Bitemedicine.Com/Watch

Aims and Objectives

• Requires some basic knowledge of clinical examinations

• Clinical examination station (OSCE) • Abdominal examination: 4 cases

• Duration: 70 mins • Slides and recordings: www.bitemedicine.com/watch

• Other common OSCE cases available in previous and upcoming webinars • Aim of the week is to cover most of the common scenarios

2 Abdominal examination: OSCE Cases list

What cases could come up? 1. Renal transplantation (+ AV fistula) 2. Stoma 3. Chronic liver disease 4. Hepatosplenomegaly 5. Cushing’s syndrome

This is not an exhaustive list • But by preparing for these you will be better at: • Your exam routine • Looking out for important signs • Formulating your findings systematically • Tackling the VIVA

3 How to present your findings?

I performed an abdominal examination on this patient If you have an idea, then • Who has signs suggestive of XXX back yourself from the start. It gets the examiner listening My main positive findings are: 1. XXX 2. YYY

My relevant negative findings are: RELEVANT negatives 1. XXX (Risk factors) 2. YYY (Signs of decompensation) 3. ZZZ (POSSIBLE associated features)

Overall, this points towards a diagnosis of XXX with no signs of decompensation

4 Abdominal examination: Case 1

Background 65M Central (1) (2) • Palpable mass in the left iliac fossa Bedside/peripheral

Tacrolimus

5 Question 1 Q1 Q2

What is the most likely diagnosis?

Chronic kidney disease

Diabetic nephropathy resulting in renal transplantation

Tacrolimus-induced nephropathy resulting in renal transplantation

Hypertensive nephropathy resulting in renal transplantation

Glomerulonephritis resulting in renal transplantation

app.bitemedicine.com 6

Abdominal examination: Case 1 – Renal transplantation

How to determine the presence of a renal transplant? • Mass in the iliac fossa • Rutherford-Morrison scar • Immunosuppressive medication • Look for evidence of previous haemo- or peritoneal dialysis

(3)

8 Abdominal examination: Case 1 – Renal transplantation

(5) Dialysis

Inspect the AV fistula • Wrist: radiocephalic • Antecubital fossa: brachiocephalic (or brachiobasilic) • Needle marks: suggests recent use

Palpate for a thrill and auscultate for a bruit • Both absent if ligated after transplantation (4) or thrombosed 9 Abdominal examination: Case 1 – Renal transplantation Please present your findings

I performed an abdominal examination on this 65M who has evidence of a renal transplant, likely secondary to diabetes mellitus.

My main positive findings: • By the bedside, I noted the presence of tacrolimus, likely as a post-transplantation immunosuppressant • Peripherally, the patient has evidence of BM fingerprick testing, suggestive of diabetes as the underlying cause, white patches on the tongue, and a right-sided non-active AV fistula in the antecubital fossa with no associated fluid thrill or bruit • On inspection of the abdomen, I noted a 7cm, well-healed, oblique, curvilinear scar extending across the LIF • A 10 x 6cm, smooth, non-tender mass was palpated in the LIF, which had a dull percussion note

10 Abdominal examination: Case 1 – Renal transplantation Please present your findings

My relevant negative findings : • No Cushingoid features • No clinical evidence of mineral bone disease • No clinical evidence of immunosuppressive toxicity

In summary, this is a 65 M with a renal transplant and previous haemodialysis, likely necessitated by diabetes mellitus, as well as iatrogenic oral candidiasis due to immunosuppressant use.

11 Abdominal examination: Case 1 – Renal transplantation What are your differentials?

Key indications for renal transplantation • Diabetes mellitus • Hypertension • Chronic glomerulonephritis • Genetic e.g. polycystic kidney disease • Autoimmune e.g. lupus

12 Abdominal examination: Case 1 – Renal transplantation

What would you like to do next? • Full history and review immunosuppressants • Peripheral neurological examination and fundoscopy: assess for other DM complications • Full set of observations

Bedside investigations • Blood pressure

Bloods • FBC: leukopaenia in view of immunosuppressant use • Renal profile: function of transplanted kidney • Calcium and phosphate levels: biochemical evidence of renal mineral bone disease • BM and HbA1c: history of DM and likely to be on steroids • Tacrolimus level

13 Question 2 Q1 Q2

How would you differentiate between a kidney and the spleen on examination?

The spleen is ballotable

The kidney has a notch

The kidney moves down on inspiration

The kidney enlarges inferiorly

You cannot get above the kidney

app.bitemedicine.com 14 Abdominal examination: Case 1 – Renal transplantation

How would you differentiate a kidney from a spleen on examination?

Kidney Spleen No notch Splenic notch Does not move on respiration Moves down on inspiration Can get above it Cannot get above it Ballotable Cannot be balloted Enlarges inferiorly Enlarges towards the RIF

15 Abdominal examination: Case 1 – Renal transplantation

Know your scars!

16 Abdominal examination: Case 2

Background Central 41M • Stoma bag is filled with liquid faeces

Bedside

(6) 17 Question 1 Q1

What is the most prominent finding on examination?

Percutaneous endoscopic gastrostomy

Colostomy

Urostomy

Ileostomy

Percutaneous endoscopic jejunostomy

app.bitemedicine.com 18 Abdominal examination: Case 2 – Stoma

Ileostomy Colostomy Urostomy Typical location Right iliac fossa Left iliac fossa Usually in the right iliac fossa Spouted or Spouted Flush Spouted flush? Contents of bag Liquid small Faecal matter Urine bowel contents

• Remove bag (if possible) • Site • Number of lumens 1 lumen • Spout • Effluent • Cough impulse (7)

(8)

(9) 19 Abdominal examination: Case 2 – Stoma Please present your findings

I performed an abdominal examination on a 41M with a healthy end ileostomy

My main positive findings: • By the bedside, I noted the presence of a stoma bag • Inspection of the abdomen revealed a single lumen, spouted stoma in the right iliac fossa containing liquid faeces, suggestive of an end ileostomy

20 Abdominal examination: Case 2 – Stoma Please present your findings

My relevant negative findings: • No evidence of stoma-related complications • Parastomal hernia: enlargement of the stoma, increased hernia size when coughing, bulging • Stoma infarction: pain at the stoma site, necrosis (black colour) of the stoma • Other: stoma prolapse, retraction, haemorrhage • No evidence of infection, and healthy surrounding skin

In summary, this is a 41M with a healthy end ileostomy. There is no evidence of stoma-related complications.

(10)

21 Abdominal examination: Case 2 – Stoma What are some indications for an ileostomy? • Inflammatory bowel disease • Familial polyposis • Colorectal cancer • Intrabdominal sepsis or haemorrhage

End ileostomy vs. Loop ileostomy

N.B remember an ileostomy may be temporary or permanent, and may be used to defunct a complex distal anastomosis, to divert faeces if the entire colon is removed

22 Abdominal examination: Case 2 – Stoma

What would you like to do next? • Full history • Review fluid balance and stoma output • Full set of observations

Bloods • Electrolyte panel: ileostomies are associated with significant electrolyte abnormalities if high-output • FBC and CRP: if evidence of complications

Imaging • CTAP: if evidence of complications e.g. parastomal hernia

23 Abdominal examination: Case 3

(11)

(14) (15)

(16)

(12) (13) Liver: • Edge is palpable 24 Question 1 Q1 Q2

What is the most likely underlying cause?

Alcohol

Hemochromatosis

Heart failure

Diabetes

Hepatocellular carcinoma

app.bitemedicine.com 25 Abdominal examination: Case 3

(11)

(14) (15)

(16)

(12) (13) Liver: • Edge is palpable 26 Abdominal examination: Case 3 – Chronic liver disease Please present your findings

I performed an abdominal examination on this gentleman who has evidence of chronic liver disease

My main positive findings are: • Peripherally: • I noted the patient had evidence of leukonychia and clubbing • Along with evidence of finger prick marks suggesting blood glucose monitoring • Centrally: • There was evidence of multiple spider telangiectasia • Gynecomastia • Mild hepatomegaly with a smooth liver edge • I also noted peripheral pitting oedema up to the shins suggestive of fluid retention 27 Abdominal examination: Case 3 – Chronic liver disease Please present your findings

My relevant negative findings are: • No evidence of decompensated liver disease • Jaundice • Asterixis • Variceal bleeding • Ascites • No evidence of infective symptoms

In summary, this is a gentleman who has evidence of chronic liver disease. I suspect the most likely underlying cause is diabetes causing non-alcoholic fatty liver disease. • He also had evidence of fluid overload likely secondary to hypoalbuminaemia • Other possible causes for liver disease include: • Alcohol • Hepatitis 28 • Carcinoma Abdominal examination: Case 3 – Chronic liver disease What are your differentials? Chronic liver disease: spectrum of chronic damage to the liver parenchyma ranging from fibrosis to cirrhosis • Alcohol • Non-alcoholic fatty liver disease • Diabetes and obesity • Infection • Hepatitis B and C • Metabolic • Alpha-1 antitrypsin deficiency • Haemochromatosis • Wilson’s disease • Autoimmune • Primary biliary cirrhosis • Autoimmune hepatitis

• Progressive sclerosing cholangitis 29 Abdominal examination: Case 3 – Chronic liver disease

What would you like to do next? • Full history • Peripheral neurological examination and fundoscopy: assess for other DM complications

Bedside • Observations • Urine dip: glycosuria

Bloods • LFTs: ALT>AST • Clotting: may be deranged in liver pathology • BM and HbA1c • Screen for other possible causes: • Hepatitis serology • Autoantibodies • Ferratin, caeruloplasmin, alpha-1 antitrypsin

Imaging • Liver ultrasound and fibroscan 30 Abdominal examination: Case 3 – Chronic liver disease What are the causes of hepatomegaly?

The 3 big ‘C’s • Cirrhosis: initially big and then small • Cancer: craggy edge • Congestive cardiac failure

31 Abdominal examination: Case 3 – Chronic liver disease

What are the abdominal causes of clubbing?

Abdominal Cardiology Respiratory Inflammatory bowel Infective endocarditis Abscess disease Cyanotic heart disease Bronchiectasis Coeliac disease Atrial myxoma Cancer Chronic liver disease Definitely not COPD Empyema Fibrosis

32 Question 2 Q1 Q2

Which of the following is NOT a cause of gynaecomastia?

Puberty

Chronic liver disease

Kleinfelter’s syndrome

Spironolactone

Chronic renal failure

app.bitemedicine.com 33 Abdominal examination: Case 4

Spleen palpable below umbilicus

(17)

34 Question 3 Q1

Which of the following is a cause of massive splenomegaly in adults?

Portal hypertension

Amyloidosis

Chronic myeloid leukaemia

Viral hepatitis

Sickle cell anaemia

app.bitemedicine.com 35 Abdominal examination: Case 4 – Haematological malignancy Please present your findings

I performed an abdominal examination on this gentleman who has evidence of a possible haematological malignancy

My main positive findings are: • Evidence of non-tender cervical lymphadenopathy, particularly affecting the posterior chain • A markedly enlarged mass in the right upper quadrant which extended inferiorly on inspiration and was palpable below the umbilicus (>8cm below the costal margin) • Suggests of massive splenomegaly

36 Abdominal examination: Case 4 – Haematological malignancy Please present your findings

My relevant negative findings are: • No evidence of decompensated liver disease • No evidence of infective symptoms

In summary, this is a gentleman who has evidence of cervical lymphadenopathy and massive splenomegaly. The likely cause is a haematological malignancy e.g. CML or myelofibrosis • Other causes of this presentation may include: • CLL or lymphoma • Infective e.g. glandular fever (EBV)

37 Abdominal examination: Case 4 – Haematological malignancy

What are your differentials?

Mild (<4cm) Moderate Severe (>8cm) Portal hypertension Lymphoproliferative disorders Myeloproliferative disorders • Cirrhosis • CLL • CML • Heart failure • Lymphoma • Myelofibrosis • Polycythaemia rubra vera Infection Infiltrative disorders Tropical infections • Enodcarditis • Amyloidosis • Malaria • EBV • Visceral leishmaniasis (Kala- • Viral hepatitis azar)

Haemolytic anaemia

38 Abdominal examination: Case 4 – Haematological malignancy What would you like to do next? • Full history • Examine axillary and inguinal lymphatics

Bedside • Observations

Bloods • FBC and blood film: evidence of immature cells

Imaging • Ultrasound abdomen: assess size of spleen • CT CAP: assess lymphadenopathy and size of spleen

Special • Biopsy: Bone marrow and lymph node • Cytogenetics: assess for chromosomal abnormalities e.g. Philadelphia chromosome

39 Abdominal examination: Case 4 – Haematological malignancy What would you like to do next? • Full history • Examine axillary and inguinal lymphatics

Bedside • Observations

Bloods • FBC and blood film: evidence of immature cells

Imaging • Ultrasound abdomen: assess size of spleen • CT CAP: assess lymphadenopathy and size of spleen

Special • Biopsy: Bone marrow and lymph node • Cytogenetics: assess for chromosomal abnormalities e.g. Philadelphia chromosome

40 Abdominal examination: Case 4 – Haematological malignancy Indications for splenectomy?

• Trauma • Malignancy e.g. lymphoma • Splenic cysts • Hypersplenism e.g. hereditary spherocytosis

How would you manage a splenectomy patient?

• Vaccination • 2 weeks prior to operation • Encapsulated bacteria: Pneumococcus, Meningococcus, Hemophilus influenzae b • Influenza

• Lifelong antibiotics • Phenoxymethylpenicillin (penicillin V)

• Medic alert bracelet

41 Top decile question

42 Abdominal examination: OSCE Cases list

What cases could come up? 1. Renal transplantation (+ AV fistula) 2. Stoma 3. Chronic liver disease 4. Hepatosplenomegaly 5. Cushing’s syndrome

43 References (1) U/ttriber. https://i.redd.it/ls1p27ofe4i41.jpg (2) James Heilman, MD / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0). https://commons.wikimedia.org/wiki/File:Human_tongue_infected_with_oral_candidiasis.jpg (3) BruceBlaus / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0). https://commons.wikimedia.org/wiki/File:Kidney_Transplant.png (4) Kbik at English Wikipedia / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0). https://commons.wikimedia.org/wiki/File:Radiocephalic_fistula.svg (5) National Kidney and Urologic Diseases Information Clearinghouse, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, USA / Public domain. https://commons.wikimedia.org/wiki/File:Peritoneal_dialysis.gif (6) Remedios44 / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0). https://commons.wikimedia.org/wiki/File:Ileostomy_bag.jpg (7) Salicyna / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0). https://commons.wikimedia.org/wiki/File:Ileostomy_2017-02-20_5350.jpg (8) BruceBlaus / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0). https://commons.wikimedia.org/wiki/File:Ileostomy.png (9) Cancer Research UK / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0). https://commons.wikimedia.org/wiki/File:Diagram_showing_a_colostomy_with_a_bag_CRUK_061.svg (10) Mikael Häggström / CC0. https://commons.wikimedia.org/wiki/File:Colostomy_and_parastomal_hernia.JPG 44

Further information

47 Further information

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48 References

11. U/ttriber. https://i.redd.it/ls1p27ofe4i41.jpg 12. Alborz Fallah / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0) 13. Desherinka / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0) 14. Herbert L. Fred, MD and Hendrik A. van Dijk / CC BY (https://creativecommons.org/licenses/by/2.0) 15. JMZ1122 Dr. Mordcai Blau www.gynecomastia-md.com / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0) 16. James Heilman, MD / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0) 17. Coronation Dental Specialty Group / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0)

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