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Phase 4 - OSCE examinations > Abdominal examination > Flashcards

Flashcards in Abdominal examination Deck (23)
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1
Q

Preparation.

a) Patient position (4 things)
b) Ask the patient what?
c) And of course what things for all examinations?

A

a) - Patient should be adequately exposed (from xiphisternum to pubis)
- Patient should be lying comfortably with the head a little elevated - 10-15 degrees (one pillow).*
- The arms should be placed alongside the body.*
- The legs should be straight (not crossed).*

  • These relax the abdominal muscles.
    b) Are they in any pain?

c) - Wash hands
- Introduce self
- Ask patient’s name, DOB and age (and check against wristband)
- Explain the examination and obtain consent

2
Q

General inspection (end-of-the-bed-o-gram).

a) General appearance - what may be noted?
b) Other features indicating GI/systemic disease
c) Paraphernalia around the bed
d) Paraphernalia attached to patient

A

a) - Do they look generally well or unwell?
- Are they obviously in pain, discomfort or distress?
- Do they appear confused?
- Are they very still (?peritonitis) or writhing around (?colic)?
- Note their observations if available

b) - Jaundice (best examined in natural light: most often found on the sclera, frenulum or abdomen)
- Bruising/ purpura
- Cachexia

c) - IV fluids
- TPN feeds
- Blood bags
- Oxygen
- ‘Nil by mouth’ sign

d) - Oxygen
- Cannulas, PICC lines, CVCs, etc.
- Catheters
- NG tubes
- Stomas - colostomy, ileostomy, urostomy, jejunostomy

3
Q

Examination of the hands/arms.

a) General observations
b) GI-specific signs
c) Other marks on the hands/arms

A

a) - Cold, clammy, warm/well-perfused
- Take pulse and CRT
- Tar staining (?malignancy)

b) - Clubbing: IBD, PBC, coeliac disease, cystic fibrosis or other malabsorption syndromes
- Kolionychia: iron deficiency
- Leukonychia striata (Muehrcke’s lines): low albumin
- Chronic liver disease: palmar erythema, Dupuytren’s contracture
- Hepatic encephalopathy - ASTERIXIS

c) - Track marks - IVDU
- Scratch marks - pruritis (bilirubinaemia)
- Bruising

4
Q

Examination of the face, neck and chest.

a) Eyes - possible signs
b) Mouth - possible signs
c) Neck - possible signs
d) Chest - possible signs

A

a) - Subconjunctival pallor
- Jaundiced sclera
- Xanthelasma around the eye (?PBC)
- Kayser-Fleischer rings (Wilson’s disease)

b) - Dry mucous membranes
- Jaundiced frenulum
- Stomatitis/ glossitis (iron/B12/folate deficiency)
- Aphthous ulcers (IBD)

c) - Lympadenopathy
- Especially Virchow’s node (usually upper GI cancer)
- Say “If the patient were at 45 degrees I would inspect the JVP”

d) - Spider naevi
- Gynaecomastia

5
Q

Inspection of the abdomen.

a) Possible signs
b) Types of surgical incisions
c) How to examine scars
d) Types of “bags”

A

a) - Distension (fat, fluid, faeces, flatus, foetus), abdominal respiration, bruising, scars, stoma, hernias, visible peristalsis (?BO), distended veins (?liver disease)
- Classical bruising of retroperitoneal haemorrhage - Cullen sign and Grey-Turner’s sign
- Sister Mary Joseph nodule - malignant metastatic umbilical nodule (sign of advanced abdominal Ca)
- A mass may be apparent. To exaggerate the presence of a mass, inspect with the head raised from the bed to tense the abdominal muscles

b) - Laparotomy scars - eg. midline, paramedian, McBurney’s/gridiron, transverse, etc.
- Laparoscopy scars - including port sites
- Surgical drain scars
- Stoma sites

c) - Inspect the scar - determine length, site, orientation and consider possible operation (eg. “a 5 cm oblique scar in the right iliac fossa, indicating possible previous open appendicectomy”)
- Feel for healing/tenderness
- Cough impulse to assess for possible incisional/port site hernia

d) - Surgical drain
- Surgical wound bag
- Fistulae bag
- Ileostomy bag (may be end or loop)
- Colostomy bag (usually end)
- Urostomy bag (ileal conduit for urine)

6
Q

General palpation of the abdomen.

a) Why must you palpate all abdominal scars?
b) If patient has pain, start palpating where?
c) Reason for superficial and deep palpation?
d) Signs of local peritonism
e) Signs of generalised peritonitis
f) Differentiating true peritonism from a wimp patient

A

a) To assess for hernia - examine for cough impulse. Also get patient to sit forward (if midline laparotomy - distinguish from divarication of the recti)
b) Start away from pain, work towards it

c) - Superficial - parietal peritoneum inflammation, tenderness, guarding
- Deep - visceral peritoneum inflammation, organomegaly, other masses

d) Signs.
- Involuntary guarding in specific area
- May have percussion tenderness or rebound tenderness
- Acute cholecystitis - Murphy’s sign
- Appendicitis - Rovsing’s, Obturator, Psoas and Pointing signs

e) - Board-like abdominal rigidity
- Involuntary guarding of entire abdomen
- Bowel sounds absent

f) Elicit true peritonism* by…
- distracting patient while palpating,
- asking them to cough or take a deep breath,
- pressing stethoscope firmly while auscultating

*Don’t be afraid of pressing firmly so that the patient jumps off the bed, as this is a good sign that they have true peritonism that will require active management

7
Q

Palpation of organs and masses.

a) What are the borders for the renal angle?
b) Which organs may be felt in normal individual?
c) Features of a renal mass
d) Features of a liver mass
e) Features of gallbladder mass
f) Features of splenic mass
g) What else should be felt?
h) If no hepatosplenomegaly found on palpation, how should you save yourself some time?

A

a) Lower border of 12th rib and lateral borders of erector spinae muscles
- DON’T FORGET to examine the back for scars

b) - Liver, possibly kidney (if very thin), possibly gallbladder
- Note: spleen should NEVER be palpable

c) - Grow downwards from flanks to iliac fossae, palpable front and back, ballottable

d) - RUQ, extends downwards to RIF if large
- Moves with respiration

e) - Globular mass in RUQ
- Moves with respiration

f) - Extends from LUQ to (if very large) RIF across umbilicus
- Moves with respiration

g) - Abdominal aorta
- Bladder
- Any hernias or enlarged lymph nodes

h) Say to examiner - “I didn’t find any HSM, so I think it will be unnecessary percussing them if you agree?”

8
Q

Palpation ?

A

?

9
Q

Percussion.

a) Ascites
b) Organomegaly*
c) Other uses

*Note: you can omit percussion of liver and spleen if no organomegaly felt on palpation - say to examiner

A

a) - Detecting ascites vs. flatus - dull vs. resonant
- Confirm with shifting dullness

b) - Liver, gallbladder, spleen, kidneys and any other solid masses (eg. GI tumours) will be dull to percuss

c) - Full bladder from chronic retention
- Percussion tenderness

10
Q

Auscultation.

a) Auscultation of BS useful in what 3 situations?
b) What else can be auscultated?

A

a) - Mechanical bowel obstruction - tinkling (high-pitched and frequent bowel sounds)
- Paralytic ileus - absent BS
- Peritonitis - absent BS

b) Bruits: aortic or renal

11
Q

After auscultation, do what final examination?

A

Legs - any pitting oedema

(and remember lymph nodes here if forgotten)

12
Q

To complete the abdominal examination.

A

I SHRUG.

  • Examine the groin for any hernias or lymphadenopathy
  • Perform a digital rectal examination and examination of the external genitalia
  • Obtain a stool sample and urine sample for analysis
13
Q

Signs of chronic liver disease.

a) List some signs from hands to chest to abdomen
b) Childs-Pugh score (5 criteria)
c) Clinical signs of ascites

A

a) Signs of CLD:
- Palmar erythema, asterixis, Dupuytren’s contracture
- Bruising
- Jaundice
- Spider naevi (differentiate from Campbell de Morgan spots/ senile angioma)
- Gynaecomastia (and testicular atrophy)
- Ascites (+ ankle oedema)
- Distended veins - abdomen (severe = caput medusae), rectal varices, parastomal varices, etc.

b) Calculates mortality risk in cirrhosis (5 criteria):
- Bilirubin level (jaundice)
- Encephalopathy grade 1 - 4 (eg. asterixis, confusion, ataxia, rigidity, hyper-reflexia, stupor, coma)
- Albumin
- Ascites
- INR (clotting dysfunction)

c) - Abdominal distension
- Dullness to percussion in the flanks when supine
- Shifting dullness when patient rotated onto side
- Fluid thrill

14
Q

Hernias.

a) Longitudinal midline mass, expands on sitting up - likely diagnosis
b) Clinical signs - how to assess?
c) Visible/palpable types
d) Non-visible types
e) Define ‘hernia’
f) Strangulated hernia - characteristics?
g) Obstructed hernia - characteristics?

A

a) Divarication of the recti (not a hernia)

b) - Cough impulse, reducible (unless incarcerated = irreducible), expand on sitting up
- Often present in the groin/testes so these must be examined if suspected hernia

c) - Incisional - previous surgical site (including port site)
- Epigastric - upper abdomen in midline
- Umbilical - through umbilicus
- Parastomal - around stoma site
- Inguinal - above and medial to the pubic tubercle. May be direct (through defect in posterior wall of inguinal canal) or indirect (through deep ring of inguinal canal)
- Femoral - below and lateral to the pubic tubercle

d) - Spigelian hernia - between layers of the abdominal muscles
- Hiatus hernia - stomach pushed up into the thoracic cavity through a weakness in the diaphragm

e) Protrusion of a viscus through the wall of its cavity

f) - Compression of hernia to the extent that blood supply is compromised, causing ischaemia and pain
- More common in femoral > inguinal hernias

g) - Compression of hernia (bowel) to the extent that the bowel lumen contents become obstructed (emergency)

15
Q

Surgical scars: differentials

a) Rooftop (bilateral subcostal incision)
b) Mercedes Benz (rooftop plus sternotomy)
c) Midline laparotomy
d) Gridiron/McBurney’s (oblique)
e) Lanz scar (transverse)
f) Hockey stick
g) Port scars: 2 most common
h) Pfannensteil

A

a) Upper GI (eg. Whipple’s procedure)
b) Liver transplant
c) Emergency abdominal surgery (may be upper or lower midline laparotomy)
d) Open appendicectomy
e) Open appendicectomy
f) Renal transplant (usually in RIF)

g) - Laparoscopic cholecystectomy: 3 or 4 port sites - umbilical, epigastric, R hypochondrium, R flank
- Laparoscopic appendicectomy: umbilical port, LIF or RIF port

h) Transverse suprapubic incision: pelvic surgery, including CS

16
Q

What test may be used to assess for peritonitis in child who may be non-cooperative with abdominal exam?

A

Ask them to hop/jump

- This will not be possible (or very painful) if peritonitic

17
Q

Stomas.

a) Colostomy - features
b) Ileostomy - features
c) Urostomy - how is it formed?
d) Jejunostomy
e) Gastrostomy
f) Differentials for a stoma bag
g) Should be what appearance if healthy?
h) Problems with stomas
i) Loop vs. end stoma

A

a) Usually LIF, poo-like brown contents, stoma flush to the skin (or sometimes small spout)
b) Usually RIF, liquid-pasty contents, spouted to protect skin from the corrosive alkaline contents of small bowel

c) - Section of small bowel resected and isolated
- Rest of small bowel joined in end-to-end anastamosis to function as normal
- Ureters removed from bladder (usually done as part of a cystectomy for eg. bladder Ca)
- Ureters then joined into resected section of small bowel, which is pulled out of the skin to form a stoma

d) - Usually used for enteral feeding of longer than 30 days (< 30 days - generally use NG feeds)
e)

f) - Surgical drain
- Wound drainage bag
- Fistula drainage bag

g) Pinkish-red (like inside of mouth, mucosal membrane)

h) - High-output
- Skin irritation (ileostomies)
- Fistulae
- Obstruction
- Parastomal hernias

i) - Loop - a loop of bowel is brought out (proximal and distal end, still connected partially) - generally to allow distal anastamosis to heal (eg. loop ileostomy in low anterior resection, or loop ileostomy in first stage of ileo-anal pouch surgery in UC) before reversal of stoma
- End - only one end brought out. Often permanent, but may be reversed (eg. Hartmann’s)

18
Q

Operations, their causes and their end result.

a) Hartmann’s
b) High anterior resection (recto-sigmoid resection)
c) Low anterior resection
d) Abdominoperineal (AP) resection
e) Right hemicolectomy
f) Left hemicolectomy (what procedure is now more often performed for transverse/proximal descending colon Ca?)
g) Sigmoid colectomy
h) Total colectomy (which patients often have this?)
i) Subtotal colectomy
j) Pan-proctocolectomy (which patients often have this?)

A

a) - Resection of sigmoid and higher part of rectum with end colostomy formation (often emergency operation - laparotomy).
- Only about 30% are reversed

b) - As per Hartmann’s, but with end-to-end anastamosis formation.
- Occasionally require temporary loop ileostomy or colostomy

c) - Resection of rectum (usually with sigmoid sparing)
- Defunctioning loop ileostomy formed to allow anastamosis to heal and reduce risk of anastamotic leak

d) - Resection of sigmoid colon, rectum and anus
- Formation of end colostomy

e) - Right sided (ascending) colon resection
- End-to-end anastamosis

f) - Left-sided (descending) colon resection
- End-to-end anastamosis
- Now more commonly an extended right hemi is performed for cancers in the transverse colon or proximal descending colon.

g) - Excision of sigmoid colon
- End-to-end anastamosis

h) - Excision of entire colon, but leave the rectum and anus in situ
- Formation of end ileostomy
- Common in UC patients (also some FAP patients)
- A select few may have ileo-anal (J) pouch formation or ileo-rectal anastamosis - may require 2-3 operations

i) - Excision of right, transverse and left colon
- Leave sigmoid in situ

j) - Excision of entire colon, rectum and anus
- Formation of end ileostomy
- Common in Crohn’s patients

19
Q

Common post-abdominal surgery complications.

A
  • Anastamotic leak and peritonitis
  • Other infection - pneumonia, catheter-associated UTI, wound infection, etc.
  • Ileus (usually only lasts 24 hours - manage conservatively, may require NG tube - drip and suck)
  • Stoma formation
  • Bleeding
  • Damage to surrounding structures (eg. bladder, ureters)
  • VTE
20
Q

Haemorrhoids.
a) What are they?
b) Grading
c)

A

a) Abnormally enlarged anal vascular cushions

b) Grading
1st Degree - Remain in the rectum
2nd Degree - Prolapse through the anus on defecation but spontaneously reduce
3rd Degree - Prolapse through the anus on defecation but require digital reduction
4th Degree - Remain persistently prolapsed

21
Q

Haemorrhoids.

a) What are they?
b) Grading
c) Complication (clinical fx)
d) Differentials
e) Management

A

a) Abnormally enlarged anal vascular cushions

b) Grading.*
1st Degree - Remain in the rectum
2nd Degree - Prolapse through the anus on defecation but spontaneously reduce
3rd Degree - Prolapse through the anus on defecation but require digital reduction
4th Degree - Remain persistently prolapsed

*Note: both internal (above dentate line) and external (below dentate line) haemorrhoids can be from grades 1-4

c) - Prolapsed haemorrhoids are at risk of thrombosing: they appear as a purple/blue, oedematous, tense, and tender perianal mass
- Other complications: skin tags, abscess

d) - Perianal: fistula, fissure, abscess
- Internal (causes of PR bleeding): diverticula, colorectal/anal malignancy

e) - Conservative: laxatives (and avoid constipating drugs), good fibre and fluid intake, warm baths, ice packs, topical lignocaine
- If unresponsive to conservative management, 1st/2nd degree can be treated with rubber band ligation, whereas 3rd/4th will likely need haemorrhoidectomy

22
Q

Inguinal lump: differentials

- mnemonic: Hernias Very Much Like To Swell

A
  • Hernias - inguinal, femoral
  • Vascular - femoral, saphena varix
  • Muscle - psoas abscess
  • Lymphadenopathy
  • Testicle - undescended
  • Spermatic cord - lipoma, hydrocele
23
Q

Splenomegaly: differentials

- mnemonic: CHICAGO

A
  • Cancer
  • Haematological (haemolysis, SCD, thalassaemia, etc.)
  • Infection (EBV, malaria, other)
  • Congestion (portal HTN)
  • Autoimmune (RA, SLE)
  • Glycogen storage disease
  • Other (amyloidosis)