
Axillary hair loss (liver)
Abdomen:
Inspection:
Distension evident by inverted umbilicus
-upper abdomen (PCKD)
-lower abdomen
Ascites
Scar (at the back of your side)
Stretch mark
Dilated veins/ caput medusa
Pulsations
Look at chest for spider naevi
Look at inguinal region for hernia
Palpation/percussion: hypochondrium/epigastrium/lumbar/umbilical/iliac/hypogastric
Surface-mass/tenderness
Deep-deep seated mass
If mass is identified over the right side,
-identify lower border
-feel upper border below the rib. Can get over the mass (kidney). Upper border in the ribs (liver)
-percuss. Resonant (kidney). Dull (liver)
-ballotable (kidney)
-comment on length (if liver: from below the rib if upper border is displaced downwards)
If mass over the left side,
-identify lower border from bottom right of umbilicus
-feel upper border below the rib. Can get over the mass (kidney). Cannot (spleen)
Moves more with inspiration towards RIF (spleen)
-percuss. Resonant (kidney). Dull (spleen)
-feel notch at the bottom/medial. Present (spleen)
-ballotable (kidney)
-comment on length (if spleen: from below the rib)
Shifting dullness (little ascites)/fluid thrill
Try to avoid the area with mass
Ascites:
Pathology- hypoalbuminimia.
Ddx:
Liver failure due to viral hepatits (commonly B & C)/alcohol/fatty liver disease/malignancy/drugs
Renal failure

Take opportunity to look for scar at the back (the opposite side)
And check sacral edema
Auscultate:
Renal bruit (2cm left and right of umbilicus)
Bowel sound (wait for 2min)
Patient sit up
Then palpate neck for lymph nodes
Sacral edema if forget
Ankle edema from distal to proximal
-comment on up to
Lungs for creps
Summary eg
Patient has bilateral ballotable kidney with AV fistula in use, thus patient has ESRF due to PCKD.
Complicated by signs of anemia such as conjunctival pallor and palmar pallor.
Clubbing ddx:
Cyanotic heart disease
Lung: Abscess/bronchiectasis/cystic fibrosis/empyema/fibrosis
Ulcerative colitis/IBD/Crohns
Bowel ds
Biliary cirrhosis
Infective endocarditis
Neoplasm eg lung ca/mesothelioma
GI malabsorption (celiac ds)
Cardio
Think of ddx:
Valvular problems
Inspection

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