- Introduce yourself
- Ask for permission
- General exam
- Ab exam
GENERAL EXAM
- General condition (eg. cachexic, in distress, well) - eg. obese, cachexic
- Head-to-toe exam
- Head - P, J, C
- Neck - LN, dilated veins
- Chest - spider angioma, gynaecomastia
- Hands - pulse, palmer erythema, clubbing, Dupuytren's contracture, flapping tremor, pallor in creases
- Ankles - L + R, oedema, ulcers, pigmentation
- Special - stigmata of liver diseases - jaundice, spider angioma, gynaecomastia, palmer erythema, finger clubbing, Dupuytren's contracture, flapping tremor
Note: Symptom vs. Sign vs. Lab Ix
- Pain (symptom) vs. Tenderness (sign) \
never use "tenderness" in Hx
- Pallor (sign) vs. Anaemia (lab Ix) \
never use "anaemia" in P/E
- If you cannot feel LN, do not say "no enlarged LN", say "LN not palpable"
- Shifting dullness suggests ascites, but ascites has to be proven by tapping/ Ix (absence of shifting dullness does not mean absence of ascites; volume of ascites may be small)
AB EXAM
- Pt comfortable, lying flat, supine, ab completely exposed (nipple to knee) vs. adequately exposed.
- Inspect (end of bed, right side) ®
Palpation (sit/ kneel) ®
Percussion ®
Auscultation
- Remember surface anat
Inspection
Stand end of bed, then right-hand:
- Shape - flat, scaphoid, obese, distended
- Symmetry, obvious mass, bulge
- Resp movt - normal/ minimal (eg. pain on movt - peritonitis; ruptured AAA, ulcer)
- Visible (distended) veins: portal HT
- Visible peristalsis: intestinal obstruction
- Umbilicus normal: cough
- Hernia - incisional, groin (cough impulse)
- Scar: ask Pt cough (incisional hernia?)
- Fistula: bile contents from hole if communication between ab and GIT (enterocutaneous fistula in IBD)
Palpation
- Sit/ kneel by bed
- Warm hands
- Ask Pt if any pain
- Look at Pt's face
GENERAL PALPATION
- Light then deep
- Dr's elbow level with Pt's abdomen
- Systematic through 4 quadrants from R side of Pt (if pain, start in quadrant away from the pain)
- Peritoneal signs - (1) Tenderness, (2) Guarding (region of palpation)/ rigidity (whole ab wall), (3) Rebound (pain on release of palpating hand - eg. Acute appendicitis), (4) Absent bowel sound - auscultation
- Tenderness - superficial or deep
- Guarding, rigidity, rebound tenderness (peritoneal signs); guarding in absence of tenderness may be Pt intolerant of palpation (not peritonitis)
ORGAN PALPATION
Enlargement: liver, spleen, kidney
- Liver: liver span, edge (irregular in ca), surface (smooth, nodular), consistency (hard in ca), bruit (vascular tumour in HCC)
- Spleen: Gardner's line; spleen may be under cover of ribcage therefore not palpable in supine position; Pt turned towards you, hand on abdomen to dampen ribcage movt, so diaphragm moves downwards more and pushes slightly enlarged spleen downwards, feeling hand in left subcostal region, do not need to start from RLQ again
- Palpable masses: site (which quadrant), size, surface, tenderness, mobility on palpation or with respiration
- Kidney ballottement (physical sign) for kidneys/ retroperitoneal mass - mass (site, size, shape, surface, tenderness, mobility), pulsation (expansile or transmitted)
- Cannot say "kidney not palpable", say "kidney not ballottable
- Pulsation: expansile (within mass itself) or transmitted
Percussion
- Distension due to fluid (dull), or gas/air (resonant)
- Dull
- Resonant
- Shifting dullness: if present, ascites/ blood (need >1 L before shifting dullness +ve)
Auscultation
- Diaphragm on ant ab wall
- Bowel sounds (peristalsis) - increased, decreased, absent, etc.
-
/ High-pitched: obstruction
- ¯
: peritonitis + paralytic ileus (after laparotomy)
- Bruits - aorta, splenic artery, renal artery (renal artery stenosis ®
stetho in transpyloric plane)
- Note: transpyloric plane = tips of the 9th costal cartilages, point where the linea semilunaris (the lateral border of rectus abdominus) crosses the costal margin
- Succussion splash - splashing sound in gastric outlet obstruction (eg. Pyloric stenosis) - heard in epigastric region (can rock Pt)
P/E groin (esp. 4 hernia) + DRE