Exam Summary


1. Introduction

  • Introduce yourself and the examination
  • Hand hygiene

2. Observations

  • Temperature
  • Heart Rate
  • Respiratory Rate
  • Blood Pressure
  • Fluids chart
  • Bowels chart
  • Request Urinalysis

3. General Inspection

  • Alertness
  • Jaundice - due to liver inflammation, damage or biliary obstruction.
  • Body Habitus - Cachexia or muscle wasting.
  • Distress or Pain
  • Depth of respiration
  • Mental State - It is important to assess mental state as hepatic encephalopathy due to chronic liver disease or fulminant hepatitis.
  • Environment - Oxygen, IV drip, drain tubes, nasogastric tube, fluid restriction, alert bracelet, etc
Jaundice.jpg
Jaundice
Hand Xanthomata.jpg
Xanthomas

4. Hands

a. Fingers

  • Clubbing - Clubbing may be present in cirrhosis, inflammatory bowel disease, coeliac disease and longstanding malnutrition.
  • Leukonychia - white nails due to hypoalbuminaemia, which may be caused by liver failure or proteinuria. Isolated leukonychia like the photo is not of concern.
  • Capillary refill - should be less than 2 seconds
clubbing.jpg
Clubbing
Leukonychia.jpg
Leukonychia

b. Palms + Dorsum

  • Temperature
  • 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)
  • Skin Turgor - increased turgor suggests dehydration
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.
  • 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.
  • Scratch marks - due to severe itch (pruritus) are often present in patients with obstructive or cholestatic jaundice
Spider naevi.jpg
Petechiae.gif
Petechiae

6. Face

Measure the patient's temperature.

a. Eyes

Jaundice - due to liver inflammation, damage or biliary obstruction.
Conjunctival Pallor - a sign of anaemia
Jaundice_eye.jpg
Scleral Jaundice
conjunctivapallor.jpg
Conjunctival Pallor

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 hygeine, ketoacidosis, alcohol, uraemia or smoking.
  • Dry Membranes - suggests dehydration

7. Neck

  • Jugular Venous Pressure - a low JVP may suggest dehydration
  • 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.
  • Lung bases - listen for reduced breathing depth which may indicate atelectasis and also for possible aspiration pneumonia after vomiting.
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 - appear 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 and Hernias
  • Drain tube contents - amount, colour
  • Inspect wounds - healing, separation, bleeding, etc.
  • Pulsation - possible abdominal aortic aneurysm
  • Ask the patient to cough. Is this painful?

Abdomen.jpg
Surgical Incisions (scars)
Abdominal Distention.jpg
Abdominal Distention with venous congestion

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

  • Start away from the site of pain
  • 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. (See Hepatomegaly, Hepatosplenomegaly)
  • 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 (See Splenomegaly). 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.
  • Abdominal aorta - palpate for an abdominal aortic aneurysm.

d. Auscultation

10. Groin - Hernia

a. Inspection

  • With the patient standing, squat to observe the inguinal region.
  • Ask the patient to cough to look for protrusion.
  • Check inguinal creases for rashes and swellings.

b. Palpation

  • Find the landmarks for the internal and external inguinal ring and again look for a cough impulse.
  • Repeat with the patient lying down.

11. Special Tests

a. Murphy's Sign

  • Firmly place a hand perpendicular to costal margin in Right Upper Quadrant
  • Ask the patient to breathe deeply
  • If there is cholecystitis, the patient will experience pain and catch their breath as the gallbladder descends and contacts the palpating hand. (See gallstones)

b. McBurney's Point

  • Palpate at the point 1/3 of the way between the ASIS and the umbilicus. This will be tender in Acute Appendicitis.

c. Rosving's Sign

  • Apply pressure on Left Lower Quadrant and look for Right Lower Quadrant. May be positive in Acute Appendicitis

d. Psoas Sign

e. Obturator Sign


f. Shifting Dullness

  • Tap the abdomen while the patient is lying flat. Assess where there is dullness (peripherally) and resonance (centrally).
  • Then 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.

12. Legs

  • 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
  • Oedema - may be a sign of hypoproteinaemeia due to liver failure. If there is unilateral swelling then a Deep Vein Thrombosis must be ruled out.
  • Neurological signs of alcoholism (eg coarse tremor) and thiamine deficiency (peripheral neuropathy and memory loss)
Piting_Oedema wiki.jpg
Pitting Oedema

13. Other Examinations

Request:

14. Conclude

Thank the patient and offer assistance

See Also

Gastrointestinal Examination

Reference

Talley and O'Connor - Clinical Examination 7th edition pp182-218 (Gastrointestinal Examination)
Principles of Clinical Practice - Clinical Examinations Guide 2015

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"
Radial Pulse image: "Radial pulse". Licensed under Public Domain via Wikimedia Commons -https://commons.wikimedia.org/wiki/File:Radial_pulse.jpg#/media/File:Radial_pulse.jpg
"Acopaquia" by Desherinka - Own work. Licensed under GFDL via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Acopaquia.jpg#/media/File:Acopaquia.jpgXanthoma 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 CommonsBy אנדר-ויק • שיחה.אנדר-ויק at he.wikipedia [Public domain], from Wikimedia Commons
  • Either passively or actively extend the right hip.
  • Positive if there is pain