Forewords - Medical Success Insiders (MSI)

MEDICAL SUCCESS INSIDERS (MSI)

© DR. JOSEPH @ WWW.MSIMASTERCLASS.COM ALL RIGHTS RESERVED SIGN UP IN WWW.FRIENDOCT.COM TO ASSESS TO SOFTCOPY

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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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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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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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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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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


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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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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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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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


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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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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