Post on 23-Jan-2023
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Forewords
First of all, thank you for purchasing this book and I am very
glad that you have taken your first step to bring your examination techniques and interpretation skill to another advanced level. I can guarantee you that after reading this book, your understanding towards the clinical examination will be deeper and clearer. This book has divided the clinical examination into two main components, mainly the technique part and interpretation of the findings part. And I strongly believe that you need to master both the technique and interpretation skill in order to help you to come to the diagnosis. This book consists of multiple authenticated references and has been arranged into systematic and organized way to ease the study and revision. The book will be updated from time to time in order for you to get the latest updated information and the contents are subject to change. The online softcopy version will be provided too as long as you have bought this book. Last but not least, I hope that this book will be a good companion in your study and career and let us work together towards the goal and achievement. We hope all the best to you. Cheers. -WE CARE, WE SHARE-
-Dr. Joseph Chia- Founder of Medical Success Insiders (MSI)
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ABDOMINAL
EXAMINATION
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Abdominal Examination Summary:
1.Introduceyourself&washhand
2.Liethepatientflatwithonepillow
3.GeneralInspection
• Agegroup• Sex• Position• Mentalstate• Anypain/distress• Build• Nutritional&hydrationstatus• Surroundingsànasalprong/oxygenmask,etc.• Growchart(paediatrics)• Checktemperature
4.UpperLimbsNails&Fingers:
• Pallor/Koilonychia• Clubbing• Leuconychia• Peripheralcyanosis• Temperature
Palm:
• Palmarerythema• Dupuytren'scontracture• Palmarcrease• Finetremor• Coarse/flappingtremorArms:
• Purpura/bruising• Spidernevi• Petechiae• Musclewasting• ScratchmarksAxilla:
• Lymphadenopathy• Acanthosisnigricans
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5.RadialPulse,RespiratoryRate,BloodPressure
6.FaceExaminationFace:
• Salivaryglands• Telangiectasia
Eyes:
• Scleraljaundice• Conjunctivalpallor• Kayser-Fleischerrings• Iritis• Xanthelasma• Periorbitalpurpura
Tongue:
• Coatingoftongue• Linguanigra(blacktongue)• Geographicaltongue• Leucoplakia• Glossitis• Enlargementoftongue(macroglossia)• Furredtongue• Wastedtongue
Teeth:
• Decayedtooth
Gum:
• Gingivitis• Gumhypertrophy
Tonsils:
• Pigmentedlesioninmouth
Mouth&Lips:
• Angularstomatitis• Pigmentedlesioninmouth&lips• Fetorhepaticus• Mouthulcers• Candidiasis(moniliasis)
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7.NeckPalpation• Virchow'snode• Otherlymphnodes
8.ChestExamination• Spidernevi• Gynaecomastia• Lossofaxillaryhair
9.AbdomenInspection(C.U.S.P2.)• Contour• Umbilicus• Skin• Peristalsis• Pulsation
10.AbdomenPalpationSuperficial:
• Tenderness/guarding/reboundtenderness/rigidity• Mass/lumps/muscles
Deep:
• Deepermass/tenderness• Specificorgansexaminationàliver,spleen,kidneys;gallbladder,stomach,
pancreas,bladder,bowel,aorta,appendix,testes• Othersàascites,succussionsplash,ventralhernia,abdominalwallmass
11.AbdomenPercussion• Liverspan• Spleen• Ascites
12.AbdomenAuscultation• Bowelsound• Bruit• Frictionrub• Venoushums
13.Hernia&GroinExamination• Lymphadenopathy• Hernia
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14.RectalExamination• Inspection• Palpation• Describe
15.ProctoscopyExamination• Inspection• Palpation• Describe
16.OtherExamination• Testingstoolsforblood• Legexamination• CVSexamination• Measurementoftemperature• Examinationofalllymphnodesgroups
17.Washthehands
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4.UpperLimbsExaminationTECHNIQUES Nails&Fingers:Ø Lookfornailpallor/koilonychiaØ CheckforclubbingØ CheckforleuconychiaØ LookforperipheralcyanosisØ Feelthetemperature
Palm:Ø LookforpalmarerythemaØ CheckforDupuytren'scontractureØ LookforpalmarcreaseØ LookforfinetremorØ Lookforcoarse/flappingtremor
o Askthepatienttoholdout/outstretchhisarmswithhandsextendedatwrists&
fingersspreadslightlyanddemonstratetothepatient
o Lookforjerky,flappingtremor(asterixis)foratleast15seconds
o Alternatively,askpatienttosqueezeyourindexandmiddlefingersandmaintain
thisfor30–60seconds.Patientswithflappingtremorcannotmaintaintheirgrip
o AlsocanaskpatientprotrudetongueORlifttheleg&keepthefootdorsiflexedØ Lookforwastingofintrinsicmuscleofhand
Arms:Ø Lookforpurpura/bruisingØ LookforspiderneviØ LookforpetechiaeØ LookformusclewastingØ Lookforscratchmarks
Axilla:Ø CheckforlymphadenopathyØ Lookforacanthosisnigricans
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FINDINGS
Findings Descriptions&Significances PicturesNails&FingersPallor/
koilonychia• Suggestsanemia• Rarely,exposuretostrongdetergent
Clubbing • Seenininflammatoryboweldisease,
coeliacdisease/malabsorption
syndrome(whichcauselong-standingnutritionaldepletion),livercirrhosis
• Upto1/3withcirrhosismayhavefingerclubbing
• Mayberelatedtoarteriovenous(AV)shuntinginlungs,resultinginarterialoxygendesaturation
• Cyanosismaybeassociatedwithseverelong-standingchronicliverdisease
Leuconychia
(whitenails)
• Whenchronicliverdisease/otherdiseaseresultsinhypoalbuminaemiaànailbedsopacify(abnormalityisofthenailbedandnotofthenail),oftenleavingonlyarimofpinknailbedatthetopofnail(Terry'snails)
• Mayalsooccurinàproteincaloriemalnutrition(kwashiorkor),malabsorptionduetoprotein-losingenteropathy(coeliacdisease),orheavyandprolongedproteinuria(nephroticsyndrome)
• Thumb&indexnailsaremostofteninvolved
• Mayduetocompressionofcapillaryflowbyextracellularfluid
• Muehrcke'slines(transversewhitelines)àcanoccurinhypo-albuminemiastates,includingcirrhosis
• BluelunulaeàmaybeseeninWilson'sdisease
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Findings Descriptions&Significances PicturesPalms
Palmar
creases• InspectpalmarcreasesforpalloràsuggestinganaemiawhichmayresultfromGITbloodloss,malabsorption(folate,vitaminB12),haemolysis(hypersplenism)orchronicdisease
Palmar
erythema
('liver
palms')
• Thisisreddeningofthepalmsofhandsaffectingthenar&hypothenareminences&pulpsoffingers;withcentreofpalmbeingspared
• Oftenthesolesoffeetarealsoaffected• Canbeafeatureofchronicliverdisease
• Whilethefindinghasbeenattributedtoraisedestrogenlevels,ithasnotbeenshowntoberelatedtoplasmaestradiollevels,soetiologyremainsuncertain
• Associatedwithreducedhepaticbreakdownofsexsteroids
• Canalsooccurwithàpregnancy,OCP,thyrotoxicosis,rheumatoid
arthritis,polycythaemia&rarelywithchronicfebrilediseasesorchronic
leukaemia• Mayalsobeanormalfinding,especiallyinwomen
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Findings Descriptions&Significances PicturesDupuytren's
contracture
• Visibleandpalpablethickeningandcontractionofpalmarfascia/aponeurosiscausingpermanentflexion
• Mostofteninvolvesringfinger;laterlittlefingerisalsoaffected
• Itisoftenbilateralandoccasionallyaffectsfeet
• Associatedwithalcoholism(notliverdisease)
• Maybefamilial(autosomaldominantwithvariablepenetrance)
• Associatedwithconditionscausingmicrovascularpathologyàdiabetesmellitus,smoking,hyperlipidaemia,
HIVinfection,chronicliverdisease
• Alsofoundinsomeheavymanual
workers• Palmarfasciaofthesepatientscontainsabnormallylargeamountsofxanthine
• Canseeverticalfurrowsintheregionof4th&5thfingersduetothickening
Hepaticflap
/asterixis
• Shouldaskpatienttostretchoutarmsinfront,separatefingersandextendthewristsfor15seconds
• Jerky,irregularflexion-extensionmovementatwristandmetacarpo-
phalangealjoints,oftenaccompaniedbylateralmovementsoffingers
• Itisthoughttobeduetointerferencewithinflowofjointpositionsense
informationtoreticularformationin
brainstemàresultsinrhythmicallapsesofposturalmuscletone
• Arms,neck,tongue,jawsandeyelidscanalsobeinvolved
• Patientisaskedtoclosetheeyesforcefully/toprotrudetongue
• Theflapisusuallybilateral,tendstobeabsentatrest,andisbroughtonbysustainedposture
[Videoavailableinthesoftcopy]
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Findings Descriptions&Significances Pictures
Eyes
Scleraljaundice
• Thinkofhypercarotinemiaasdifferentialdiagnosis
• Inmyxedema,metabolismslowsdownduetounderactivethyroid&conversionofcarotenetovitaminAisreduced
Conjunctivalpallor
• Bloodlosscanbeobviousandspectacular(esophagealvarices/bleedingstomachulcers)orinsidiousandoccult(colonicpolyps)
• Chronicanemiaàkoilonychia,angularstomatitis,atrophicglossitis,esophagealweb
• Alsocanbeduetoseverebleedinghemorrhoid
Kayser-Fleischerrings
• Brownishgreenringsoccurringatperipheryofcornea,affectingupperpolemorethanlower
• DuetodepositsofexcesscopperinDescemet'smembraneofcornea
• Slit-lampexaminationisoftennecessarytoshowthem
• FoundinWilson'sdisease,othercholestaticliverdiseases
• Usuallypresentbythetimeneurologicalsignshaveappeared
Iritis • Maybeseenininflammatoryboweldisease
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Findings Descriptions&Significances Pictures
Xanthelasma • Yellowishplaques/fattydepositinsubcutaneoustissuesinperiorbitalregion
• Mayindicateprotractedelevationofserumcholesterol/hyperlipidemia
• Incholestasis,anabnormallipoprotein(lipoproteinX)isfoundinplasma&isassociatedwithelevationofserumcholesterol
• Suggestsprolongedcholestasis• Commoninprimarybiliarycirrhosis
Periorbital
purpura
• Followingproctosigmoidoscopy('blackeyesyndrome')àcharacteristicsignofamyloidosis(perhapsrelatedtofactorXdeficiency)
Tongue
Coatingof
tongue
• Thickenedepitheliumwithbacterialdebris&foodparticles
• Especiallyinsmokers• Moremarkedontheposteriorpartoftongueàlessmobility&papillaedesquamatemoreslowly
• Occursfrequentlyinrespiratorytractinfections
Linguanigra
(blacktongue)
• Duetoelongationofpapillaeovertheposteriorpartoftongue
• Appearsdarkbrownàduetoaccumulationofkeratin
• Noknowncause• Justaestheticproblems;symptomless
• Bismuthcompoundsmayalsocause
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Findings Descriptions&Significances Pictures
Geographical
tongue
• Describeslowlychangingredringsandlinesthatoccuronsurfaceoftongue
• Itisnotpainful• Tendstocomeandgo• Canbeasignofriboflavin(vitamin
B2)deficiency
Leucoplakia • White-colouredthickeningofmucosaoftongueandmouth
• Cannotberemovedafterfewattempts
• Thisconditionispremalignant• Mostofthecausesbeginwith'S'àsoreteeth(poordentalhygiene),smoking,spirits,sepsisorsyphilis
• Mayalsooccuronlarynx,anus,vulva
Glossitis • Smoothappearanceoftonguewhichmayalsobeerythematous(beefytongue)
• Duetoatrophyofpapillae• Inlaterstagestheremaybeshallowulceration
• Resultofnutritionaldeficienciestowhichtongueissensitivebecauseofrapidturnoverofmucosalcells
• Duetodeficienciesofiron,folate,vitaminB(especiallyvitaminB12)
• Commoninalcoholics&rareincarcinoidsyndrome
Enlargement
oftongue
(macroglossia)
• Mayoccurincongenitalconditions(Downsyndrome)/inendocrinedisease(acromegaly,
hypothyroidism)• Alsocanbeduetotumour
infiltration(e.g.haemangiomaorlymphangioma)/infiltrationoftonguewithamyloidmaterialinamyloidosis
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Findings Descriptions&Significances Pictures
Furredtongue • Afterantibiotictherapy• BenignconditionduetoovergrowthofpapillaeoftonguetogetherwithinfectionduetoCandidanigricans
Wasted
tongue
• Neurologicalcause• Alsolookforfasciculation&tonguemovement
Teeth
Teeth • Notewhethertheyarereal/false• Falseteethwillhavetoberemovedforcompleteexaminationofmouth
• Notewhetherthereisgumhypertrophy/pigmentation
• Loose-fittingfalseteethàmayberesponsibleforulcers
• Decayedteethàmayberesponsibleforfetor(badbreath)
• Poordentition&gingivitisàmarkersofself-neglect
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Findings Descriptions&Significances Pictures
Gum
Gum
hypertrophy
• Causes:o Phenytoin
o Pregnancy
o Scurvy(vitaminCdeficiency:thegumsbecomespongy,red,bleedeasilyandareswollenandirregular)
o Gingivitis,e.g.fromsmoking,calculus,plaque,Vincent'sangina(fusobacterialmembranoustonsillitis)
o Leukaemia(usuallymonocytic)
Tonsils
Pigmented
lesionin
mouth
• Lookforenlargement,pus,
inflammation
• Lookforanydeviation
Mouth&lips
Angular
stomatitis
• Painfulcracksincorner• Maybeduetocandidalinfection,chronicanemia,vitamindeficiencies
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FINDINGS
Ø Inspectionfindingscanbedividedinto:[C.U.S.P2.]
o Contour(shape,symmetry,bulge,distension,masses,stoma,hernia)o Umbilicus
o Skin(scars,striae,dilatedveins,rashes/lesions)o Peristalsis
o Pulsation
Findings Descriptions&Significances Pictures
ContourFlat • Abdomenisnormallyflatorslightly
scaphoidandsymmetrical• Atrest,respirationisprincipallydiaphragmaticàabdominalwallmovesout&liver,spleenandkidneysmovedownwardsduringinspiration
Scaphoid • Malnourishment• Dehydration
Rounded • Obesity
Protruberant • Generalizeddistentionwithinvertedumbilicusàobesity,recentgas
• Generalizeddistentionwithevertedumbilicusàascites,tumor,umbilicalhernia
Localbulging • Distensionoflowerhalfàovariantumor,pregnancy,distendedbladder
• Distensionofupperhalfàcarcinomatosis,pancreaticcyst,gastricdilatation
• Sidebulging
x=xyphoidu=umbilicusp=pubic
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Findings Descriptions&Significances Pictures
Abdominal
distension
• Decidewhetheritisgeneralized/localized?Fatorascites?
• Looktangentiallyacrossabdomen&fromthefootofbedàlookforanyasymmetryassociatedwithlocalisedmass(enlargedliver/bladder)
• Causes:6'F’s:o Fat(grossobesity)o Fluid(ascites)o Fetuso Flatus(gaseousdistensiondueto
bowelobstruction)o Faeceso 'Filthy'bigtumour(e.g.ovarian
tumourorhydatidcyst)or'phantom'pregnancy
Visiblemass • Inparticularlargelivermaybeseentomovebelowrightcostalmargin/largespleenbelowleftcostalmargin
Hernia • Checkforvisible&palpableimpulse
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Findings Descriptions&Significances Pictures
Lesions/
Rashes
• Inolderpatients,seborrhoeicwarts,rangingincolourfrompinktobrownorblack&haemangiomas(Campbellde
Morganspots)àcommonandnormal• Noteanystriae(stretchmark),bruisingorscratchmarks
• Mayhavevesiclesofherpeszosteràmayberesponsibleforsevereabdominalpainthatisofmysteriousoriginuntiltherashappears
• Sister-Mary-Josephnoduleàmetastatictumourdepositinumbilicus(anatomicalregionwhereperitoneumisclosesttoskin)
• DiscolorationofumbilicuswherefaintlybluishhueispresentinextensivehaemoperitoneumandacutepancreatitisàCullen'ssign(umbilical'blackeye)
• SkindiscolorationmayalsorarelyoccurinflanksinacutepancreatitisàGrey-Turner'ssign
• Stretchingofabdominalwallsevereenoughtocauseruptureofskinelasticfibresproducespinklinearmarkswithawrinkledappearanceàstriae
• Whenitiswideandpurple-colouredàCushing'ssyndromemaybethecause
• Causesofstriae:o Asciteso Pregnancyo Recentweightgaino Cushing’ssyndrome
• Striaealsocanbeseenontheshoulders,upperarms,back,thigh,buttock
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Findings Descriptions&Significances Pictures
Visibleveins
(Continued)
• Dilatedtortuousveinswithbloodflowsuperiorlyàcollateralveinsduetoobstructionofinferiorvenacava(duetotumour/thrombosisbutsometimesbecauseoftenseascites)
• Inthiscaseabdominalveinsenlargetoprovidecollateralbloodflowfromlegs,avoidingtheblockedinferiorvenacava
• TodistinguishcaputMedusaefrominferiorvenacavalobstruction:determinedirectionofflowbelowumbilicusàitwillbetowardslegsinformerandtowardsheadinlatter
• Superiorvenacavaobstructionàcausedistendedabdominalveins,whichallflowinferiorly
PulsationsPulsations
• Expandingcentralpulsationintheepigastriumàsuggestsabdominal
aorticaneurysm
• Abdominalaortacanoftenbeseentopulsateinnormalthinpeople
[Videoavailableinthesoftcopy]
PeristalsisVisible
peristalsis
• Mayoccuroccasionallyinverythinnormalpeople
• Usuallysuggestsintestinalobstruction• Pyloricobstructionduetopepticulceration/tumouràslowwaveofmovementpassingacrossupperabdomenfromlefttoright
• Obstructionofdistalsmallbowelàmovementsinaladderpatternincentreofabdomen
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Abdominalsurgicalscars(filledwithanswers)
PictureSourceCreatedAndDesignedBy:Dr.JosephChia
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10.AbdomenPalpation
TECHNIQUES
Preparation:
Ø EnsurethatyourhandsarewarmØ Ifbedislow,kneelorsquatbesideit/takeachairtositØ Askpatienttoshowyouwherethepainisandtoreportanytendernesselicited
duringpalpationØ AskpatientifanyparticularareaistenderandexaminethisarealastØ AskpatienttoplacearmsbythesidestohelprelaxabdominalwallØ EncouragepatienttobreathegentlythroughmouthØ Ifnecessary,askpatienttobendkneestorelaxabdominalwallmusclesSuperficialpalpation:
Ø Componentstocheckfor:o Masses/lumps/muscles
o Tenderness/reboundtenderness/guarding/rigidity
Ø PalpationineachregionisperformedwithpalmarsurfaceoffingersactingtogetherØ Forpalpationoftheedgesoforgansormasses,lateralsurfaceofforefingeristhe
mostsensitivepartofhandØ PalpationshouldbeginwithlightpressureineachregionØ Allmovementsofhandshouldoccuratmetacarpophalangealjoints&handshould
bemouldedtotheshapeofabdominalwallØ Useyourrighthand,keepingitflatandincontactwithabdominalwallØ Observepatient’sfaceforanysignofdiscomfortthroughouttheexaminationØ BeginwithlightsuperficialpalpationawayfromanysiteofpainØ Palpateeachregioninturn,andthenrepeatwithdeeperpalpationØ Testabdominalmuscletonebylight,dippingmovementswithyourfingersØ ItalsoservestoreassureandrelaxthepatientØ Notethepresenceofanyabdominaltenderness/lumps,muscularresistance,and
somesuperficialorgansandmassesineachregionØ Lookforguarding,reboundtenderness,rigidityØ Describeanymassàdescribeitssite,size,surface,shapeandconsistency,andnote
whetheritmovesonrespiration.Isthemassfixedormobile?Ø Abdominalmassesmaybecategorizedinseveralways:
o Physiologic(pregnantuterus)o Inflammatory(diverticulitisofthecolon)o Vascular(ananeurysmoftheabdominalaorta)o Neoplastic(carcinomaofthecolon)o Obstructive(adistendedbladderordilatedloopofbowel)
Ø AskthepatienttocoughanddeterminewherethecoughproducedpainØ Abdominalpainoncoughing/withlightpercussionàsuggestsperitoneal
inflammationØ Reboundtendernessàsuggestsperitonealinflammation
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Deeppalpation:
Ø Componentstocheckfor:o Deepermasses/tenderness
o Organsbasedàliver,spleen,kidneys;gallbladder,stomach,pancreas,bladder,bowel,aorta,appendix,testes
o Otherspecificàascites,succussionsplash,ventralhernia,abdominalwallmassØ Deeppalpationofabdomenisperformednext,thoughcareshouldbetakentoavoid
tenderareasuntiltheendoftheexaminationØ Deeppalpationisusedtodetectdeepermassesandtodefinethosealready
discovered.Anymassmustbecarefullycharacterizedanddescribed Ø Todetermineifamassissuperficialandintheabdominalwallratherthanwithin
abdominalcavityàaskpatienttotenseabdominalmusclesbyliftinghisheadØ Abdominalwallmasswillstillbepalpable,whereasintra-abdominalmasswillnotØ Decidewhetherthemassisenlargedabdominalorgan/separatefromsolidorgansØ Examineliver,gallbladder,spleenandkidneysinturnduringdeepinspiration.Keep
yourexamininghandstillandwaitfortheorgantodescend.Donotstartpalpationtooclosetothecostalmargin,missingtheedgeofliverorspleen
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Liverpalpation:
Ø Placeyourhandflatontheskinofrightiliacfossawithhandalignedparalleltorightcostalmargin
Ø Pointyourfingersupwardsandyourindexandmiddlefingerslateraltorectusmuscle,sothatyourfingertipslieparalleltorectussheath.Keepyourhandstationary
Ø Itisthe2nd&3rdfingersthatseekingtheliverØ Somepeopleprefertousedistalend/radialborderoftheindexfingerØ AskpatienttobreatheindeeplythroughmouthØ FeelfortheliveredgeasitdescendsoninspirationØ Witheachexpirationthehandisadvancedby1or2cmcloseruntilyoureachcostal
margin/detectliveredgeØ Duringinspiration,handiskeptstillandlateralmarginofforefingerwaits
expectantlyfortheliveredgetostrikeit
Ø TracetheliveredgebothlaterallyandmediallyØ Ifyoufeelliveredge,describe:
o Size
o Surfaceàsmoothorirregularo Edgeàsmoothorirregularo Consistencyàsoftorhardo Tenderness
o WhetheritispulsatileØ Additionally,placeyourlefthandbehindthepatient,paralleltoandsupportingthe
right11thand12thribsandadjacentsofttissuesbelowØ Bypressingyourlefthandforward,thepatient’slivermaybefeltmoreeasilyby
yourotherhand
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Liverspan:
Ø Toestimateliverspan,percussdownalongrightmid-clavicularlineuntiltheliverdullnessisencounteredandmeasurefromheretopalpableliveredge
Ø Moredetailswillbedemonstratedinabdominalpercussion
Hookingtechnique:
Ø The“hookingtechnique”maybehelpful,especiallywhenthepatientisobeseØ Standtotherightofthepatient’schestØ Placebothhands,sidebyside,ontherightabdomenbelowtheborderofliver
dullnessØ PressinwithyourfingersanduptowardthecostalmarginØ AskthepatienttotakeadeepbreathØ Theliveredgeshownbelowispalpablewiththefingerpadsofbothhands
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Gallbladder:
Ø Gallbladderisoccasionallypalpablebelowrightcostalmarginwherethiscrosseslateralborderofrectusmuscles
Ø Ifbiliaryobstructionoracutecholecystitisissuspected,examininghandshouldbeorientedperpendiculartocostalmargin,feelingfrommedialtolateral
Ø Murphy'ssignshouldbesoughtifcholecystitisissuspected
Ø ExaminingforenlargedgallbladdermustalwaysbemindfulofCourvoisier'slawØ Kehr’ssignàoccurrenceofacutepainoverthetipofshoulderduetopresenceof
bloodorotherirritantsinperitonealwhenapersonislyingdownandwhenlegsareelevated
Ø Boas'ssignàhyperaesthesia(increasedoralteredsensitivity)belowtherightscapula(between9th&11thribsposteriorlyright)canbeasymptominacutecholecystitis(inflammationofthegallbladder)
Ø Ortner’ssignàtendernesswhenhandtapstheedgeofrightcostalarchØ Shotkin-blumbergsignàreferstopainuponremovalofpressureratherthan
applicationofpressuretotheabdomen(reboundtenderness)
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Succussionsplash/stomach:
Ø Insuspectedgastricoutletobstruction,afterwarningpatientwhatistocome,grasponeiliaccrestwitheachhand,placeyourstethoscopeclosetoepigastriumandshakepatientvigorouslyfromsidetoside
Ø Thelisteningearseagerlyawaitasplashingnoiseduetoexcessivefluidretainedinobstructedstomach
Ø Thetestisnotusefulifthepatienthasjustdrunkalargeamountofmilkorotherfluidforhisorherulcer
Ø Clinicianmustthenreturn3hourslater,havingforbiddenthepatienttodrinkanythingfurther
• AlsoknownasCVAtenderness,Murphy's
punchsign,Pasternacki'ssign,orGoldflam'ssign(Latin:succusiorenalis)
• Costovertebralangleàananglemadebyvertebralcolumn&costalmargin
• Inthistest,painiselicitedbypercussionoftheareaofthebackoverlyingthekidney
• Becausethekidneyisdirectlyanteriortothisarea,knownascostovertebralangle,tappingdisturbstheinflamedtissue,causingpain
• Thetestispositiveinàinfectionaroundthekidney(perinephricabscess),pyelonephritis,hemorrhagicfeverwithrenalsyndromeorrenalstone
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Components Descriptions&Significances Pictures
Psoassign • Placeyourhandjustabovethepatient’srightkneeandaskthepatienttoraisethatthighagainstyourhand
• Alternatively,askthepatienttoturnontotheleftside.Thenextendthepatient’srightlegatthehip
• Flexionofthelegatthehipmakesthepsoasmusclecontract;extensionstretchesit
Obturatorsign • Flexthepatient’srightthighatthehip,withthekneebent,androtatetheleginternallyatthehip
• Thismaneuverstretchestheinternalobturatormuscle
Cutaneous
hyperesthesia
• Ataseriesofpointsdowntheabdominalwall,gentlypickupafoldofskinbetweenyourthumbandindexfinger,withoutpinchingit.Thismaneuvershouldnotnormallybepainful
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Spleenvs.kidneys:
Spleen Differences Kidneys
Morelikelysmoothandregularinshape
Surface&shape Polycystickidneysarebilateralirregularmasses
Yes,travelssuperficiallyanddiagonally/inferomedially
Massdescendsin
inspiration
Yes,movesdeeplyandvertically/inferiorly
Yes Abilitytofeeldeepto
themass
No
Yes Palpablenotchon
medialsurface
No
No Bilateralmasses
palpable
Sometimes,e.g.polycystickidneys
No Percussionresonant
overthemass
Sometimes(liesposteriortoloopsofgas-filledbowel)
Sometimes Massextendsbeyond
themidline
No(exceptwithhorseshoekidney)
Nopalpableupperborder(spacebetweenspleen&costalmargin)
Upperborder Palpableupperborder
Usuallynotballotable Ballottement Ballotable(retroperitoneal)
Mayoccasionallybeheard Frictionrub Neveroverthekidneybecauseitistooposterior
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Abdominalmasscauses:
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Abdominalpaincauses:
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11.AbdomenPercussion
TECHNIQUES Ø AskthepatienttoholdhisbreathinfullexpirationØ Percussdownwardsfromright5
thintercostalspaceinrightmid-clavicularline,
listeningforthedullnessthatindicatesupperborderoftheliverØ Measurethedistanceincmbelowtherightcostalmargininrightmid-clavicularline
orfromtheupperborderofdullnesstopalpableliveredgeØ Componentstolookforinpercussion:
o Liverspano Spleeno Ascitesàshiftingdullness,fluidthrill/wave,puddlesign,dippingmethod
Liverspan:
Ø Toestimateliverspan,percussdownalongrightmid-clavicularlineuntiltheliverdullnessisencounteredandmeasurefromheretopalpableliveredge
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Ascites:
Shiftingdullness:Ø Withpatientsupine,percussfrommidlineouttotheflankswithfingerpointing
towardsthefeet
Ø Noteanychangefromresonanttodull,alongwithareasofdullnessandresonanceØ Keepyourfingeronthesiteofdullnessintheflank&askpatienttoturnontohis
oppositeside
Ø Pausefor10secondstoallowanyascitestogravitate,thenpercussagainØ Iftheareaofdullnessisnowresonant,shiftingdullnessispresent,indicatingascites
Fluidthrill/wave:Ø Iftheabdomenistenselydistendedandyouarenotcertainwhetherascitesis
present,feelforafluidthrillØ Placethepalmofyourlefthandflatagainsttheleftsideofpatient’sabdomenand
flickafingerofyourrighthandagainsttherightsideofabdomenØ Ifyoufeelarippleagainstyourlefthand,askanassistant/patienttoplacetheedge
ofhishandonthemidlineofabdomentopreventtransmissionofimpulseviatheskinratherthanthroughascites
Ø Ifyoustillfeelarippleagainstyourlefthand,fluidthrillispresent(onlydetectedingrossascites)
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Puddlesign:Ø PatientkneelingonallfoursØ SensitivetodetectsmallamountoffluidØ However,itisundignified
Dippingmethod:Ø Whensignificantascitesispresent,abdominalmassesmaybedifficulttofeelby
directpalpation,thereforedippingmethodcanbeused(sharp&rapidmovement)Ø Usingthehandplacedflatontheabdomen,thefingersareflexedat
metacarpophalangealjointsrapidlysoastodisplaceunderlyingfluidØ Liverandspleenmaybecomeballottablewhengrossascitesispresent
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Scratchtest:
Ø Toidentifyliverborderifabdomenisverytender,tenseordistended
Ø Placestethoscopebelowthexiphoidandlightlybutbrisklystroketheskininadirectionatrightanglestotheexpectedliveredge,startingattherightlowerquadrant&slowlyuptotherightcostalmarginalongmidclavicularline
Ø Whenliveredgeisreached,soundofscratchistransmittedtostethoscope
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FINDINGS
Ø HerniaàprotrusionofanorganthroughitscontainingwallØ Itcanbeappliedto:
o Herniationofamusclethroughitsfascialcoveringo Herniationofbrainthroughaskullfracture/throughforamenmagnumintothe
spinalcanalo Protrusionofanintra-abdominalorganthroughadefectinabdominalwall,pelvis
ordiaphragmØ Theremustbeaweaknessinthatwallbeforeanorgancanherniatethroughits
retainingwallàmaybeduetocongenitalabnormality,oracquiredasresultoftraumaordisease
Ø Abdominalherniagenerallycanbeclassifiedinto2types:A. Internal
o Paraduodenal(right&left)o ForamenofWinslowo Intersigmoido Pericecal/paracecal,retrocecalo Transmesenteric,transmesocolic,transomentalo Retroanastomotico Falciformligament,broadligamento Supravesical,paravesical,pelvico Hiatushernia(type1/sliding,type2/rolling/paraesophageal,type3/
mixed)o Diaphragmatichernia
B. Externalo Inguinal(direct&indirect)o Umbilical(congenital&acquired)o Paraumbilicalo Incisionalo Femoralo Epigastrico Spigelian(herniaoflineasemilunaris)o Obturatoro Lumbar(Petit’strianglehernia)o Glutealo Separationofrectiabdominishernia
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Internalhernias
Externalhernias
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FINDINGS
Normalfindings
Ø Normalrectumisusuallyemptyandsmooth-walledØ Thenormalprostateàsmoothandhasfirmconsistency,withlaterallobesanda
mediangrooveinbetween/bilobedmasswithcentralfurrowØ Thenormalprostateisafirm,rubbery.ItbecomesfirmerwithageØ Theupperendofanalcanalismarkedbypuborectalismuscle,whichisreadily
palpableandcontractsasareflexactiononcoughingoronconsciouscontractionAbnormalfindings
Findings Descriptions&Significances Pictures
InspectionThrombosed
external
haemorrhoids
(piles)
• Small(<1cm),tensebluishswellings
• Painful&duetoruptureofaveininexternalhaemorrhoidalplexus
• Alsocalledperianalhaematomas• Haemorrhoids(‘piles’,congested
venousplexusesaroundtheanalcanal)areonlypalpableifthrombosed
Skintags • CanbeanincidentalfindingoroccurwithhaemorrhoidsorCrohn's
disease
Rectalprolapse • Circumferentialfoldsofredmucosaarevisibleprotrudingfromanus
• Gappinganusàsuggestlossofinternalandexternalsphinctertone
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Findings Descriptions&Significances Pictures
Analfissure
(fissure-in-ano)• Crackintheanalwallwhichmaybe
painfulenoughtopreventrectalexamination
• Usuallyoccurdirectlyposteriorly&inthemidline
• Atagofskinmaybepresentatthebaseàcalledsentinelpile&indicatesthatthefissureischronic
• Multipleorbroad-basedfissuresàmaybepresentininflammatoryboweldisease,malignancyorvenerealdisease
Fistula-in-ano • Usuallywithin4cmofanus• Themouthhasaredpouting
appearancecausedbygranulationtissue
• MayoccurwithCrohn'sdiseaseorperianalabscess
Condylomata
acuminata
(analwarts)
• Pedunculatedpapillomaswithawhitesurfaceandredbase
Carcinomaof
anus• Maybevisibleasafungatingmass
attheanalverge
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Stoolappearance Cause Pictures
Blackandtarry
(melaena)
• Bleedingfromtheuppergastrointestinaltract
Grey/black • Oralironorbismuththerapy
Silvery • Steatorrhoeaplusuppergastrointestinalbleeding,e.g.pancreaticcancer
Freshbloodinor
onstool
• Large-bowel,rectaloranalbleeding
Stoolmixedwith
pus
• Infectivecolitisorinflammatoryboweldisease
Ricewaterstool
(waterywith
mucusandcell
debris)
• Cholera
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REFERENCES
1. OxfordClinicalSkills–OxfordCoreTexts2. BatesGuidetoPhysicalExaminationandHistoryTaking(InternationalEdition)3. TalleyandO’Connor-ClinicalExaminationASystematicGuidetoPhysicalDiagnosis4. MacLeod’sClinicalExamination5. Hutchison’sClinicalMethods6. Browse’sIntroductionToTheSymptomsAndSignsOfSurgicalDiseases7. Harrison’sPrinciplesofInternalMedicine8. Davidson’sPrinciplesandPracticeofMedicine9. Kumar&ClarksClinicalMedicine10. OtherjournalsandarticlesFOLLOWUS&LIKEUS____
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