Abdominal Examination Summary

MEDICAL SUCCESS INSIDERS (MSI) 1

Forewords

First of all, thank you for purchasing this book and I am very glad that you have taken your first step to bring your examination techniques and interpretation skill to another advanced level. I can guarantee you that after reading this book, your understanding towards the clinical examination will be deeper and clearer. This book has divided the clinical examination into two main components, mainly the technique part and interpretation of the findings part. And I strongly believe that you need to master both the technique and interpretation skill in order to help you to come to the diagnosis. This book consists of multiple authenticated references and has been arranged into systematic and organized way to ease the study and revision. The book will be updated from time to time in order for you to get the latest updated information and the contents are subject to change. The online softcopy version will be provided too as long as you have bought this book. Last but not least, I hope that this book will be a good companion in your study and career and let us work together towards the goal and achievement. We hope all the best to you. Cheers.

-WE CARE, WE SHARE-

-Dr. Joseph Chia- Founder of Medical Success Insiders (MSI)

ABDOMINAL EXAMINATION

Abdominal Examination Summary:

1. Introduce yourself & wash hand

2. Lie the patient flat with one pillow

3. General Inspection • Age group • Sex • Position • Mental state • Any pain / distress • Build • Nutritional & hydration status • Surroundings à nasal prong / oxygen mask, etc. • Grow chart (paediatrics) • Check temperature

4. Upper Limbs Nails & Fingers: • Pallor / Koilonychia • Clubbing • Leuconychia • Peripheral cyanosis • Temperature

Palm: • Palmar erythema • Dupuytren's contracture • Palmar crease • Fine tremor • Coarse / flapping tremor

Arms: • Purpura / bruising • Spider nevi • Petechiae • Muscle wasting • Scratch marks

Axilla: • Lymphadenopathy • Acanthosis nigricans

5. Radial Pulse, Respiratory Rate, Blood Pressure

6. Face Examination Face: • Salivary glands • Telangiectasia

Eyes: • Scleral jaundice • Conjunctival pallor • Kayser-Fleischer rings • Iritis • Xanthelasma • Periorbital purpura

Tongue: • Coating of tongue • Lingua nigra (black tongue) • Geographical tongue • Leucoplakia • Glossitis • Enlargement of tongue (macroglossia) • Furred tongue • Wasted tongue

Teeth: • Decayed tooth

Gum: • Gingivitis • Gum hypertrophy

Tonsils: • Pigmented lesion in mouth

Mouth & Lips: • Angular stomatitis • Pigmented lesion in mouth & lips • Fetor hepaticus • Mouth ulcers • Candidiasis (moniliasis)

7. Neck Palpation • Virchow's node • Other lymph nodes

8. Chest Examination • Spider nevi • Gynaecomastia • Loss of axillary hair

9. Abdomen Inspection (C.U.S.P2.) • Contour • Umbilicus • Skin • Peristalsis • Pulsation

10. Abdomen Palpation Superficial: • Tenderness / guarding / rebound tenderness / rigidity • Mass / lumps / muscles

Deep: • Deeper mass / tenderness • Specific organs examination à liver, spleen, kidneys; gallbladder, stomach, pancreas, bladder, bowel, aorta, appendix, testes • Others à ascites, succussion splash, ventral hernia, abdominal wall mass

11. Abdomen Percussion • Liver span • Spleen • Ascites

12. Abdomen Auscultation • Bowel sound • Bruit • Friction rub • Venous hums

13. Hernia & Groin Examination • Lymphadenopathy • Hernia

14. Rectal Examination • Inspection • Palpation • Describe

15. Proctoscopy Examination • Inspection • Palpation • Describe

16. Other Examination • Testing stools for blood • Leg examination • CVS examination • Measurement of temperature • Examination of all lymph nodes groups

17. Wash the hands

4. Upper Limbs Examination

TECHNIQUES

Nails & Fingers: Ø Look for nail pallor / koilonychia Ø Check for clubbing Ø Check for leuconychia Ø Look for peripheral cyanosis Ø Feel the temperature

Palm: Ø Look for palmar erythema Ø Check for Dupuytren's contracture Ø Look for palmar crease Ø Look for fine tremor Ø Look for coarse / flapping tremor o Ask the patient to hold out / outstretch his arms with hands extended at wrists & fingers spread slightly and demonstrate to the patient o Look for jerky, flapping tremor (asterixis) for at least 15 seconds o Alternatively, ask patient to squeeze your index and middle fingers and maintain this for 30–60 seconds. Patients with flapping tremor cannot maintain their grip o Also can ask patient protrude tongue OR lift the leg & keep the foot dorsiflexed Ø Look for wasting of intrinsic muscle of hand

Arms: Ø Look for purpura / bruising Ø Look for spider nevi Ø Look for petechiae Ø Look for muscle wasting Ø Look for scratch marks

Axilla: Ø Check for lymphadenopathy Ø Look for acanthosis nigricans

FINDINGS

Findings Descriptions & Significances Pictures Nails & Fingers Pallor / • Suggests anemia koilonychia • Rarely, exposure to strong detergent

Clubbing • Seen in inflammatory bowel disease, coeliac disease / malabsorption syndrome (which cause long-standing nutritional depletion), liver cirrhosis • Up to 1/3 with cirrhosis may have finger clubbing • May be related to arteriovenous (AV) shunting in lungs, resulting in arterial oxygen desaturation • Cyanosis may be associated with severe long-standing chronic liver disease Leuconychia • When chronic liver disease / other (white nails) disease results in hypoalbuminaemia à nail beds opacify (abnormality is of the nail bed and not of the nail), often leaving only a rim of pink nail bed at the top of nail (Terry's nails) • May also occur in à protein calorie malnutrition (kwashiorkor), malabsorption due to protein-losing enteropathy (coeliac disease), or heavy and prolonged proteinuria (nephrotic syndrome) • Thumb & index nails are most often involved

• May due to compression of capillary flow by extracellular fluid • Muehrcke's lines (transverse white lines) à can occur in hypo- albuminemia states, including cirrhosis • Blue lunulae à may be seen in Wilson's disease © DR. JOSEPH @ WWW.MSIMASTERCLASS.COM ALL RIGHTS RESERVED SIGN UP IN WWW.FRIENDOCT.COM TO ASSESS TO SOFTCOPY MEDICAL SUCCESS INSIDERS (MSI) 15

Findings Descriptions & Significances Pictures Palms Palmar • Inspect palmar creases for pallor à creases suggesting anaemia which may result from GIT blood loss, malabsorption (folate, vitamin B12), haemolysis (hypersplenism) or chronic disease

Palmar • This is reddening of the palms of hands erythema affecting thenar & hypothenar ('liver eminences & pulps of fingers; with palms') centre of palm being spared • Often the soles of feet are also affected • Can be a feature of chronic liver disease • While the finding has been attributed to raised estrogen levels, it has not been shown to be related to plasma estradiol levels, so etiology remains uncertain • Associated with reduced hepatic breakdown of sex steroids • Can also occur with à pregnancy, OCP, thyrotoxicosis, rheumatoid arthritis, polycythaemia & rarely with chronic febrile diseases or chronic leukaemia • May also be a normal finding, especially in women

Findings Descriptions & Significances Pictures Dupuytren's • Visible and palpable thickening and contracture contraction of palmar fascia/ aponeurosis causing permanent flexion • Most often involves ring finger; later little finger is also affected • It is often bilateral and occasionally affects feet • Associated with alcoholism (not liver disease) • May be familial (autosomal dominant with variable penetrance) • Associated with conditions causing microvascular pathology à diabetes mellitus, smoking, hyperlipidaemia,

HIV infection, chronic liver disease • Also found in some heavy manual workers • Palmar fascia of these patients contains abnormally large amounts of xanthine • Can see vertical furrows in the region of 4th & 5th fingers due to thickening

Hepatic flap • Should ask patient to stretch out arms [Video available in the / asterixis in front, separate fingers and extend softcopy] the wrists for 15 seconds • Jerky, irregular flexion-extension movement at wrist and metacarpophalangeal joints, often accompanied by lateral movements of fingers • It is thought to be due to interference with inflow of joint position sense information to reticular formation in brainstem à results in rhythmical lapses of postural muscle tone • Arms, neck, tongue, jaws and eyelids can also be involved • Patient is asked to close the eyes forcefully / to protrude tongue • The flap is usually bilateral, tends to be absent at rest, and is brought on by sustained posture

Findings Descriptions & Significances Pictures Eyes Scleral • Think of hypercarotinemia as jaundice differential diagnosis • In myxedema, metabolism slows down due to underactive thyroid & conversion of carotene to vitamin A is reduced

Conjunctival • Blood loss can be obvious and pallor spectacular (esophageal varices / bleeding stomach ulcers) or insidious and occult (colonic polyps) • Chronic anemia à koilonychia, angular stomatitis, atrophic glossitis, esophageal web • Also can be due to severe bleeding hemorrhoid

Kayser- • Brownish green rings occurring at Fleischer rings periphery of cornea, affecting upper pole more than lower • Due to deposits of excess copper in Descemet's membrane of cornea • Slit-lamp examination is often necessary to show them • Found in Wilson's disease, other cholestatic liver diseases • Usually present by the time neurological signs have appeared

Iritis • May be seen in inflammatory bowel disease

Findings Descriptions & Significances Pictures Xanthelasma • Yellowish plaques / fatty deposit in subcutaneous tissues in periorbital region • May indicate protracted elevation of serum cholesterol / hyperlipidemia • In cholestasis, an abnormal lipoprotein (lipoprotein X) is found in plasma & is associated with elevation of serum cholesterol • Suggests prolonged cholestasis • Common in primary biliary cirrhosis

Periorbital • Following proctosigmoidoscopy purpura ('black eye syndrome') à characteristic sign of amyloidosis (perhaps related to factor X deficiency)

Tongue Coating of • Thickened epithelium with bacterial tongue debris & food particles • Especially in smokers • More marked on the posterior part of tongue à less mobility & papillae desquamate more slowly • Occurs frequently in respiratory tract infections

Lingua nigra • Due to elongation of papillae over (black tongue) the posterior part of tongue • Appears dark brown à due to accumulation of keratin • No known cause • Just aesthetic problems; symptomless • Bismuth compounds may also cause

Findings Descriptions & Significances Pictures Geographical • Describe slowly changing red rings tongue and lines that occur on surface of tongue • It is not painful • Tends to come and go • Can be a sign of riboflavin (vitamin B2) deficiency

Leucoplakia • White-coloured thickening of mucosa of tongue and mouth • Cannot be removed after few attempts • This condition is premalignant • Most of the causes begin with 'S' à sore teeth (poor dental hygiene),

smoking, spirits, sepsis or syphilis • May also occur on larynx, anus, vulva

Glossitis • Smooth appearance of tongue which may also be erythematous (beefy tongue) • Due to atrophy of papillae • In later stages there may be shallow ulceration • Result of nutritional deficiencies to which tongue is sensitive because of rapid turnover of mucosal cells • Due to deficiencies of iron, folate, vitamin B (especially vitamin B12) • Common in alcoholics & rare in carcinoid syndrome

Enlargement • May occur in congenital conditions of tongue (Down syndrome) / in endocrine (macroglossia) disease (acromegaly, hypothyroidism) • Also can be due to tumour infiltration (e.g. haemangioma or lymphangioma) / infiltration of tongue with amyloid material in amyloidosis

Findings Descriptions & Significances Pictures Furred tongue • After antibiotic therapy • Benign condition due to overgrowth of papillae of tongue together with infection due to Candida nigricans

Wasted • Neurological cause tongue • Also look for fasciculation & tongue movement

Teeth Teeth • Note whether they are real / false • False teeth will have to be removed for complete examination of mouth • Note whether there is gum hypertrophy / pigmentation • Loose-fitting false teeth à may be responsible for ulcers • Decayed teeth à may be responsible for fetor (bad breath) • Poor dentition & gingivitis à markers of self-neglect

Findings Descriptions & Significances Pictures Gum Gum • Causes: hypertrophy o Phenytoin o Pregnancy o Scurvy (vitamin C deficiency: the gums become spongy, red, bleed easily and are swollen and irregular) o Gingivitis, e.g. from smoking, calculus, plaque, Vincent's angina (fusobacterial membranous tonsillitis) o Leukaemia (usually monocytic)

Tonsils Pigmented • Look for enlargement, pus, lesion in inflammation mouth • Look for any deviation

Mouth & lips Angular • Painful cracks in corner stomatitis • May be due to candidal infection, chronic anemia, vitamin deficiencies

FINDINGS

Ø Inspection findings can be divided into: [C.U.S.P2.] o Contour (shape, symmetry, bulge, distension, masses, stoma, hernia) o Umbilicus o Skin (scars, striae, dilated veins, rashes / lesions) o Peristalsis o Pulsation

Findings Descriptions & Significances Pictures Contour Flat • Abdomen is normally flat or slightly scaphoid and symmetrical • At rest, respiration is principally diaphragmatic à abdominal wall moves out & liver, spleen and kidneys move downwards during inspiration Scaphoid • Malnourishment • Dehydration

Rounded • Obesity

Protruberant • Generalized distention with inverted umbilicus à obesity, recent gas • Generalized distention with everted umbilicus à ascites, tumor, umbilical hernia

Local bulging • Distension of lower half à ovarian tumor, pregnancy, distended bladder • Distension of upper half à carcinomatosis, pancreatic cyst, gastric dilatation • Side bulging

x = xyphoid u = umbilicus p = pubic

Findings Descriptions & Significances Pictures Abdominal • Decide whether it is generalized / distension localized? Fat or ascites? • Look tangentially across abdomen & from the foot of bed à look for any asymmetry associated with localised mass (enlarged liver / bladder) • Causes: 6 'F’s: o Fat (gross obesity) o Fluid (ascites) o Fetus o Flatus (gaseous distension due to bowel obstruction) o Faeces o 'Filthy' big tumour (e.g. ovarian tumour or hydatid cyst) or 'phantom' pregnancy

Visible mass • In particular large liver may be seen to move below right costal margin / large spleen below left costal margin

Hernia • Check for visible & palpable impulse

Findings Descriptions & Significances Pictures Lesions / • In older patients, seborrhoeic warts, Rashes ranging in colour from pink to brown or black & haemangiomas (Campbell de Morgan spots) à common and normal • Note any striae (stretch mark), bruising or scratch marks • May have vesicles of herpes zoster à may be responsible for severe abdominal pain that is of mysterious origin until the rash appears • Sister-Mary-Joseph nodule à metastatic tumour deposit in umbilicus (anatomical region where peritoneum is closest to skin) • Discoloration of umbilicus where faintly bluish hue is present in extensive haemoperitoneum and acute pancreatitis à Cullen's sign (umbilical 'black eye) • Skin discoloration may also rarely occur in flanks in acute pancreatitis à Grey- Turner's sign • Stretching of abdominal wall severe enough to cause rupture of skin elastic fibres produces pink linear marks with a wrinkled appearance à striae • When it is wide and purple-coloured à Cushing's syndrome may be the cause • Causes of striae: o Ascites o Pregnancy o Recent weight gain o Cushing’s syndrome • Striae also can be seen on the shoulders, upper arms, back, thigh, buttock

Findings Descriptions & Significances Pictures Visible veins • Dilated tortuous veins with blood flow (Continued) superiorly à collateral veins due to obstruction of inferior vena cava (due to tumour / thrombosis but sometimes because of tense ascites) • In this case abdominal veins enlarge to provide collateral blood flow from legs, avoiding the blocked inferior vena cava • To distinguish caput Medusae from inferior vena caval obstruction: determine direction of flow below umbilicus à it will be towards legs in former and towards head in latter Superior vena cava obstruction à • cause distended abdominal veins, which all flow inferiorly

Pulsations Pulsations • Expanding central pulsation in the [Video available in the epigastrium à suggests abdominal softcopy] aortic aneurysm • Abdominal aorta can often be seen to pulsate in normal thin people Peristalsis Visible • May occur occasionally in very thin peristalsis normal people • Usually suggests intestinal obstruction • Pyloric obstruction due to peptic ulceration / tumour à slow wave of movement passing across upper abdomen from left to right à • Obstruction of distal small bowel movements in a ladder pattern in centre of abdomen

Abdominal surgical scars (filled with answers)

Picture Source Created And Designed By: Dr. Joseph Chia

10. Abdomen Palpation

TECHNIQUES

Preparation: Ø Ensure that your hands are warm Ø If bed is low, kneel or squat beside it / take a chair to sit Ø Ask patient to show you where the pain is and to report any tenderness elicited during palpation Ø Ask patient if any particular area is tender and examine this area last Ø Ask patient to place arms by the sides to help relax abdominal wall Ø Encourage patient to breathe gently through mouth Ø If necessary, ask patient to bend knees to relax abdominal wall muscles

Superficial palpation: Ø Components to check for: o Masses / lumps / muscles o Tenderness / rebound tenderness / guarding / rigidity Ø Palpation in each region is performed with palmar surface of fingers acting together Ø For palpation of the edges of organs or masses, lateral surface of forefinger is the most sensitive part of hand Ø Palpation should begin with light pressure in each region Ø All movements of hand should occur at metacarpophalangeal joints & hand should be moulded to the shape of abdominal wall Ø Use your right hand, keeping it flat and in contact with abdominal wall Ø Observe patient’s face for any sign of discomfort throughout the examination Ø Begin with light superficial palpation away from any site of pain Ø Palpate each region in turn, and then repeat with deeper palpation Ø Test abdominal muscle tone by light, dipping movements with your fingers Ø It also serves to reassure and relax the patient Ø Note the presence of any abdominal tenderness / lumps, muscular resistance, and some superficial organs and masses in each region Ø Look for guarding, rebound tenderness, rigidity Ø Describe any mass à describe its site, size, surface, shape and consistency, and note whether it moves on respiration. Is the mass fixed or mobile? Ø Abdominal masses may be categorized in several ways: o Physiologic (pregnant uterus) o Inflammatory (diverticulitis of the colon) o Vascular (an aneurysm of the abdominal aorta) o Neoplastic (carcinoma of the colon) o Obstructive (a distended bladder or dilated loop of bowel) Ø Ask the patient to cough and determine where the cough produced pain Ø Abdominal pain on coughing / with light percussion à suggests peritoneal inflammation Ø Rebound tenderness à suggests peritoneal inflammation © DR. JOSEPH @ WWW.MSIMASTERCLASS.COM ALL RIGHTS RESERVED SIGN UP IN WWW.FRIENDOCT.COM TO ASSESS TO SOFTCOPY MEDICAL SUCCESS INSIDERS (MSI) 49

Deep palpation: Ø Components to check for: o Deeper masses / tenderness o Organs based à liver, spleen, kidneys; gallbladder, stomach, pancreas, bladder, bowel, aorta, appendix, testes o Other specific à ascites, succussion splash, ventral hernia, abdominal wall mass Ø Deep palpation of abdomen is performed next, though care should be taken to avoid tender areas until the end of the examination Ø Deep palpation is used to detect deeper masses and to define those already discovered. Any mass must be carefully characterized and described Ø To determine if a mass is superficial and in the abdominal wall rather than within abdominal cavity à ask patient to tense abdominal muscles by lifting his head Ø Abdominal wall mass will still be palpable, whereas intra-abdominal mass will not Ø Decide whether the mass is enlarged abdominal organ / separate from solid organs Ø Examine liver, gallbladder, spleen and kidneys in turn during deep inspiration. Keep your examining hand still and wait for the organ to descend. Do not start palpation too close to the costal margin, missing the edge of liver or spleen

Liver palpation: Ø Place your hand flat on the skin of right iliac fossa with hand aligned parallel to right costal margin Ø Point your fingers upwards and your index and middle fingers lateral to rectus muscle, so that your fingertips lie parallel to rectus sheath. Keep your hand stationary Ø It is the 2nd & 3rd fingers that seeking the liver Ø Some people prefer to use distal end / radial border of the index finger Ø Ask patient to breathe in deeply through mouth Ø Feel for the liver edge as it descends on inspiration Ø With each expiration the hand is advanced by 1 or 2 cm closer until you reach costal margin / detect liver edge Ø During inspiration, hand is kept still and lateral margin of forefinger waits expectantly for the liver edge to strike it Ø Trace the liver edge both laterally and medially Ø If you feel liver edge, describe: o Size o Surface à smooth or irregular o Edge à smooth or irregular o Consistency à soft or hard o Tenderness o Whether it is pulsatile Ø Additionally, place your left hand behind the patient, parallel to and supporting the right 11th and 12th ribs and adjacent soft tissues below Ø By pressing your left hand forward, the patient’s liver may be felt more easily by your other hand

Liver span: Ø To estimate liver span, percuss down along right mid-clavicular line until the liver dullness is encountered and measure from here to palpable liver edge Ø More details will be demonstrated in abdominal percussion

Hooking technique: Ø The “hooking technique” may be helpful, especially when the patient is obese Ø Stand to the right of the patient’s chest Ø Place both hands, side by side, on the right abdomen below the border of liver dullness Ø Press in with your fingers and up toward the costal margin Ø Ask the patient to take a deep breath Ø The liver edge shown below is palpable with the fingerpads of both hands

Gallbladder: Ø Gallbladder is occasionally palpable below right costal margin where this crosses lateral border of rectus muscles Ø If biliary obstruction or acute cholecystitis is suspected, examining hand should be oriented perpendicular to costal margin, feeling from medial to lateral Ø Murphy's sign should be sought if cholecystitis is suspected Ø Examining for enlarged gallbladder must always be mindful of Courvoisier's law Ø Kehr’s sign à occurrence of acute pain over the tip of shoulder due to presence of blood or other irritants in peritoneal when a person is lying down and when legs are elevated Ø Boas's sign à hyperaesthesia (increased or altered sensitivity) below the right scapula (between 9th & 11th ribs posteriorly right) can be a symptom in acute cholecystitis (inflammation of the gallbladder) Ø Ortner’s sign à tenderness when hand taps the edge of right costal arch Ø Shotkin-blumberg sign à refers to pain upon removal of pressure rather than application of pressure to the abdomen (rebound tenderness)

• Also known as CVA tenderness, Murphy's punch sign, Pasternacki's sign, or Goldflam's sign (Latin: succusio renalis) • Costovertebral angle à an angle made by vertebral column & costal margin • In this test, pain is elicited by percussion of the area of the back overlying the kidney • Because the kidney is directly anterior to this area, known as costovertebral angle, tapping disturbs the inflamed tissue, causing pain • The test is positive in à infection around the kidney (perinephric abscess), pyelonephritis, hemorrhagic fever with renal syndrome or renal stone

Succussion splash / stomach: Ø In suspected gastric outlet obstruction, after warning patient what is to come, grasp one iliac crest with each hand, place your stethoscope close to epigastrium and shake patient vigorously from side to side Ø The listening ears eagerly await a splashing noise due to excessive fluid retained in obstructed stomach Ø The test is not useful if the patient has just drunk a large amount of milk or other fluid for his or her ulcer Ø Clinician must then return 3 hours later, having forbidden the patient to drink anything further

Components Descriptions & Significances Pictures Psoas sign • Place your hand just above the patient’s right knee and ask the patient to raise that thigh against your hand • Alternatively, ask the patient to turn onto the left side. Then extend the patient’s right leg at the hip • Flexion of the leg at the hip makes the psoas muscle contract; extension stretches it

Obturator sign • Flex the patient’s right thigh at the hip, with the knee bent, and rotate the leg internally at the hip • This maneuver stretches the internal obturator muscle

Cutaneous • At a series of points down the hyperesthesia abdominal wall, gently pick up a fold of skin between your thumb and index finger, without pinching it. This maneuver should not normally be painful

Spleen vs. kidneys:

Spleen Differences Kidneys

More likely smooth and Surface & shape Polycystic kidneys are regular in shape bilateral irregular masses

Yes, travels superficially and Mass descends in Yes, moves deeply and diagonally / inferomedially inspiration vertically / inferiorly

Yes Ability to feel deep to No the mass

Yes Palpable notch on No medial surface

No Bilateral masses Sometimes, e.g. polycystic palpable kidneys

No Percussion resonant Sometimes (lies posterior to over the mass loops of gas-filled bowel)

Sometimes Mass extends beyond No (except with horseshoe the midline kidney)

No palpable upper border Upper border Palpable upper border (space between spleen & costal margin) Usually not ballotable Ballottement Ballotable (retroperitoneal)

May occasionally be heard Friction rub Never over the kidney because it is too posterior

Abdominal mass causes:

Abdominal pain causes:

11. Abdomen Percussion

TECHNIQUES

Ø Ask the patient to hold his breath in full expiration Ø Percuss downwards from right 5th intercostal space in right mid-clavicular line, listening for the dullness that indicates upper border of the liver Ø Measure the distance in cm below the right costal margin in right mid-clavicular line or from the upper border of dullness to palpable liver edge Ø Components to look for in percussion: o Liver span o Spleen o Ascites à shifting dullness, fluid thrill / wave, puddle sign, dipping method

Liver span: Ø To estimate liver span, percuss down along right mid-clavicular line until the liver dullness is encountered and measure from here to palpable liver edge

Ascites:

Shifting dullness: Ø With patient supine, percuss from midline out to the flanks with finger pointing towards the feet Ø Note any change from resonant to dull, along with areas of dullness and resonance Ø Keep your finger on the site of dullness in the flank & ask patient to turn on to his opposite side Ø Pause for 10 seconds to allow any ascites to gravitate, then percuss again Ø If the area of dullness is now resonant, shifting dullness is present, indicating ascites

Fluid thrill / wave: Ø If the abdomen is tensely distended and you are not certain whether ascites is present, feel for a fluid thrill Ø Place the palm of your left hand flat against the left side of patient’s abdomen and flick a finger of your right hand against the right side of abdomen Ø If you feel a ripple against your left hand, ask an assistant / patient to place the edge of his hand on the midline of abdomen to prevent transmission of impulse via the skin rather than through ascites Ø If you still feel a ripple against your left hand, fluid thrill is present (only detected in gross ascites)

Puddle sign: Ø Patient kneeling on all fours Ø Sensitive to detect small amount of fluid Ø However, it is undignified

Dipping method: Ø When significant ascites is present, abdominal masses may be difficult to feel by direct palpation, therefore dipping method can be used (sharp & rapid movement) Ø Using the hand placed flat on the abdomen, the fingers are flexed at metacarpophalangeal joints rapidly so as to displace underlying fluid Ø Liver and spleen may become ballottable when gross ascites is present

Scratch test: Ø To identify liver border if abdomen is very tender, tense or distended Ø Place stethoscope below the xiphoid and lightly but briskly stroke the skin in a direction at right angles to the expected liver edge, starting at the right lower quadrant & slowly up to the right costal margin along midclavicular line Ø When liver edge is reached, sound of scratch is transmitted to stethoscope

FINDINGS

Ø Hernia à protrusion of an organ through its containing wall Ø It can be applied to: o Herniation of a muscle through its fascial covering o Herniation of brain through a skull fracture / through foramen magnum into the spinal canal o Protrusion of an intra-abdominal organ through a defect in abdominal wall, pelvis or diaphragm Ø There must be a weakness in that wall before an organ can herniate through its retaining wall à may be due to congenital abnormality, or acquired as result of trauma or disease Ø Abdominal hernia generally can be classified into 2 types: A. Internal o Paraduodenal (right & left) o Foramen of Winslow o Intersigmoid o Pericecal / paracecal, retrocecal o Transmesenteric, transmesocolic, transomental o Retroanastomotic o Falciform ligament, broad ligament o Supravesical, paravesical, pelvic o Hiatus hernia (type 1 / sliding, type 2 / rolling / paraesophageal, type 3 / mixed) o Diaphragmatic hernia

B. External o Inguinal (direct & indirect) o Umbilical (congenital & acquired) o Paraumbilical o Incisional o Femoral o Epigastric o Spigelian (hernia of linea semilunaris) o Obturator o Lumbar (Petit’s triangle hernia) o Gluteal o Separation of recti abdominis hernia

Internal hernias

External hernias

FINDINGS

Normal findings Ø Normal rectum is usually empty and smooth-walled Ø The normal prostate à smooth and has firm consistency, with lateral lobes and a median groove in between / bilobed mass with central furrow Ø The normal prostate is a firm, rubbery. It becomes firmer with age Ø The upper end of anal canal is marked by puborectalis muscle, which is readily palpable and contracts as a reflex action on coughing or on conscious contraction

Abnormal findings

Findings Descriptions & Significances Pictures Inspection Thrombosed • Small (< 1 cm), tense bluish external swellings haemorrhoids • Painful & due to rupture of a vein in (piles) external haemorrhoidal plexus • Also called perianal haematomas • Haemorrhoids (‘piles’, congested venous plexuses around the anal canal) are only palpable if thrombosed Skin tags • Can be an incidental finding or occur with haemorrhoids or Crohn's disease

Rectal prolapse • Circumferential folds of red mucosa are visible protruding from anus • Gapping anus à suggest loss of internal and external sphincter tone

Findings Descriptions & Significances Pictures Anal fissure • Crack in the anal wall which may be (fissure-in-ano) painful enough to prevent rectal examination • Usually occur directly posteriorly & in the midline • A tag of skin may be present at the base à called sentinel pile &

indicates that the fissure is chronic • Multiple or broad-based fissures à may be present in inflammatory bowel disease, malignancy or venereal disease

Fistula-in-ano • Usually within 4 cm of anus • The mouth has a red pouting appearance caused by granulation tissue • May occur with Crohn's disease or perianal abscess

Condylomata • Pedunculated papillomas with a acuminata white surface and red base (anal warts)

Carcinoma of • May be visible as a fungating mass anus at the anal verge

Stool appearance Cause Pictures Black and tarry • Bleeding from the upper (melaena) gastrointestinal tract

Grey/black • Oral iron or bismuth therapy

Silvery • Steatorrhoea plus upper gastrointestinal bleeding, e.g. pancreatic cancer

Fresh blood in or • Large-bowel, rectal or anal bleeding on stool

Stool mixed with • Infective colitis or inflammatory pus bowel disease

Ricewater stool • Cholera (watery with mucus and cell debris)

REFERENCES

1. Oxford Clinical Skills – Oxford Core Texts

2. Bates Guide to Physical Examination and History Taking (International Edition)

3. Talley and O’Connor - Clinical Examination A Systematic Guide to Physical Diagnosis

4. MacLeod’s Clinical Examination

5. Hutchison’s Clinical Methods

6. Browse’s Introduction To The Symptoms And Signs Of Surgical Diseases

7. Harrison’s Principles of Internal Medicine

8. Davidson’s Principles and Practice of Medicine

9. Kumar & Clarks Clinical Medicine

10. Other journals and articles

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