Abdomen
1. Greeting, hand hygiene
2. Speak to doc first, like exposure (nipple to mid-thigh), Claim to
start from periphery
3. THEN STAND AT 床尾 FIRST!!!
4. Then check env IV bottle, respiration, alertness(reduced in liver
disease), ECG, monitor, obvious abdominal bulging, dialysis
tube
5. Inspection: hand(Ask by saying I am going to have general
inspection of patient,)
a. Clubbing (each nailbed press nail fluctuation)
Palmar erythema (chronic liver disease, all reddening at periphery)
b. Tendon xanthomata by lipid deposit
c. Dupyltren contracture: harder tendon, tendon obvious near ring
finger: alcoholism
d. Leukonychia: white things on nail, hyperalbuminemia
e. Koilonychia
f. Hepatic flap (10~15s)
g. Scratch marks, needle puncture(arm) (risking IV mark is for
drug taking addiction hepatitis C)
6. I: head
Mouth cyanosis, pallor, jaundice, parotid glands enlargement for
alcoholism, xanthelasma, glossitis, oral ulcer, lymph node
7. I: trunk
The abdomen has spider Navi, check for gynecomastia
(spirlactone, digoxin use) telangiectasia (dilated vein), Loss of
axillary hair, caput medusa, Scar, tenckhoff catheter
Sit down to palpate
8. Palpation
a. Nine Quadrant palpation: LOOK AT PATIENT
Light palpation tenderness (look at patient eye to see pain)
Deep for palpable mass(Look at abdomen)
(Change in metatarsals movement only)
***Additional notes on 8a
If a mass is palpable, ask patient to take a deep breath to see
moving or not.
Ask patient to 下巴掂心口 at last. As it can show the
parastomal, paraumbilical and incisional hernia. It also
appears in 抖大氣 so ask patient to do it also.
Rmb liver one lv one lv move, move when expire end, and try to
touch the hepatomegaly, then percuss in similar method
Rmb to start from right iliac fossa, then measure liver size
Normal liver 6-12 cm
b. Same for spleen, but from right iliac fossa to left rib end(Can
palpate from LLQ after the above route to make sure
splenomegaly )
Spleen hook: palpate splenic hook by touching Ant, pos rib,
compress to feel tip of spleen (if abnormal)
Should roll patient to your side if cannot palpate.
c. Kidney do not need percuss (the tapping maneuver is called
ballot)
Ascites do Shifting dullness (roll patient test first, normally med
resonance and lat are dull, after roll lat are dull due to ms, if
problem will be air so resonance)
Do fluid thrills also if have time.
9. Auscultation:
Bowel sound (just random slide over)
Renal a , above umbilicus at lat side for renal bruit, also liver bruit.
Hear the mass (if present in liver spleen or kidney) also as it may
be bulging.
10. Ankle edema(rmb to ask patient to remove sock!)
11. End by saying: complete my examination by checking perrectal test, external genitalia.
RMB to remove to only at most 1 pillow!
Breathing will move spleen and liver but not kidney.
*If no specific finding, consider the following:
Epigastric mass (can be hindered by rectus abdominis divarication)
Ballotable kidney: polycystic, stone,
Incisional, paraumbilical, parastomal hernia and rectus abdominis
divarication, all 4 will show up when ask 下巴掂心口
Umbilical hernia can be from severe abdominal distension.
If tenderness hinders deep palpation, ask patient to flex hips.
DDX analysis: special notice
Describe the symmetry of abdomen if distended! (L/R,
upper/lower)
Pedal/pitting edema:
1. 4th metatarsal
2. Lateral/medial malleolus
3. Anteromedial side of calf(tibial bone )
4. Use 2 fingers, grip back of the thigh, from distal to upper thigh
5. If still has, sacral spine then keep going up.
Kidney
Transplant kidney: scar and mass at inguinal area, usually
RLQ region
Uremic syndrome: dehydration, pruritus, scratch mark, note
tenckhoff catheter.
Abdominal distension
1. Ascites color: straw color (normal) Chylous(milky with fat)
If X transparent infection, may be purulent.
- Distended stomach can cause umbilical hernia and diminish it.
- Dull percussion at RUQ: not colon mass
- Note ascites can be portal HTN(Liver problems or portal v.
fibrosis! DO NOT SAY LIVER CIRRHOSIS TOO FAST!)
Non-portal v. HTN(Peritonitis, etc.)
- Abdominal Tapping: Extract ascities for Tx
- If drain too fast, this cause HRS( People already intravascular
dry, this can cause AKI then may developed to HRS)
Prevention: albumin cover: controlled paraentesis.
Add 6-8 g albumin per litre of fluid removed
Criteria: If INR>1.3 Platelet<100, tapping is risky, make sure
patient is well-hydrated (once may drain 3L)
2. Flatus (gas, e.g. pneumoperitoneum, gas gangrene by
Clostridium perfringens.)
3. Faeces: IO
4. Fetus
5. Fat
Epigastric mass
CA pancreas, transverse colon, stomach, pancreatic cyst. rectus
abdominis divarication(rectus abdominus muscle are separated.)
Right Lower Quadrant mass
a. CA colon, ileum
b. Iliac chondrosarcoma/angioma
c. Rupture of inferior epigastric vein hematoma
d. Acute appendicitis with acute peritonitis, forming abscess
(severe)
Greater omentum can wrap around the appendix and form a
mass(can resolve by using antibiotics)
e. Right diverticulum causing diverticulitis(congenital, 3
layers(epithelium, mucosal, muscular))
f. TB small bowel with psoas abscess or lymphadenopathy
g. Crohn’s disease: if done surgery, wound X heal fistula
Left Lower Quadrant mass
a. CA colon (usually L side with circumferential growth narrowing
lumen with IO )
b. L diverticulum (acquired, only 1 layer(mucosa))
HBP
*Chronic HBV will shrink liver! Even acute HBV will a bit big
only.
- Infection:
TB, malaria, syphilis, causing swollen lymph node
- Malignancy:
When mentioning enlarged lymph node, if cancer, can mention
primary, secondary, and hematological classes as DDX
In Hepatomegaly, cholangiocarcinoma, metastasis, and
encephalopathy can be the cause!
In triphasic CT, HCC at Arterial phase is hyperdense, washed out
as hypodense in portal venous and non-contrast phase.
Chronic drinker can have hepatomegaly even cirrhosis shrink liver.
Gallstone: different presentation
a. General: colicky pain radiating to back, jaundice, (need to
differentiate from gastritis by OGD)
DDx: cholangitis (blockage of bile duct cause mucocele of
gallbladder, i.e. bile accumulation in dilated gallbladder)
b. Cholecystitis (Chronic cholecystitis causes shrinkage of gall
bladder wrapping the gall stone)
Untreated cholecystitis: Peritonitis, pancreatitis if blocking
sphincter of Oddi, cholecystoduodenal/cholecystocolic fistula
gallstone ileus
Presentation on KUB/X-ray: 90% gallstone cannot be seen, but
90% of renal stone can be seen.
***Difference from gallbladder polyp: Gallstone is not adhering to
gallbladder, move with patient moving. Polyp is a non-shadowing
hyperechoic nodule adhering to gallbladder, and most likely
asymptomatic. If polyp grow and >1cm, may be cholecystectomy.
Spleen
- Spleen only has lower border! (It is between ribs…)
- Splenomegaly cause:
Moderate splenomegaly: CML, CLL , PHT, lymphoma, hemolytic
anemia IE, amyloidosis, b12 deficiency, SLE,
Massive: CML, PMF
- Traube space: lateral to anterior axillary line, ~6th ribs. If
dullness=splenomegaly
Others
Lipoma: Movable in all direction. Ganglioma: only 1 direction
Chronic diarrhea
SBP(subacute bacterial peritonitis): diagnosed by 250 neutrophils
Description technique
1. Liver mass: non-ballotable, move with respiration! (exclude
renal cyst)
Chronic diarrhea: Hx need bowel habits, stool texture and any
SOB, esp nocturnal symptoms (normally won’t poop at night)
If hemorrhoid: Fresh blood and not mixed with stool. 唔會屙咩都
有血
Warning sign: tenesmus, weight loss, vomiting
DDx: CRC, IBD, IBS(this one will not have constitutional
symptoms), Infection, hyperthyroidism, pancreatic insufficiency,
celiac disease, carcinoid tumour, lactose intolerance(usually acute,
not chronic)
*Ferritin is low in Fe deficiency anaemia, but abnormally high in
inflammation even in bleeding.
IBD: check CRP, ESR, If other autoimmune, ANA
Steatorrhea: pancreatic insufficiency