Abdominal examination

GENERAL INSPECTION:

1. comfortable
2. mental state (encephalopathy)
3. cachexia
4. pigmentation (yellow/ haemachomatosi- bronze)
5. scratch (pruritis)

HANDS:

1. Warm / well perfused
2. Palmar erythema –
   • chronic liver disease
   • thyrotoxicosis / RA
3. Nails
   • Clubbing
     • Liver cirrhosis
     • Lung disease
     • CHF
   • Leuconychia (white nails)
     • Chronic liver disease
     • Hypoalbuminemia
   • Koilonychia (spoon nails)
     • Fe def
4. Dupuytrens contr – alcoholism / trauma / DM
5. Hepatic flap (eyes closed, dorsiflex 15 sec)
   • Sign of hepatic encephalopathy
   • Abnormal NH4 metabolism

FACE:

1. eyes
2. jaundice
3. conjunctiva pallor
4. Mouth
5. Pigmentation (peutz jeghers)
6. Hydration
7. Ulcers - IBD/coeliac
8. angular stomatitis - VB6/B12/folate/Fe def

NECK: 1.     Virchows Node (Trossiers sign)

CHEST:

1. Spider nevi
   • telangectiasia, chronic liver disease because increase oestrogen which dilates central arteriole + capillaries
2. Gynecomastia
   • liver disease, testicular atrophy. Increase oestrogen
   • diuretics / marijuana

OTHERS:

1. Genital exam
2. DRE
3. Rigid sigmoidoscopy
4. Leg / ankle oedema
5. Erythema nodosum (pretibial)
6. Pyoderma gangrenosum

ABDOMEN: INSPECTION:

1. Scars (hernia ?- ‘lift head off pillow..’)
2. swellings / masses / distension
   • fluid / flatus / tumour / faeces / fat / fetus
3. moving with respiration
4. pulsations
5. prominent veins
   • caput medusae
   • spider nevi

PALPATION:

1. LIGHT for PAIN / TENDERNESS
2. DEEP for masses
3. ORGANS:
   • Liver
   • Spleen (only palp when 2x size)
   • Kidneys x 2
   • Aorta (above umbo)
   • Bladder (suprapubic)
4. Umbilicus
   • Hernia / nodule
5. Hernias
   • Incisional
   • Groin
     • Inguinal
     • Femoral
   • Testicles PERCUSSION:
6. ascites - shifting dullness
7. Percussion splash
8. Liver AUSCULTATION:
9. Bowel sounds
10. Bruits (renal / AAA)
11. +/- succession splash

Ascites causes: • Liver disease • Cirrhosis • PHT • Budd chiari • CHF • cancer

DDx HEPATOMEGALY

1. Cancer
   • HCC
   • Mets
2. Fatty liver
   • Alcoholic
   • DM
   • Obesity
   • Toxins
3. Biliary obstruction
4. Infectious
   • Hydatid
   • Amebic
   • Bacterial
   • HIV
5. Hereditary
   • Haemochromatosis
   • Hepatitis
6. RHF

DDx SPLENOMEGALY:

1. Vascular
   • PHT
   • Splenic vn thrombosis
2. Infectious
   • Viral hepatits
   • Infectious mononucleosis
   • CMV
   • Toxoplasma
   • Hydatid
3. Infiltrative
   • Amyloid
   • Sarcoid
4. Connective tissue
   • SLE
5. Haematological
   • Lymphoma
   • Leukaemia
   • Myloproliferative disorders
6. Lysosomal storage disease
   • Gauchers disease
7. Cancer
   • Benign
   • Malignant - hemangiosarcoma
   • Mets
8. Trauma – haematoma / cyst

GALLBLADDER ENLARGEMENT With JAUNDICE:

1. Ca HOP
2. Ca Ampulla of Vater
3. CBD stone
4. Mucocele of GB from obsctn of flow with stone at Hartmans and in CBD No Jaundice:
5. Empyema GB
6. Ca GB
7. Cholecystits