ABDOMINAL EXAM 1.

Ensure patient is lying comfortably on one pillow, hands by side, abdomen exposed from nipples to pubic symphysis (ideally to knees for hernia & groin pathology). 2. General inspection Look around the bed (drips, diet sheets) Patient Appearance Jaundice hyperbilirubinaemia, liver disease Pigmentation haemochromatosis, Whipple's disease (systemic disease due
to Gram-positive bacteria, causing small bowel malabsorption, & Joint, CNS, cardiac Sx)

Reduced body hair Body habitus Wasting Loose skin folds Obesity

liver disease

Malabsorption recent weight loss can cause NASH

Increased muscle bulk liver tumours, anabolic steroids

Cognition Hepatic encephalopathy Decompensated advanced cirrhosis/chronic liver failure, fulminant hepatitis, acute liver failure failure of liver to remove toxic metabolites from portal blood
Mx: lactulose to flush out toxins, bypassing the liver

Devices 3. Nails Clubbing Leuconychia (opacification of nail bed) 4. Hands Dupuytren's contracture Palmar erythema **Hepatic flap (hepatic encephalopathy Crohn's disease nutrition depletion cirrhosis AV shunt, arterial O2 desaturation Crohn's disease, cirrhosis hypoalbuminaemia

alcoholism, manual labour, familial cirrhosis raised oestrogen Acute/early sign of liver failure

interference of joint position sense). Cardiac, respiratory, renal failure, Ddx fine resting tremor (alcoholism); apparent tremor metabolic disturbance (low glc, K, (Wilson's disease: inherited copper storage disorder Mg), barbiturate OD causing cirrhosis & neuro disturbances)

Arthropathy Anaemia Pulse (rate & rhythm)

haemochromatosis GI bleed, malabsorption (folate, B12), haemolysis AF in mesenteric infarction

5. Arms & Shoulders Spider naevi, >2-3 Bruising

cirrhosis alcohol, viral hepatitis oestrogen excess due to impaired

hepatic inactivation

clotting abnormality hepatocellular damage affecting clotting factor synthesis; malabsorption of vit K e.g. Obstructive jaundice causing
decreased bile acids

Wasting Scratch marks 6. Eyes Lower eyelid Sclerae/Conjunctiva Cornea

late manifestation of malnutrition in alcoholic patients obstructive jaundice, chronic cholestasis pruritis

Proximal myopathy alcohol

anaemia jaundice, iritis (IBD) Kayser-Fleischer rings (Wilson's disease excess copper deposits) + encephalopathy

Xanthelasma (periorbital Longstanding hypercholesterolaemia, chronic cholestasis, lipid plaques) primary biliary cirrhosis 7. Parotid enlargement bilaterally (alcoholic toxicity fatty infiltration) 8. Mouth Breath: fetor hepaticus [severe hepatocellular disease failure to demethylate methionin (amino acid)], sweet smell (diabetic ketoacidosis) Inspection: dentition Lips Cyanosis liver disease Localised peri-orbital pigmentation Peutz-Jeghers syndrome, assoc with
hamartomas of the small bowel and colon, p/w bleeding or intussusception)

Telangiectasia (visibly dilated bld vessel) Aphthous ulcers

hereditary haemorrhagic telangiectasia Unknown cause, Crohn's, coeliac disease

Angular stomatitis (cracks at corners of mouth) B6, B12, folate, iron deficiency Gums Gingivitis, bleeding, hypertrophy, pigmentation Moniliasis/ Candidiasis: creamy white curd-like patches (associated with immunosuppression, antibiotics, poor oral hygiene, iron deficiency, DM) Tongue Atrophic glossitis nutritional deficiency (iron, folate, B12): terminal ileectomy in
Crohn's, gastrectomy (stomach produces B12 co-factor), alcoholic papillae atrophy

Leucoplakia (white sorry teeth, smoking, spirits, sepsis, syphilis

mucosal thickening)

9. Neck JVP Cervical lymph nodes esp L supraclavicular node (Virchow's node) Hepatomegaly RHF intra-abdominal malignancy (lymphoma, gastric/GI/lung cancer)

10. Anterior chest wall Gynaecomastia - Chronic liver disease: cirrhosis, chronic autoimmune hepatitis altered
oestradiol:testosterone ratio.

- Drugs (spironolactone, digoxin) Spider naevi 11. Abdomen Inspection General: lying still, shallow breathing = Acute abdomen Observe rise/fall of abdomen with breathing. Ask patient to cough: observe pain, hernias Scars (including periumbilical laparoscopic scars, nephrectomy scars posteriorly) Stoma (ileostomy usually in LIF and smaller than a colostomy which is often on the R) Skin lesions Sister Mary Joseph node metastatic liver/intra abdominal tumour deposit in the umbilicus (peritoneum is closest to skin) Cullen's sign (umbilical 'black acute pancreatitis eye' or discoloration) Grey-Turner's sign (skin discoloration in flanks) Striae (wrinkled pink linear marks) Bruising, pigmentation severe acute pancreatitis, retroperitoneal haemorrhage rapid weight gain, ascites, pregnancy, Cushing's (purple) stretched abdominal wall, rupture of elastic
fibres in the skin

as above

Visible peristalsis Intestinal obstruction Upper abdomen: Pyloric obstruction (peptic ulcer or tumour) Central abdomen: Distal small bowel obstruction Thin normal people Visible pulsation Abdominal aorta in normal thin people AAA: expanding central epigastric pulsation Distension: Generalised Causes: fat, fluid, foetus, flatus (bowel obstruction), faeces, filthy big tumour (ovarian tumour, hydatid cyst) Localised (upper abdo, periumbilical, suprapubic, flanks, iliac fossae) Inspect from the side, squatting to patient's level. Ask patient to take slow deep breaths and look for the hepatic, splenic and gallbladder outlines Enlargement of abdo/pelvic organs or hernias (protrusion of intra-abdominal structure through an abnormal opening)

 Prominent veins Determine direction of flow (test separately in veins above and below umbilicus; but is best assessed in veins below umbilicus): occlude the vein, empty the vein below occluding finger. Remove second finger and see if vein refills. Cranially IVC obstruction (tumour, thrombosis, tense ascites) abdo
veins enlarge to provide collateral blood flow from legs

Away from umbilicus portal hypertension/ caput medusae (superficial collaterals

making their way back to systemic circulation)

Palpation Enquire about areas of pain, examine it last Superficial palpation in a systematic fashion tenderness, outline any mass, guarding, rigidity, rebound tenderness Start from opposite quadrant to pain OR traditionally start at RIF, anticlockwise, end in the umbilicus Use pulps, not tips, of fingers Deep palpation / Internal organ palpation organomegaly (liver, spleen, kidney) any masses Liver: work upwards to RUQ. Move hand during expiration, keep still during inspiration and wait for liver edge to strike forefinger. Attempt to feel liver surface (Hard? Tender? Regular? Pulsatile?) Measure liver span (normal lower border: 3cm below costal margin; upper border: 6th rib; normal span <13cm) Gallbladder: enlarged if palpable below right costal margin; feel from medial to lateral Murphy's sign (RUQ/costal Cholecystitis margin on inspiration) Courvoisier's law if gallbladder is enlarged and pt is jaundiced, unlikely to be gallstones ( fibrosed gallbladder). CA of pancreas or lower biliary tree causing obstructive jaundice more likely.

Spleen: work diagonally to LUQ Enlarges inferiorly and medially. Palpable if 2-4 times enlarged Start by feeling for edge below umbilicus in the midline, hand parallel to L costal margin. Feel for the splenic notch. Kidneys: left and right flank by bimanual palpation Keep upper hand still and firmly pressed down while lower hand ballotts the kidney If any organs are felt: Ask patient to take a deep breath in to assess for movement with respiration Assess edge of the mass contour, texture Kidney: Assess if you can 'get above' the mass, assess if it is separate to the costal margin Groin (inguinal hernia, masses), testes, femoral pulses

Percussion (principle is to move from resonant to dull) Elicit tenderness in patients with peritonitis (localised or generalised) Liver Percuss up from RIF until lower border of liver dullness is reached, then repeat from lower right chest downwards Spleen Percuss over lowest intercostal space in L) anterior axillary line. Dull note or dull on complete inspiration suspect splenomegaly Bladder Suprapubic dullness may indicate upper border of enlarged bladder or pelvic mass Shifting dullness (ascites, rarely small bowel obstruction, ovarian cyst) Normal percussion note is resonant (air in intestines) First check for stony dullness in flanks if absent (rare), there is gross ascites, no need to continue. Start percussing in the midline, move laterally to patient's left until the note becomes stony dull, then Ask patient to roll on to their right (facing you) and allow 30s for fluid to settle before percussing over the marked point back towards the midline and listen to the note of the dullness that has shifted. If the abdomen is resonant right out to the flanks, do not roll the patient over. Fluid thrill (massive ascites, ovarian cyst) Ask pt to place medial edge of one or both palms firmly on centre of abdomen Flick the side of the abdominal wall, feel a pulsation (thrill) by the hand placed on the other side Auscultate Bowel sounds: Just below the umbilicus Absent Paralytic ileus (No sound over 3-4min in all quadrants) High pitched Loud gurgling Obstructed bowel sounds due to air & liquid Intestinal hurry or rush, in diarrhoeal states

Venous hum between xiphisternum and umbilicus (portal hypertension, liver cirrhosis)
large vol of blood flowing in the umbilical or paraumbilical veins in the falciform ligament

Artery bruit: higher pitched, not continuous, well-localised compared to venous hum Liver: cancer, acute alcoholic hepatitis, AVM Renal: renal artery stenosis Epigastrium: chronic intestinal ischaemia from mesenteric arterial stenosis Spleen: pancreatic tumour, splenic arteriovenous fistula Succussion splash (gastric outlet obstruction due to peptic ulcer or gastric CA, or just eaten/drank) excessive fluid in the (obstructed) stomach Friction rub (liver abscess/tumour/infarct/Fitz-Hugh-Curtis syndrome, or splenic infarct) inflammation of parietal and visceral peritoneum 12. Groin **Hernia (standing & lying) lumps, usually bilateral (Irreducible? Obstructed [SBO]? Strangulated [pain, red, tense, tender]?), cough impulse Inguinal (direct/indirect): Difficult to differentiate clinically; direct hernias are typically
easier to demonstrate and reduce immediately and spontaneously.

Femoral: Medial to femoral pulse. Usually smaller and firmer, no cough impulse,

irreducible (compared to inguinal hernia). Ddx inguinal lymphadenopathy, hydrocoele Incisional: Scars = abdominal wall weakness Inguinal lymph nodes Examine testes, external genitalia Testicular atrophy in chronic liver disease (alcohol, haemochromatosis)

13. Rectal examination Inspect

excoriation/rash, external haemorrhoids, anal fissure, rectal prolapse, fistulae, fungating mass, tags, warts

Ask patient to strain and watch incontinence, leakage, abnormal descent, gaping anus, the perineum internal haemorrhoids @ 3,7,11 o'clock, rectal prolapse Anal wink (reflex contraction) Sacral nerve pathways Palpate Observe nature of stool 14. Legs Brusing, oedema Trophic changes e.g. Hair loss Ulcers, erythema nodosa, pyoderma gangrenosum Neurological signs liver disease) peripheral vascular disease, nutrition IBD Coarse tremor (alcoholism) Peripheral neuropathy (thiamine deficiency from alcoholism or chronic liver disease) DVT prophylaxis sphincter tone, masses, prostate size and texture, cervix blood, mucus, colour

Compression stockings 15. Further examinations Enlarged or cirrhosed liver

JVP & cardiovascular exam (cardiac failure, constrictive

pericarditis can cause liver disease; haemochromatosis can cause cardiomyopathy)

Ascites Liver disease Malignancy Anorectal or large bowel symptoms Anaemia, iron deficiency, GI bleeding, symptoms of cancer Acute abdomen, infection

Examine chest for pleural effusion Urinalysis (bilirubin, urobilinogen, glucose) Examine all lymph node groups, breasts, and lungs Proctosigmoidoscopy (blood, erythematous/ulcerated areas,
mucosal oedema, polyp, tumour, stricture, diverticula, fissure)

Faecal occult blood test Temperature & obs chart Inspect stool and vomitus Sacral oedema

Common OSCE Cases (Medical) It is essential to look for features of other diseases, to help identify causes. Hepatomegaly Common causes: Cirrhosis Right heart failure Lymphoma Myeloproliferative disorder Malignancy (irregular liver edge) If also anaemic, diagnosis may be: Cirrhosis with portal hypertension Lymphoma Myeloproliferative disorder Tropical disorders (malaria) If lymphadenopathy present, diagnosis may be: Chronic lymphocytic leukaemia Lymphoma Massive most commonly: Myeloproliferative disorder Cirrhosis with portal hypertension Lymphoma Infections (infectious mononucleosis, infectious hepatitis, bacterial endocarditis) Bilateral: Polycystic kidney disease Amyloidosis Bilateral hydronephrosis Unilateral: Hydronephrosis Renal carcinoma Usually with features of chronic liver disease or hepatomegaly, but may be isolated. Look for signs of paracentesis and of causes other than liver disease (heart failure, intra-abdominal malignancy, operative scars) Have a list of causes and complications of cirrhosis at your fingertips

Hepatosplenomegaly

Splenomegaly

Enlarged kidneys

Isolated ascites

Chronic liver disease