Abdominal Exam Routine General Demeanour, wind, gynaecomastica Feet Pitting oedema Hands Temp, Pigmentation, Dupuytren's contracture

ure Face Colour Eyes Scelera, conjunctiva, corneal arcus, xanthelasma Nails Leuconychia, Koilonychia, Brown, Clubbing Mouth Angular Stomatitis Tongue Colour, sublingual veins Neck - JVP Chest spider naevi Abdomen Observe caput medusa, longitudinal veins (IVC obstruction) Abdomen Ausculation - bruit, borgarythmia Abdomen Palpate AAA, each quadrant gently, each quadrant deeper Balot Kidneys

History Pain, Nausea/Vomit, Bleeding, Weight change, Distension (fat, fluid, foetus, faecal, flatulence), Stool/Urine Observation General Demeanour Breath Skin Habitus Feet Pitting oedema Distress on exertions. Wind (diet?), Belching (excess swallowing hiatus hernia?) Smelly Liver Sweet Diabetes Pruritis (itchy skin) - Jaundice Oedema, Gynacomastia (man growing breasts due to liver not breaking down-oestrogen), Obesity/cachexia press 20 sec, again higher up. R heart fail, congested vena cava, liver, kidney disorder, DVT, hypoalbuminia (osmotic pressure), low protein diet Albumin is the main protein in blood plasma its job is to regulate colloidal osmaotic pressure. Produced by the liver. As in hands anxiety, hyperthyroidism Cold + blue peripheral cyanosis Warm + blue central cyanosis Red, erytheama Liver, hyperthyroidism, RA, nicotine stains Liver, alcohol, diabetes, smoking Not >5 on hands+trunk above nipples. Chronic liver disease, Oestrogen, pregnant Cambell de Morgan spots, dots, no legs harmless White nails Liver, chronic hepatitis Iron deficiency, possibly blood loss Kidney failure

Hands

Temp and colour Sweaty Temp Colour Dupuytren's contracture Spider naevi

Nails

Haemangeoma Leuconychia Koilonychia Brown

Clubbing

Face

Colour

Eyes

Sclera Conjunctiva Around orbit Ulcers Angular stomatitis Colour

Mouth Tongue

Chest Abdomen

Sub-lingual Gynacomastia Spider Naevi Scars Striae Bruised umbilicus Distension Varicose veins Caput medusa Engorged superficial veins

Fluctuation nail/bed angle, nail curvature, ST bulk GI Cirrhosis, Ulcerative colitis, Crohns disease Heart Subacute bact endocarditis, Cyanotic congenital heart disease Lung Bronchial carcinoma, Fibrosing alveolitis Idiopathic Yellow jaundice Silver/grey Iron Pallor Oxygenated Hb in skin Blue Cyanosis Malar flush rosy cheeks Yellow jaundice Corneal arcus Silvery white line (>50), in young hyperlipedemia Pale Anemia Blue cyanosis Bleeding capillaries NSAID, hypertension Xanthelasma yellow blisters, hyperlipedemia, poss liver dysfunction Virus, HIV, rheumatological conditions Crack at corners, dont heal well Anemia, malabsorbtion, iron/folic A, Vit B Big beefy smooth red sore Glossitis, iron/folic A, Vit B Pale Anemia Brown/dry Mouth breathers, dehydrated , smokers Blue central cyanosis Creamy curd like Candida Albicus (Corticosteroids med) Engorged sublingual veins Portal hypertension Oestrogen, liver dysfunction ( breakdown) Not >5 on hands+trunk above nipples. Chronic liver disease, Oestrogen, pregnant Surgery appendicectomy, C-section, Cholysystectomy (R subcostal), Liver (B subcostal-mercedes-Benz scar) Herniation umbilical, femoral, inguinal-in/direct pink normal dark Cushings syndrome Hemorrhage, pancreatitis look horizontally, stomach or pulsating aorta? Longitudinal. IVC obstruction Portal hypertension around umbilicus IVC obstruction portal hypertension Normal Bowel sounds every 5-10 sec Absent paralysis, peritonitis High pitch gas Audible sounds bowel obstruction, dysmotility Renal (2-3 cm above and lat to umbilicus) Stenosis, hypertension in young Femoral (between ASIS, pubic tubercle) inguinal lig, Stenosis, aortic/iliac/femoral aneurism Liver (Below R nipple, ribs 510) Carcinoma, alcohol hepatitis

Auscultation Borborygma

Bruit

Rub Palpation Supraclavicular lymph node (L drains abdomen) Each quadrant Liver Large palpable, soft Shotty Firm/rubbery/irregular General lumps, masses Rebound tenderness Downward displacement Reidel lobe Hepamegaly (enlarged) + smooth + irregular Atrophy (small) Splenomegaly Splenectomy (absent) Murphys point Murphys sign Cholecystitis Mc Burneys point Rovsings sign Iliopsoas sign Atrophy Enlarged Aorta Femoral Radio-femoral delay Percussion Liver Spleen Peritoneum Signs and Symptoms Pain Ascites Time Type

Liver if creak inflamed capsule Spleen (L rib 911 in midline) inflamed capsule Infection Remains of old infection Malignant disease Peritoneal irritation Hyperinflated lung (percuss to check) Lower lobe normal, especially in women Right heart failure, malignant, hepatitis Fatty liver. alcohol Cirrhosis, Tumour Cirrhosis, hepatitis Portal hypertension, hemolytic anemia, virus, glandular fever previous trauma, Hodgins disease R mid cost margin Press + inhale pain or catch breath Inflamed from stones, cancer in pancreatic head 2/3 from ASIS umbilicus. Pain Appendicitis (pain typically starts at umbilicu Press L iliac fossa pain R fossa = Acute appendicitis Active resist psoas pain, inflammation = Retroiliac or Perinephic abscess Most common. infection, trauma Hydronephritis (blocked), polysystic kidney Palpate between xiphisternum and umbilicus Aneurysm pulsating, expanding at lat border of rectus abdominis Between ASIS/pubic tubercle, below inguinal lig (get consent first!) If weaker femoral aortic aneurysm or coarctaction (narrow) Below R nipple, Ribs 5 10 From resonant dull L axillary line, Ribs 9 11 Fluid in peroteneal cavity ( albumin, osmotic pressure) pain on empty stomach or at night peptic ulcers pain after fatty diet, epigastric pain gallbladder Visceral pain Deep at midline, diffuse, referred pain, sympathetic nerves from T5-L2 Perotineal pain Localised pain Colicky pain From hollow structures (intestine) short (sec-min) intermittent pain. If colicky pain suddenly become chronic poss mesenteric infarct Epigastric area Foregut Umbilical midgut

Spleen (L axillary line, rib 9 11) Gallbladder Appendix Kidney (Upper poles: L rib 11, R rib 12. Lower poles: 3-4cm sup iliac crest) Pulses

Location

Nausea Vomiting

With nausea Without nausea

Flatulence Fluctuating distension ( day, night) Diarrhoea

With pain Without pain Acute Chronic Type Pale Pale + greasy Black tarry Grey/black Fresh blood Mixed with pus Watery with grain Prehepatic (haemolytic) Hepatocellular Obstructive

Stools

Jaundice

Supra pubic hind gut Medication, pregnancy, upper GI (+vomiting) Upper GI With blood Oesophagus or gut Green (bile) obstruct in deudenum past bile duct Poss intra cranial pressure lactase deficiency, intestinal malabsorbtion IBS, pregnancy ovarian pathology drugs (anti biotic), infection IBS, hyperthyroid, cancer inflammation Osmotic H20 absorption in colon, drugs, motility disorders Secretory mucosal inflammation, viral/bacterial, ulcerative colitis, Crohns disease Biliary obstruction (lack of pigment) Fat malabsorbtion Melaena, upper GI bleeding Oral iron or bismuth therapy Rectal/anal/large colon bleeding ulcerative colitis, dysentery Cholera (odorless rice water) Stool + urine normal colour Stool normal Urine dark Stool pale Urine dark + pruritus

Disorders IBS Liver disease Cirrhosis Primary biliary cirrhosis Anastomoses

Abdominal pain, change of bowel habits and stool consistency, chronic, no rectal bleeding or weight loss. Pt more sensitive to dairy, wheat, fat, caffeine. 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 Damage of liver structure, scars, nodules, poss from hypertension Auto immune. >50 women. Granular inflammation destroy intra lobular bile ducts, unexplained pruritis

3 types: Oesophagus, umbilicus, anus Portal hypertension round Carina, Caput medusa, haemorroids Hepatitis Inflammation. Symptoms: Arthralgia, jaundice, pyrexia, fatigue, diarrhea, pigmentation Hep A Faecal oral. Self-limiting. No TTT Hep B Blood, body fluid, sex. Chronic infection rare. Anti virus TTT Hep C Blood, body fluid 80% get chronic infection cirrhosis, liver fail Hep D Only in Hep B patient cirrhosis , live failure Hep E Oral contact with faces. No TTT. Self limiting What can cause Pitting Oedema? Obstructive heart failure R ight sidesd? Hypo albumin Congestive heart disease DVR ,Liver cancer or cyrosis