Presenting Complaints
- Abdominal Pain
- SOCRATES
- Distension
- Nausea and Vomiting
- Timing
- Relation to meals
- Amount of vomit
- Contents of vomit (liquid, solid, bile, blood)
- Frequency of vomiting
- Hematemesis
- Bright red or dark or coffee ground?
- Weight loss? (neoplasia)
- Dysphagia?
- Pain medication (peptic ulcer)
- Dark stools?
- Dysphagia
- Level of dysphagia? i.e. neck, chest
- Onset? (sudden or gradual)
- Intermittent?
- Progressive?
- Associated with pain? (odynophagia)
- Indigestion/dyspepsia/reflux
- Timing in relation to meals
- Changes in bowel habit
- Associated weight loss?
- Dysphagia?
- Black stools?
- Diarrhea and Constipation
- Rectal bleeding or dark stools?
- Associated pain on defecation?
- Mucus?
- Fresh/dark/black blood?
- Mixed with stool?
- On the surface?
- On toilet paper?
- Weight change
- Intentional weight loss or gain? (Quantify)
- Associated dysphagia?
- Associated pain?
- Jaundice
- Associated with pruritus?
- Dark urine?
- Pale stools?
Physical Examination
General Inspection
Observe facial expression, body posture, and evidence of distress. Look for symmetry, color, and obvious masses and scars. Does the patient look generally sick?
| Sign | |
|---|---|
| Obvious signs of smoking | bladder, esophageal, colorectal cancer |
| Drip | |
| Nasogastric or IV feeding tubes | |
| Cartons of food around | |
| Medications lying around | |
| Uniform distension of the abdomen | Obesity, Intestinal obstruction, Ascites, Pregnancy, Fecal impaction |
| Regional distension | Solid mass |
Inspection of the hands
| Sign | |
|---|---|
| Polished nails | Sign of scratching |
| DIY Tattos | May have contracted Hepatitis B or Hepatitis C |
| Clubbing | Crohn’s disease, Ulcerative colitis, Coeliac disease |
| Koilonychia | Iron Deficiency |
| Leukonychia | Hypoalbuminemia due to liver failure, malnutrition (coeliac) |
| Beau’s line | Acute severe illness |
| Terry’s nails | Liver or Renal failure |
| Dupuytren’s contracture | Alcoholic Liver Disease or Spontaneous |
| Asterixis | Slow frequency. The whole hand tilts forward due to encephalopathy caused by urea. |
| Palmar erythema | Chronic liver disease, pregnancy, skin condition |
| Tar stained fingers | Cigarette smoking |
Inspection of the arms
| Sign | |
|---|---|
| Spider naevi | blanches on pressure. Due to excess estrogen in pregnancy and cirrhosis. Can occur in healthy individuals |
| Bruising | Chronic liver disease (Factor II, VII, IX, X are liver dependent) |
Inspection of the eyes
| Sign | |
|---|---|
| Conjunctival pallor | Anaemia |
| Scleral Icterus | Jaundice |
| Kayser-Fleischer rings | Wilson disease |
| Xanthelasma | Diabetes or high cholesterol |
| Corneal arcus | Natural in old age. Pathological in young individuals. |
Inspection of the mouth
| Sign | |
|---|---|
| Angular stomatitis | Iron deficiency |
| Inflammed gums | Scurvy |
| Hypertrophied gums | Leukemia |
| Loss of enamel | Gastroesophageal reflux |
| Glossitis | Iron Deficiency Anaemia |
| Thrush | Immunosuppression |
| Ulceration | Ill-fitting dentures. Has a nutritional consequence. |
| Leukoplakia | Malignant |
| Geographical tongue | Midway between glossitis and a normal tongue |
| Pigmentation around the lips | Peutz-Jeghers Syndrome |
Inspection of the neck
| Sign | |
|---|---|
| Virchow’s node (Trosier’s sign) | Abdominal metastasis (Gastric carcinoma?) |
Inspection of the chest
| Sign | |
|---|---|
| Spider naevi | Liver failure |
| Gynecomastia | Spironolactone and liver failure (+ hair loss) |
| Nipple retraction | Congenital, Breast cancer |
- Spider naevi
- Gynecomastia: spironolactone and liver failure (manifests with hair loss)
Inspection
Expose the abdomen proximally from the 2nd intercostal space above the nipples to the level of the greater trochanter (pubic symphysis) or mid-thigh distally.
| Sign | |
|---|---|
| Uniform distension | Obesity, Intestinal obstruction, Ascites, Pregnancy, Fecal impaction |
| Regional distension | Solid masses |
| Scaphoid abdomen | Malnutrition, Congenital Diaphragmatic Hernia in children |
| Obvious masses and scars and sinuses | |
| Pubic hair distribution | |
| Superficial dilated abdominal veins | Portal Hypertension, IVC obstruction |
| Spider Naevi | Pregnancy, Cirrhosis |
| Skin color | Yellow tinge in jaundice |
| Gynecomastia and indentation of the breasts | Cirrhosis |
Palpation
| Sign | |
|---|---|
| Superficial palpation | Hernias, Lymph nodes, Tenderness, Massess |
| Deep palpation | Define hernias, lymph nodes, tenderness, and other masses. Attempt to feel organs. |
| Guarding | Peritonitis |
| Rebound tenderness | Peritonitis |
| Rovsing sign | Appendicitis |
| Murphy sign | Appendicitis |
Palpating the liver
Enlarges downwards vertically. Palpate proximally from the right iliac fossa to feel the liver margin. It is normal to feel nothing at all. You cannot palpate above the liver and it descends with inspiration. Measure distance of the liver margin from the costal margin in the mid-clavicular line.
| Sign | |
|---|---|
| Hepatomegaly | Congestion in RHF and Budd-Chiari syndrome, Metastasis of primary malignancy, EBV, Amoebic abscess, hydatid cyst, Lymphoma and myeloproliferative disease |
| Gallbladder palpable | Can be palpated in carcinoma of the head of the pancreas |
| Courvoisier’s law | A palpable gallbladder in the presence of jaundice is very unlikely to be due to gallstones (with gallstones there is thickening and fibrosis of the gallbladder which make it not palpable) |
Palpating the spleen
Enlarges diagonally towards the right iliac fossa. Palpate diagonally from the right iliac fossa towards the left hypochondrium. The spleen descends with inspiration, has a notch, and cannot palpate above it. Measure the distance of the apex of the spleen from the costal margin in the mid-clavicular line
| Sign | |
|---|---|
| Splenomegally | CML, Myelofibrosis, Malaria, Leishmaniasis, Sequestration crisis in young sicklers |
| Tipping the spleen | Good when it is only slightly enlarged and normal methods reveal nothing or were inconclusive |
| Traube’s note | Dull 9th intercostal space on percussion |
Palpating the kidneys
The kidneys are palpated bimanually. May be non-palpable unless the individual is thin.
- Features differentiating the spleen from a large kidney
- Cannot get above th espleen
- Dull to percussion (the kidney is resonant to percussion due to overlying bowel)
- The spleen moves to the right iliac fossa with respiration while the kidney moves downwards
- The spleen has a palpable notch on the medial side
| Sign | |
|---|---|
| Enlarged kidney | PKD, Tumor, Amyloidosis |
Palpating the aorta
Palpate for the aorta on either side of the umbilicus
| Sign | |
|---|---|
| Pulsating | Thin individuals. Should be < 4.5 cm |
| Pulsating and expanding | Aneurysm? |
Percussion
Experts percuss first before palpating (anxious patients do not expect percussion to hurt. Percussion tenderness is alarming) Percuss to define the liver span and to define the upper border of the spleen. To measure liver span percuss from the 2nd ICS (superior to the nipple) and proceed distally towards the left iliac fossa. To percuss for fluid start at the umbilicus (sagittal plane) and move laterally. middl eof the chest and move distally
***looking for fluid in the abdomen? Begin in the middle of the chest and gradually move to the side. To measure liver span, begin 2 ICS superior to the nipple proximally, then at the left Iliac region distally
| Sign | |
|---|---|
| Normal liver span | 8-12 cm |
| Shifting dullness | Ascites |
| Fluid thrill | Massive ascites |
| Percussion tenderness | Peritonitis |
Auscultation
Auscultate 2 inches above the umbilicus for bowel sound and renal bruits.
| Sign | |
|---|---|
| Hyperactive bowel sounds | Early bowel obstruction |
| Tinkling noise | Small Bowel Obstruction |
| Absent bowel sounds | Bowel obstruction. Peritonitis |
| Renal bruit | Atherosclerosis or Renal artery stenosis |
Digital Rectal Examination
Introduce yourself and confirm the patient. Explain why you need to do a DRE. Get a chaperone and use plenty of gel.
- Positioning
- Left lateral decubitus with the right lower limb flexed towards the chest (preferred)
- Knee chest position
- Bent over
Inspection
| Sign | |
|---|---|
| Gaping anus | Neuropathy or Megarectum |
| Unilateral bulge | Abscess |
| Prolapse | |
| Fissures | At 12 and 6 O’clock position. Crohn’s diseae, Constipation |
| Hemorrhoids | 1st degree are within the rectum. 2nd degree prolapse but reduce spontaneously. 3rd degree require manual reduciton. 4th degree are prolapsed permanently and ulcerated/thrombosed. |
| Fistula | Abscess, Crohn’s disease |
| Skin tags | Crohn’s disease, Previous hemorrhoid |
| Excoriation | Diarrhoea |
| Anal wards | HPV |
Palpation
Ask the patient to take a deep breath to relax the anal sphincters and gently insert your finger by teasing adjacent to the orifice. Feel what is in the rectum, feel posteriorly, feel the sides, feel anteriorly. Take your finger out and check for blood, feces, or mucus. Hand the patient a towel to wipe and thank them.
| Sign | |
|---|---|
| Hypertonic sphincter tone | Crohn’s disease, Fissure, Stricture |
| Hypotonic sphincter tone | Old age, Neurological damage, Muscular damage |
| Polyp | Soft and mobile mass |
| Cancer | Fixed, hard, irregular, lumpy mass |
| Prostate | Walnut sized, 2 lobes, separated by a sulcus |
| Faecal loading | In the elderly. May mimic tumors but can be separated from the rectal wall |
- Further examination
- Examining the hernial orifices
- Examining the genitals (testicular atrophy in liver disease)
- Examine for ankle oedema (Liver failure)
- Bedside urine dipstick test if available
Demonstrations
https://youtu.be/w8Jo2xdxLXo?feature=shared
