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Abdo exam.pptx - Confidentiality: Protecting and Providing Information

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    Abdo exam.pptx - Confidentiality: Protecting and Providing Information Abdo exam.pptx - Confidentiality: Protecting and Providing Information Presentation Transcript

    • Rashad Jurangpathy (4th year)
      THE ABDOMINAL EXAMINATION
    • BASICS!!
      INTRODUCTION & CONSENT
      INSPECTION
      PALPATION
      PERCUSSION
      AUSCULTATION
      CLOSE
    • Introduction
      Introduce yourself
      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? This will 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)’
    • BASICS!!
      INTRODUCTION & CONSENT
      INSPECTION
      PALPATION
      PERCUSSION
      AUSCULTATION
      CLOSE
    • End of bed examination / ‘outside-in’
      Around the bed
      Patient itself
      • Medication / lines / PCA
      • Monitors
      • Fluids
      • Catheter bags
      • Comfortable?
      • Well?
      • Nutritional state / unfinished food
      • Quick inspection of abdomen
      • Distension
      • Stoma bags
      • Obvious masses
      • Pulsatile masses
      • Scars
      • Any obvious signs?
    • Hands
    • Hands
      Warmth & perfusion
      Clubbing
      Leuconychia
      Koilonychia
      Palm
      • Palmarerythema
      • Dupuytren’s contracture – ‘thickening + shortening of palmarfascia, resulting in flexion deformities of 4 and 5
      Pulse
      Asterixis (30 seconds)
      BP
    • Causes of clubbing
      GI Causes (4 C’s):
      IBD (esp. Crohn’s)
      Cirrhosis
      GI lymphoma
      Malabsorption disease, e.g. coeliac
      Resp Causes:
      Lung cancer
      Chronic lung suppurative disease:
      CF
      Empyema
      Bronchiectasis
      Fibrosingalveolitis
      Mesothelioma
      Cardiac Causes:
      Congenital cyanotic heart disease
      Endocarditis
      Atrialmyxoma
    • 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
      Capudmedusae
      Oedema
    • Causes of palmarerythema
      Hyperdynamic states:
      Pregnancy
      Polycythaemia
      Cirrhosis
      Thyrotoxicosis
    • 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
    • Face
    • Neck, Chest & Abdomen
      Palpate for Virchow’s node
      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
    • Neck, Chest & Abdomen
      Caput medusae
      Spider naevi
      Grey-turner’s sign
      Cullen’s sign
      A- Ileostomy– End ileostomy – UC sufferers who have a proctocolectomy
      B – Loop colostomy – Colon Ca palliation
      R hemicolectomy – Crohn’s (removal of affected ileum + proximal colon) – Crohn’s predominantly affects terminal ileum leading to stricturing + episodic SBO
      C – End colostomy – Hartmann’s procedure for diverticular disease – sigmoid region excised, proximal region brought to surface with rectum conserved
    • Rooftop + thoracotomy - oesophagectomy
      Rooftop incision (mercedesbenz scar without the top vertical line) – liver transplant / upper GI / pancreas
      Liver transplant
      Midline scars – laparotomy / AAA repair / bowel resection
      Open cholecystectomy
      L loin/lumbar incision – nephrectomy / renal transplant (hockey stick scar)
      Rarely used – R hemicolectomy
      Lanz scar (appendicectomy)
      Vertical groin incision – embolectomy in femoral artery
      McBurney’s scar (appendicectomy)
      Hysterectomy / cystectomy
    • BASICS!!
      INTRODUCTION & CONSENT
      INSPECTION
      PALPATION
      PERCUSSION
      AUSCULTATION
      CLOSE
    • Palpation
      Always start off by asking: ‘Where is the pain?’
      Always start palpation away from site of pain
      Get to level of abdomen – either kneel down or raise bed
      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
      If tender on light palpation, ask pt. it ok to press deeper
      Rebound tenderness indicates if parietal peritoneum is inflamed (peritonitis) – in exam, say that you would test for rebound tenderness
      DEEP palpation:
      Feel for any masses: site, size, shape, mobility, consistency, pulsation, bruit
    • For any mass/lump/bump, try and assess the following:
      Site
      Size
      Shape
      Colour
      Consistency
      Surface
      Temperature
      Tenderness
      Translucency
      Mobility
      Pulsation
      Fluctuation
      Reducibility
      Edge
      Regional lymph nodes
      Perhaps auscultate as well
    • 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? Knobblygeneralised 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
    • 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
    • Palpation cont.
      Palpate for AAA:
      AAA = pulsatile & expansile
      If present, don’t press too hard
      Check for ascites if distension visible
      Shifting dullness
      Fluid thrill
      Check hernial orifices
      - Ask them to cough
    • BASICS!!
      INTRODUCTION & CONSENT
      INSPECTION
      PALPATION
      PERCUSSION
      AUSCULTATION
      CLOSE
    • Percussion
      Percussion of liver and spleen – do after palpating each organ
    • BASICS!!
      INTRODUCTION & CONSENT
      INSPECTION
      PALPATION
      PERCUSSION
      AUSCULTATION
      CLOSE
    • Auscultation
      Listen for bowel sounds:
      Active, absent, tinkling
      Listen for 2 minutes at one area before concluding absence
      Listen at 3 areas
      Absent BS = paralytic ileus or peritonitis
      Tinkling BS = bowel obstruction (BS are also more frequent)
      Listen for bruits:
      • Aortic bruits (atheroma or aneurysm) – above umbilicus
      • Renal artery bruits (renal artery stenosis) - 2.5cm above and lateral to umbilicus
    • BASICS!!
      INTRODUCTION & CONSENT
      INSPECTION
      PALPATION
      PERCUSSION
      AUSCULTATION
      CLOSE
    • 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)
    • EXAMPLE ABDOMINAL EXAMINATION
    • Next week
      ‘ECG & Abdo X-rays’
      With
      IsmaQureshi (4th year) &
      AdeelIqbal (5th year)
      Wednesday 28th October, Drewe LT, 2pm
    • Final Reminders
      Remember to purchase MM membership for priority for MM OSCE
      All slides are available online