ripped-body-man bikini-abs header-med-print ABDOMINAL EXAMINATION Afonso Sequeira 3rd year – General Medicine Clinical Sessions 2011 50276_82989623131_8357482_n GASTROINTESTINAL EXAMINATION ¢General examination lGeneral inspection lHands and arms lFace, eyes and mouth lNeck ¢Abdominal examination lInspection lPalpation lPercussion lAuscultation l ¢Nutritional state (wasting) ¢Pallor ¢Jaundice (liver disease) ¢Pigmentation (hemochromatosis) ¢Mental state (encephalopathy) GENERAL INSPECTION https://online.epocrates.com/data_dx/reg/346/img/346-1-hlight.jpg hiv www Nutritional state – record weight, height, waist circumference May indicate haemochromatosis iron overload indicates accumulation of iron in the body HANDS ¢Nails lClubbing lKoilonychia lLeuconychia ¢Palmar erythema ¢Dupuytren’s contractures ¢Hepatic flap www lmedicinenet health-writings Koilonychia (spoon shaped) iron-deficiency anemia Leuconychia Are a sign of hypoalbuminaemia due to liver d., malabsorption, protein malnutrition or nephrotic syndrome. Dupuytren’s contracture is a painless thickening and contracture of tissue beneath the skin on the palm of the hand and fingers. Presence of thickened scar tissue (fibrosis) and contracture Hepatic flap Asterixis describes a motor disturbance characterised by intermittent lapses of an assumed posture. It is commonly associated with liver failure where it produces the flapping tremor of hepatic encephalopathy characterised by jerky, irregular flexion-extension movements at the wrist and metacarpophalangeal joints, often accompanied by lateral movements of the fingers. HANDS en http://dermatology.cdlib.org/132/letters/erythema/1.jpg Palmar erythema Dupuytren’s contractures Dupuytren’s contracture is a painless thickening and contracture of tissue beneath the skin on the palm of the hand and fingers. Presence of thickened scar tissue (fibrosis) and contracture ARMS ¢Spider naevi (telangiectatic lesions) ¢Bruising ¢Wasting ¢Scratch marks (chronic cholestasis) http://upload.wikimedia.org/wikipedia/commons/thumb/4/42/Spider_nevus.jpg/230px-Spider_nevus.jpg community ¢Conjuctival pallor (anaemia) ¢Sclera: jaundice, iritis ¢Cornea: Kaiser Fleischer’s rings (Wilson’s disease) ¢Xanthelasma (primary biliary cirrhosis) ¢Parotid enlargement (alcohol) FACE, EYES … 36f4 imgJaundiceBig Kayser-Fleischer_ring Uveitis, Iritis Uveitis is swelling and irritation of the uvea, the middle layer of the eye. The uvea provides most of the blood supply to the retina. Kayser-Fleischer rings are dark rings that appear to encircle the iris of the eye. They are due to copper deposition as a result of particular liver diseases. 1471-2407-4-7-2-l xanthelasma Parotid enlargement Xanthelasma Xanthoma is a skin condition in which fat builds up under the surface of the skin. … AND MOUTH ¢Breath (fetor hepaticus) ¢Lips lAngular stomatitis lCheilitis lUlceration lPeutz-Jeghers syndrome ¢Gums lGingivitis, bleeding lCandida albicans lPigmentation ¢Tongue lAtrophic glossitis lLeicoplakia lFurring dodotay AngularCheilitis Monilia is a yeast-like fungus (Candida albicans), which by nature is a saprophyte Atrophic glossitis - B12 and folate deficiency Leukoplakia is a clinical term used to describe patches of keratosis. It is visible as adherent white patches on the mucous membranes of the oral cavity, including the tongue, but also other areas of the gastro-intestinal tract, urinary tract and the genitals. candidiasis-fx4 AtrophicGlossitis Atrophic glossitis Thrush NECK AND CHEST ¢Cervical lymphadenopathy ¢Left supraclavicular fossa (Virchov’s node) ¢Gynaecomastia ¢Loss of hair pdevitt139 prostom23 Troisier's Sign Enlargement of Virchov’s node More widespread lymphadenopathy with hepato-splenomegaly suggests lymphoma. Due to reduced oestrogen metabolism by the liver. In men may be a feminizing effect (gynaecomastia, loss of hair and testicular atrophy) ABDOMINAL EXAMINATION POSITIONING ¢Abdomen can be divided in four quadrants ¢Patient should be lying on supine position 19578 exposure%5B1%5D In order to accurately localize the findings on physical examination, one usually divides the abdomen into four quadrants: Upper right and left Lower right and left The dividing lines are: Vertically, a connecting line between the xiphoid process and the pubic symphysis; Horizontally, a line across the umbilicus. Examine the patient in good light and warm surroundings. Position the patient comfortably supine with the head resting on one pillow in order to relax the muscles of the abdominal wall. ABDOMINAL EXAMINATION INSPECTION ¢Shape and movements ¢Scars ¢Distension lLocalised: mass, organomegaly lGeneralized: 5 F’s ¢Prominent veins (caput medusae) ¢Striae ¢Bruises ¢Pigmentation ¢Visible peristalsis scars end-stage-liver-1 Shape and movements with respiration – flat or slightly scaphoid (shaped like a boat) Scars from previous surgical procedures Distension Localised: malignancy, hepatopathy, splenomegaly Generalized: Fat (obesity), fluid (ascites), flatus (obstruction), faeces (constipation), fetus (pregnancy) Prominent veins (caput medusae) in portal hypertension blood flows trough portocaval anastomoses. Image: end stage liver disease Striae Visible peristalsis ¢Tête de Méduse, by Peter Paul Rubens (1618) http://upload.wikimedia.org/wikipedia/commons/6/6b/Rubens_Medusa.jpeg ¢Campbell de ¢Morgan spots cherry_hemang1 http://diseasedietcentral.com/wp-content/uploads/2011/04/Paracentesis-for-Ascites.jpg Ascitic abdomen Pigmentation: Cherry angiomas "Campbell De Morgan spots," cherry red papules on the skin containing an abnormal proliferation of blood vessels. They are the most common kind of angioma. Ascites – bulging flanks ABDOMINAL EXAMINATION PALPATION 1.Ensure that your hands are warm 2.Stand on the patient’s right side 3.Help to position the patient 4.Ask whether the patient feels any pain before you start 5.Begin with superficial examination 6.Move in a systematic manner through the abdominal quadrants 7.Repeat palpation deeply. light deep Leave the painful area for last. Move in a systematic manner through the nine regions of the abdomen in the direction of the painful area. Make sure you use the pads of your fingers and not the finger tips as this might hurt the patient. ABDOMINAL EXAMINATION PALPATION ¢Tenderness: discomfort and resistance to palpation ¢Involuntary guarding: reflex contraction of the abdominal muscles ¢Rebound tenderness: patient feels pain when the hand is released ¢Tenderness + rigidity: perforated viscus ¢Palpable mass (enlarged organ, faeces, tumour) ¢Aortic pulsation ABNORMAL FINDINGS ¢Pain in RUQ ¢Inflammation of gallbladder (cholecystitis) ¢Courvoisier's law 5b-AcuteChole- ABDOMINAL EXAMINATION MURPHY’S SIGN Abdo3 Murphy's sign sign of gallbladder disease consisting of pain on taking a deep breath when the examiner's fingers are on the approximate location of the gallbladder. Pain on inspiration during gentle palpation below the right subcostal arch. As the patient breathes in, the liver moves down exposing the gallbladder to pressure from the examiners hand. Murpy’s sign may also be present with hepatitis. The gallbladder (GB) is filled with echogenic sludge (Sl) and a gallstone (red arrow) is impacted in the gallbladder neck. The gallbladder wall (red arrowheads) is markedly thickened indicative of wall edema and there are pericholecystic fluid (blue arrows) pockets surrounding the gallbladder. Courvoisier's law states that in the presence of an enlarged gall bladder which is nontender and accompanied with jaundice, the cause is unlikely to be gallstones. ¢a.k.a. rebound tenderness ¢Pain upon removal of pressure rather than application of pressure to the abdomen ¢Peritonitis and/ or appendicitis ¢ ABDOMINAL EXAMINATION BLUMBERG’S SIGN a ¢1/3 ASIS to umbilicus ¢Location of AV in retrocecal position ¢Deep tenderness (= acute appendicitis) ¢ ABDOMINAL EXAMINATION MCBURNEY’S POINT mcburneys_point1 Normal anatomy From ASIS (anterior superior iliac spine) to the umbilicus. Determines: - location of appendix (varies) - deep tenderness @ point = acute appendicitis ¢ ¢ ABDOMINAL EXAMINATION FLUID THRILL abdomen_fluidwave ¢Place the palm of your left hand against the left side of the abdomen ¢Flick a finger against the right side of the abdomen ¢Ask the patient to put the edge of a hand on the midline of the abdomen ¢If a ripple is felt upon flicking we call it a fluid thrill = ascites ¢ IF IT IS NOT CLEAR ABDOMINAL EXAMINATION PALPATION OF THE LIVER 1.Start palpating in the right iliac fossa 2.Ask the patient to take a deep breath in 3.Move your hand progressively further up the abdomen 4.Try to feel the liver edge http://meded.ucsd.edu/clinicalmed/abdomen_hepatomegaly.jpg ANd9GcRIjZnsDgAe6STWao2-TFoCDyZoy58YLQAfQp5LVuhNOrC4MaZZqg&t=1 Try to feel the liver edge and work out if it is enlarged or displaced downwards. ABDOMINAL EXAMINATION PALPATION OF THE SPLEEN 1.Roll the patient towards you 2.Palpate with your left hand while using your left hand to press forward on the patient’s lower ribs from behind 3.Feel along the costal margin abdomen_splenomegaly ch80f8 Try to feel the liver edge and work out if it is enlarged or displaced downwards. ABDOMINAL EXAMINATION PERCUSSION ¢Dull sounds: solid or fluid-filled structures ¢Resonant sounds: structures containing air or gas percuss liverPercussion ABDOMINAL EXAMINATION AUSCULTATION ¢Place the diaphragm of the stethoscope to the right of the umbilicus ¢Bowel sounds (borborygmi) are caused by peristaltic movements ¢Occur every 5-10 sec. ¢Absence of b.s.: paralytic ileus or peritonitis ¢Bruits over aorta and renal a. could be a sign of an aneurysm and stenosis auscult bruits VIDEO movie%20theatre1 http://www.ccunitedway.com/images/video%20button.png http://www.ccunitedway.com/images/video%20button.png ABDOMINAL EXAMINATION ¢ l_675dd0eeafd54f39807ba4fcf1e14b71 bestof5 header-med-print THANK YOU FOR YOR ATTENTION. Afonso Sequeira 3rd year – General Medicine Clinical Sessions 2011 50276_82989623131_8357482_n