Abdominal Examination: Findings
General
Generalized Peritonitis
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Diffuse abdominal tenderness and guarding
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'Board like' rigidity
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No bowel sounds
Rebound tenderness
Visceral inflammation under this spot.
Jaundice
Courvosier's Law
: In the presence of jaundice, an enlarged gallbladder is unlikely to
be gallstones; rather it is more likely to be cancer of the pancreas
(or biliary tree). Many exceptions exist but it is useful for
undergraduate level.
Gallstones and cancer constitute 1/3 of cases of jaundice.
Other causes can be divided as follows:
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Prehepatic
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Haemolytic (most bilirubin is unconjugated): anaemia.
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Hepatic
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(Most bilirubin conjugated. Pale stools, dark urine, weightt loss.) Hepatitis, drugs (e.g. alcohol, paracetamol),
cirrhosis, pregnancy, α-1 trypsin deficiency. Congenital
(Gilbert's)
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Posthepatic
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(Most bilirubin conjugated) Common bile duct stone, cancer of the head
of the pancreas, biliary stricture (incluing cancer, and cholecystitis), pancreatitis, sclerosing
cholangitis, primary biliary cirrhosis.
Hepatomegaly
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Cirrhosis: (usually alcoholic) signs of chronic liver disease
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Secondary Carcinoma: hard, knobbly, cachexia
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Congestive cardiac failure: raised JVP, ankle oedema, tender and pulsatile liver
Hepatosplenomegaly + generalised lymphadenopathy: Lymphoproliferative disorders
Splenomegaly
Examine all other LNs
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Very big: CML, myelofibrosis, trauma
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Big: Myeloproliferative, lymphoproliferative, portal
hypertension (from cirrhosis)
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Slightly enlarged: Myeloproliferative, lymphoproliferative, portal
hypertension, infx (glandular fever, hepatitis, endocarditis)
Large kidneys
A common OSCE case. Large kidneys are identified as bilateral flank masses, bimanually ballotable, they are resonant
to percussion, and it is possible to get above them.
The diagnosis is most often polycystic kidneys, so look for evidence of renal disease.
Ascites
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Transudate
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Cirrhosis (80% of causes, most commonly alcoholic), Heart failure (3%), hypoalbuminaemia (e.g. nephrotic syndrome).
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Exudate
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Cancer (10%), TB (2%), pancreatitis
(1%), serosititis. nephrotic syndrome.
Gynaecomastia
The growing of breasts in men. Common causes:
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Physiological
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Young & old
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Pathological
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↓Testosterone (e.g. Klinefelters, trauma), ↑Estrogen (liver
disease, thyrotoxicosis, testicular tumours)
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Drug
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Estrogen, testosterone, gonadotrophins (e.g. hCG, T
inhibitors: spironolactone, ketoconazole, cimetidine)
Dupuytren's Contracture
Bilateral if cause is excess alcohol (beware the other hand might have
thickening but not yet contraction). Other: trauma from vibrating
tools.
Caput medusa
This
is veins running from the umbilicus and indicates porto-venous shunt.
Must squeeze blood out & see which way it now flows in, should come
out from umbilicus
Spider naevi
Blanching lesions due to chronic liver disease. Consist of a large
arteriole from which radiate small vessels that somenody once thought
looked like spider's legs. Only present in the draining distribution of
the SVC (i.e. nipple and up). May also originate in hyperthyroidism.
Koilonychia
Iron deficency anaemia
Leuchonychia
Low albumin, occurs in chronic liver disease.
Palmer erythema
Hyperdynamic circulation. Most often due to chronic liver disease. Also
occurs in pregnancy, thyrotoxicosis, rheumatoid arthritis,
polycythaemia.
Eponymous signs you should know about
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Trossier's sign
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Virchov's node: a lymph node in the right supraclavicular region classically related to gastric carcinoma.
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Grey-Turner's sign
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Bruising of loins due to subcutaneous
intraperitoneal haemorrhage due to ruptured ectopic pregnancy, acute
pancreatitis (2-3d after) or ruptured AAA.
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Cullen's sign:
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pancreatitis, ectopic pregnancy
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Murphy's sign for acute cholecysititis
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Hand in RUQ &
asking pt to breathe deeply causes pain due to inflamed GB. Should be
negative in LUQ.
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Saint's triad
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Gallstones, diverticulosis of the colon, and
hiatus hernia. The pt presents with dyspepsia.
Scars
Common Abdominal scars
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Kochers
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Right Subcostal incision for cholecystectomy
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Midline Laporotomy
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Incision down the middle of the abdomen
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McBurney's incision
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Oblique right lower quadrant scar for appendicectomy. Made 1/3 of the
way from the anterior superior iliac spine to the umbilicus.
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Pfannenstiel
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Low transverse incision for gynaecological procedures.
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Nephrectomy
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A loin incision
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Liver Transplant
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Known as the
Mercedes
incision, as you must be driving a car at least this expensive before you are allowed to make it.
Stomas
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Tube Gastrostomy
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Over stomach, LUQ
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(Tube) Feeding jejunostomy
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LUQ
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Ileostomy
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Spout. Usually RLQ sided. If 2 openings then loop ileostomy
(temporarily bringing the bowel to the surface to avoid bad
anastomosis), if 1 opening then end ileostomy.
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Colostomy
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No spout. Usually LLQ sided. Can be loop, defunctioning w mucous
fistula (separating out the loop afferent and efferent to avoid
contamination), Hartmans (bringing bowel to surface and temporarily
sewing up distal end), or end (obliterating end, hence no anus).
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Ileal conduit
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Epigastric neobladder, connecting the urethra to the ski surface