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

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

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

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