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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! © BiteMedicine 2020 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 •
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