Video


Exam Summary


1. Introduction

Introduce yourself and wash your hands.

2. Observations

  • Temperature
  • Heart Rate
  • Blood Pressure
  • Respiratory Rate
  • Oxygen Saturation
  • Bowel status (opened?)
  • Request Urinalysis for bilirubin, ketones, nitrites, white cell count and red cell count (haematuria)

3. General Inspection

Jaundice.jpg
Jaundice
Hand Xanthomata.jpg
Xanthomas

4. Hands

a. Nails

clubbing.jpg
Clubbing
Leukonychia.jpg
Leukonychia
Koilonychia.jpg
Koilonychia

b. Palms
  • Palmar erythema - may be a sign of liver damage leading to high levels of oestrogen.
  • Dupuytren's Contracture - contracture of the palmar fascia which may be related to chronic alcohol consumption.
  • Palmar creases - look for pallor (anaemia which may result for Gastrointestianal bleeding)
palmar_erythema.jpg
640px-Morbus_dupuytren_fcm.jpg
Dupuytren's Contracture

5. Arms

a. Wrists

  • Metabolic Flap (Asterixis)

b. General

  • Spider Naevi - A red spot with radiating small vessels that look like spiders' legs. They blanch when pressed. Most frequently due to alcohol abuse or pregnancy.
  • Bruising - Large bruising may be a result of liver damage impairing clotting factor production. Obstructive jaundice limits Vitamin K absorption which is also required for coagulation.
  • Petechiae - Pinhead-sized bruises which may be a result of thyrombocytopaenia related to chronic alcohol consumption.
  • Muscle Wasting - Muscle wasting could suggest malnutrition. Look particularly for deltoid wasting.
  • Scratch marks - due to severe itch (pruritus) are often present in patients with obstructive or cholestatic jaundice
Spider naevi.jpg
Petechiae.gif
Petechiae
Deltoid atrophy.jpg

6. Face

  • Measure the patient's temperature.

a. Eyes

  • Jaundice - due to liver inflammation, damage or biliary obstruction.
  • Conjunctival Pallor - a sign of anaemia
  • Kayser-Fleischer rings - Copper deposits forming brown-green rings around the edge of the iris due to Wilson's Disease.
  • Xantheslemata - cholesterol deposits which may be related to cholestasis and particularly common in Primary Biliary Cirrhosis.
Jaundice_eye.jpg
Scleral Jaundice

conjunctivapallor.jpg
Conjunctival Pallor
Kayser-Fleischer_ring.jpg
Kayser-Fleischer rings
Xanthelasma_wiki.jpg
Xantheslemata

b. Parotids

  • When the patient clenches their jaws the parotid gland should not be palpable. Parotid enlargement could be due to alcoholism causing fatty infiltration.

c. Mouth and Tongue

  • Breath - check for the sweet breath of fetor hepaticus due to severe hepatocellular damage. Bad breath (fetor) may also be due to poor oral hygiene, ketoacidosis, alcohol abuse, uraemia or smoking.
  • Angular Stomatitis - or angular cheilitis is inflammation of the corners of the mouth. It is often due to immunosuppression.
  • Leukoplakia - A premalignant condition resulting in white tongue and/ or mucosa. The causes are poor dental hygiene, smoking, alcohol abuse, sepsis or syphilis.
  • Ulceration - usually nothing of note but sometimes may Crohn's disease or Coeliac disease.
  • Pigmentation - Pigmentation of mucosae may be due to Heavy metals (Lead or Bismuth), Haemochromatosis, antimalarials, Addison's Disease or Malignant melanoma.
  • Glossitis
Angular_Cheilitis_wiki.JPG
Angular Stomatitis
Leukoplakia02-04-06.jpg
Leukoplakia
Mouth Ulcer.jpg
Mouth ulcer
Glossitis.jpg
Glossitis

7. Neck

  • Cervical lymph nodes - best felt from behind the patient. The supraclavicular lymph node is of significant importance and may be due to abdominal malignancy or tuberculosis.
  • Axillary Lymph nodes

8. Chest

  • Gynaecomastia - Liver damage may result in excessive oestrogen causing breast development in males.
  • Spider naevi - A red spot with radiating small vessels that look like spiders' legs. They blanch when pressed. Most frequently due to alcohol or pregnancy.
Gynecomastia.jpg
Gynaecomastia
Spider naevi.jpg
Spider Naevi

9. Abdomen

  • Make sure the patient is lying flat with arms by their side.

a. Inspection

  • Scars - Scars from previous surgery may be evident.
  • Abdominal Distension - Abdominal distension may be a result of Fluid (Ascites), Flatus (Gas), Foetus (Pregnancy), Faecal matter, Fat (Obesity) or a Tumour.
  • Caput Medusae - Dilated veins around the umbilicus due to portal hypertension.
  • Striae - appears in Cushing's Syndrome
  • Bruising - Large bruising may be a result of liver damage impairing clotting factor production. Obstructive jaundice limits Vitamin K absorption which is also required for coagulation
  • Local masses
  • Visible peristalsis - is usually due to small bowel obstruction.
Abdomen.jpg
Surgical Incisions (scars)
Abdominal Distention.jpg
Abdominal Distention

b. Percussion

  • Percussion over the abdomen may be enough to induce a pain response and further palpation may not be possible if the pain is severe.

c. Palpation

  • Tenderness - Must be done while the patient is relaxed. First softly, then deeper. Over the 9 regions of the abdomen. Guarding refers to abdominal muscle contraction in response to palpation. It a reflex mechanism, to reduce pain. (see Abodominal Pain)
  • Liver - Palpate the liver while the patient breathes in deeply. The liver can also be percussed from above and below to measure it size.
  • Gallbladder - Murphy's sign should be sought if gallstones are suspected. Place your hand below the right costal margin and apply pressure. Ask the patient to take a deep breath, as they do so the inflamed gallbladder will push against the examiner's hand and cause significant pain. The gallbladder is not usually palpable. Courvoisier's law states that a palpable gallbladder with painless jaundice is most likely to be pancreatic cancer.
  • Pancreas - If there are pseudocysts following acute pancreatitis then the pancreas may be palpable near the umbilicus.
  • Aorta - If there is an Abdominal Aortic Aneurysm, then the aorta may be felt as an expansile pulsatile mass, usually in the epigastrium.
  • Spleen - Attempt to palpate the spleen starting from the right lower quadrant and moving towards the left upper quadrant. Palpate when the patient is inspiring. Repeat with the patient rolled over on their right side at 45º. If the spleen is palpable then it is enlarged. Percuss over the lowermost intercostal space in the left axillary line
  • Kidney - The kidneys are balloted by placing on hand on the patient's abdomen and tapping the patient's kidney with the other hand from underneath. The kidneys are not normally palpable.
  • Hernias - Incisional hernias and other hernias may be present.

d. Percussion (second time)

  • Shifting Dullness - tap the abdomen while the patient is lying flat. Assess where there is dullness (peripherally) and resonance (centrally). Now get the patient to lie on their side. If the dullness is in a different place it suggests free fluid which is most commonly ascites.

e. Auscultation

  • Bowel sounds - Place the diaphragm above the umbilicus Bowel sounds are poorly localised so only need to be heard in one place. They are either present, absent, or 'high-pitched'/ 'tinkling' which occurs during bowel obstruction.
  • Bruits - Listen above the renal arteries if Renal Artery Stenosis is suspected. Listen for a liver bruit of Hepatocellular Carcinoma.

10. Groin

11. Legs

Piting_Oedema wiki.jpg
Pitting Oedema

12. Digital Rectal Examination

Request. See Men's Health Examination.

13. Conclude

Thank the patient and offer assistance

Citation

Talley and O'Connor - Clinical Examination 7th edition pp182-218. Summary p228

Jaundice image: "Jaundice08" by James Heilman, MD - Own work. Licensed under CC BY 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Jaundice08.jpg#/media/File:Jaundice08.jpg
Clubbing image: "Acopaquia" by Desherinka - Own work. Licensed under GFDL via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Acopaquia.jpg#/media/File:Acopaquia.jpg
Xanthoma photo: By Anita A Kumar , Ghanshyam Palamaner Subash Shantha , Yadav Srinivasan , N Senthil , K Rajkumar , Neeta Paunikar and MK Sudhakar [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons
Leukonychia photo: "Leukonychia" by Keitei - Own work. Licensed under CC BY 2.5 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Leukonychia.jpg#/media/File:Leukonychia.jpg
Palmar erythema photo: https://thebileflow.wordpress.com/2012/03/22/pathology-palmar-erythema/
Dupuytren's contracture image: Dupuytren's image: "Morbus dupuytren fcm" by Frank C. Müller. Licensed under CC BY-SA 4.0 via Wikimedia Commons -http://commons.wikimedia.org/wiki/File:Morbus_dupuytren_fcm.jpg#/media/File:Morbus_dupuytren_fcm.jpg
Spider naevi image: "Spider nevus" by Herbert L. Fred, MD and Hendrik A. van Dijk - http://cnx.org/content/m14900/latest/. Licensed under CC BY 2.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Spider_nevus.jpg#/media/File:Spider_nevus.jpg
Petechiae image: "Positive-tourniquet-test" by Centre for disease control and prevention - http://ci.vbi.vt.edu/pathinfo/pathogens/Dengue1.html. Licensed under Public Domain via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Positive-tourniquet-test.gif#/media/File:Positive-tourniquet-test.gif
Deltoid Atrophy image: http://www.scielo.br/img/revistas/anp/v65n2b/32f1.jpg. Licensed under CC BY 4.0
Conjunctival Pallor image: http://image.frompo.com/4f21b9b2c559bfd71fc1c2f6c49d4c08
Kayser-Fleischer Ring image: "Kayser-Fleischer ring" by Herbert L. Fred, MD, Hendrik A. van Dijk - http://cnx.org/content/m15007/latest/. Licensed under CC BY 3.0 via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Kayser-Fleischer_ring.jpg#/media/File:Kayser-Fleischer_ring.jpg
Xanthoslemata image: http://www.huidziekten.nl/zakboek/dermatosen/xtxt/Xanthomen.htm
Angular Stomatitis image: "Angular Cheilitis" by James Heilman, MD - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Angular_Cheilitis.JPG#/media/File:Angular_Cheilitis.JPG
Leukoplakia image: "Leukoplakia02-04-06" by Photo uploaded by: dozenist. - Photo taken by Michael Gaither, and he has agreed to release this picture with the following license.. Licensed under CC BY-SA 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Leukoplakia02-04-06.jpg#/media/File:Leukoplakia02-04-06.jpg
Mouth Ulcer image: "Aphthe Unterlippe". Licensed under CC BY-SA 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Aphthe_Unterlippe.jpg#/media/File:Aphthe_Unterlippe.jpg
Glossitis image: "Scharlach". Licensed under CC BY-SA 2.5 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Scharlach.JPG#/media/File:Scharlach.JPG
Abdominal Distention: "Hepaticfailure" by James Heilman, MD - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Hepaticfailure.jpg#/media/File:Hepaticfailure.jpg
Pitting Oedema image: "Combinpedal" by James Heilman, MD - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Combinpedal.jpg#/media/File:Combinpedal.jpg
Abdominal Surgical Incisions Image: By Alex Miles modified form "By אנדר-ויק • שיחה.אנדר-ויק at he.wikipedia [Public domain], from Wikimedia Commons"
Scleral Jaundice image: "Jaundice08" by James Heilman, MD - Own work. Licenced under CC BY 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Jaundice08.jpg#/media/File:Jaundice08.jpg
Koilonychia image: from https://yourfingernails.wordpress.com/tag/skin/