THE ABDOMINAL EXAMINATION

1. Rashad Jurangpathy (4th year) THE ABDOMINAL EXAMINATION

2. Mini- Mock OSCE � common mistakes! Wash hands! JVP at 45 degrees Ask pt. to pull their own eyelid? No need to check cervical lymph nodes and windpipe Compare Virchow�s node with Rt supraclavicular node Clearly show to examiner that you are closely inspecting chest and abdomen Always examine at patient�s level � i.e. get on 1 knee! - & always look at patient�s face Palpating kidneys � ask patient to roll over and put hand underneath � as they roll, can inspect back for scars Always check for hernias � either ask pt. to cough or sit up Palpation of liver � press when pt. inspires Always ask pt. to inspire & expire when attempting to palpate liver & spleen Use radial border of hand to palpate Check for ankle oedema Abdominal aorta � pulsatility & then expansility BELL for bruits; DIAPHRAGM for bowel sounds

3. BASICS!! INTRODUCTION & CONSENT INSPECTION PALPATION PERCUSSION AUSCULTATION CLOSE

4. Introduction Introduce yourself & check patient�s identity Explain � what�s involved / how long Consent Exposure Wash hands Position WIPE �Good morning/afternoon Mr/Mrs, my name is Rashad Jurangpathy and I am a 3rd year medical student. Is it ok if I quickly examine your tummy? Could I firstly confirm your name and date of birth please? Right, so this examination will just involve me inspecting your tummy, having a quick feel and listen to it, as well as looking at your hands and your face. It will only take about 10 minutes of your time. Is that ok? For this examination, I�d like you to undress from waist upwards � you can do so behind the curtains whilst I go and wash my hands. Tell me when you�re ready. (Tell examiner, ideally I�d like the patient exposed from nipples to knee, but will not ask in this case, to preserve the dignity of the patient)�

5. BASICS!! INTRODUCTION & CONSENT INSPECTION PALPATION PERCUSSION AUSCULTATION CLOSE

6. End of bed examination / �outside-in� Around the bed

7. Hands

8. Hands Warmth & perfusion Clubbing Leuconychia Koilonychia Palm Palmar erythema Dupuytren�s contracture � �thickening + shortening of palmar fascia, resulting in flexion deformities of 4 and 5 Pulse Asterixis (30 seconds) BP

9. Causes of clubbing GI Causes (4 C�s): IBD (esp. Crohn�s) Cirrhosis GI lymphoma Malabsorption disease, e.g. coeliac

10. Signs of chronic liver disease COMPENSATED SYMPTOMS Parotid enlargement Spider naevi Gynaecomastia Clubbing, dupuytren�s contracture, xanthomas Scratch marks Testicular atrophy Purpura GENERAL SYMPTOMS Jaundice Loss of body hair DECOMPENSATED SYMPTOMS Encephalopathy, asterixis, fetor hepaticus, drowsy Ascites Capud medusae Oedema

11. Causes of palmar erythema Hyperdynamic states: Pregnancy Polycythaemia Cirrhosis Thyrotoxicosis

12. Face Eyes Jaundice Conjunctival pallor Kayser-fleischer rings Face Malar flush Mouth STICK TONGUE OUT: Hydration status / Glossitis (smooth, red, sore tongue) � iron, folate or b12 def. TONGUE TO ROOF OF MOUTH: jaundice / central cyanosis SHOW TEETH: dental caries / irregular dentition GUMS: gingivitis / scurvy (soft & haemorrhagic) Ulcers Angular stomatitis (cheilitis) � iron def. Abnormal pigmentation: Peutz-Jeghers Telangiectasia Hallitosis / Fetor

13. Face

14. Neck, Chest & Abdomen Palpate for Virchow�s node � compare with other side Inspect chest for: Spider Naevi: >6 = abnormal; along course of SVC; can be blanched when pressed in middle and will then refill Gynaecomastia Loss of hair Inspect abdomen more closely now � make sure to check flanks closely: Distension � size/shape/symmetry � 5F�S: fluid (ascites), foetus, faeces, fat, flatus Stoma bags Obvious masses Pulsatile masses Scars Spider naevi Purpura Caput medusae Grey Turner�s & Cullen�s signs Scratch marks Striae Bruising Hernias � including umbilical, incisional & para-stomal

15. Neck, Chest & Abdomen

17. BASICS!! INTRODUCTION & CONSENT INSPECTION PALPATION PERCUSSION AUSCULTATION CLOSE

18. Palpation Always start off by asking: �Where is the pain?� Always start palpation away from site of pain Get to level of abdomen � KNEEL DOWN! Always look at patient�s face whilst palpating Start with LIGHT palpation (1 hand), and then DEEP palpation (2 hands) Palpate all the 9 segments LIGHT palpation: Check for tenderness (+ rebound tenderness) / guarding / rigidity VOLUNTARY GUARDING INVOLUNTARY GUARDING � involuntary contraction of muscles when pressing parietal peritoneum on inflamed area RIGIDITY � due to generalised peritonitis � muscles of ant. abdominal wall held rigid REBOUND TENDERNESS � sign of peritonitis � mention without doing or instead test for percussion tendernesss If tender on light palpation, ask pt. it ok to press deeper DEEP palpation: Feel for any masses: site, size, shape, mobility, consistency, pulsation, bruit

19. For any mass/lump/bump, try and assess the following: Site Size Shape Surface Surrounding Smoothness / Consistency Tethering Tenderness Temperature Transluminancy Fluctuant Mobility Colour Pulsation Reducibility Edge Regional lymph nodes Perhaps auscultate as well

20. Palpation for organomegaly Palpation of liver: RIF & upwards to RUQ; move up 2cm at a time Push in on inspiration to feel lower border Normal liver size � M: 10-12cm / F: 8-10cm To assess accurately for hepatomegaly, need to percuss for upper and lower borders (liver is dull, lung is resonant) Normal upper border: 5th ICS If can feel liver border, need to assess: Size, surface, edge, consistency (craggy � hepatocellular cancer), tender, pulsatile (tricuspid regurgitation) Is it smooth generalised enlargement? Knobbly generalised enlargement? Localised swellings? Palpation of spleen: RIF & upwards diagonally to LUQ Spleen situated against diaphragm, in area of rib IX-X - Can only feel spleen if enlarged Ways to differentiate it from enlarged kidney: Cannot get above it (ribs in the way) Moves on inspiration (towards RIF) Overlying percussion note is dull May have a palpable notch on medial side

21. Palpation for organomegaly Palpation of kidneys: Bimanual (balloting) � keep top hand steady on abdomen, and use bottom hand to push up Left higher than right Lt superior pole: rib XI Rt superior pole: rib XII Lower poles around level of disc between LIII and LIV Check for any difference in the kidneys; if palpable, check for size, surface, consistency

22. Palpation cont. Palpate for AAA: AAA = pulsatile & expansile If present, don�t press too hard

23. BASICS!! INTRODUCTION & CONSENT INSPECTION PALPATION PERCUSSION AUSCULTATION CLOSE

24. Percussion Percussion of liver and spleen � do after palpating each organ

25. BASICS!! INTRODUCTION & CONSENT INSPECTION PALPATION PERCUSSION AUSCULTATION CLOSE

26. Auscultation Listen for bowel sounds: Active, absent, tinkling Listen for 2 minutes at one area before concluding absence Listen at 3 areas � 10 seconds in each area Absent BS = paralytic ileus or peritonitis Tinkling BS = bowel obstruction (BS are also more frequent)

27. BASICS!! INTRODUCTION & CONSENT INSPECTION PALPATION PERCUSSION AUSCULTATION CLOSE

28. Conclusion Thank patient, ask if he has any questions, tell him he can redress now and then WASH HANDS Present the examination To complete my examination, I would: Check the external genitalia Perform a DRE Dipstick the urine Check the hernial orifices (if not done already)

29. EXAMPLE ABDOMINAL EXAMINATION

30. Rashad Jurangpathy (4th year) DIGITAL RECTAL EXAMINATION

31. Indications Perianal complaints Bleeding Pain on defaecation Haemorrhoids Lumps, e.g. skin tags Alimentary complaints Persistent diarrhoea/constipation Change in bowel habit IBD malaena Genitourinary complaints Prostate symptoms Gynae problems CONTRAINDICATION � acute anal fissure

32. Anatomy Anterior � membranous urethra / bladder and prostate / cervix and vagina Anterior = 12 o�clock

33. Introduction Introduce yourself � Hello, my name is Rashad Jurangpathy and I am 3rd year medical student. I�ve been asked by the doctor to examine your back passage Check patient identity � Can I firstly check your name and date or birth please? Explain what�s involved � So this examination would involve me gently putting my gelled, gloved index finger into your back passage and just having a feel for any abnormalities. It�ll feel slightly uncomfortable but I�ll try to minimise the pain.

34. Introduction cont. Consent � Is that ok with you? Chaperone � Would you like a chaperone for this examination? Exposure � If you could please expose yourself from the waist downwards including underwear whilst I go and wash my hands. You can do so behind the curtains. Tell me when you are ready Wash hands and glove up Check lighting! Position patient � Lt. lateral side / knees bent up to chest / bottom towards the edge of bed

35. Inspection Part the gluteal folds and inspect for following: Mucus Perianal abscesses External haemorrhoids Blood Erythema Discharge Discolouration Fistulae Fissures

36. Palpation Tell patient: �I�m now going to carry out the examination � you�ll feel slight pressure but I will try to minimise the discomfort for you� Lubricate index finger Tell patient to breathe in and out deeply Place finger on anus and gently pass finger in when sphincter relaxes � make sure to look at patient�s face and tell them to say if they�re in any pain As inserting finger, rotate it such that you feel the anterior side first Palpate whole circumference of anal canal; then palpate a bit deeper anteriorly to feel prostate

37. Palpation cont. Anal canal Pain/Tenderness/Thickening/Masses? Rectum Masses/ulcers? Prostate NORMAL: Smooth Symmetrical Median sulcus Rubbery Mobile mucosa over it BPH: Smooth Asymmetrical large Mobile mucosa over it

38. Palpation cont. & Conclusion Prostate Malignancy: Irregular Asymmetrical (often unilateral) Loss of median sulcus Hard / craggy Ask patient to clench their bottom to check for sphincter function Take finger out and inspect for blood (fresh or malaena?) & mucus Clean gel and give patient more tissues if they need Cover patient and thank them � �thank you for your time and sorry for the inconvenience� Wash hands

39. Further tests Proctoscopy PSA Abdo exam