Alimentary: Examination
- Environment, general appearance
- Nails, hands, arms
- Eyes, mouth, neck, chest ,back
- Abdomen inspection
- Abdomen palpation: general,
liver, gallbladder,
spleen, kidneys,
stomach, pancreas,
aorta, bowel, testes
- Abdomen percussion, ascites,
auscultation
- Groin, hernias,
rectal, legs
- NG tube.
- Feeding tube.
- Cans of special food.
- Colors:
• Anemic (iron malabsorption, hemorrhage, CA).
• Jaundiced (liver dz).
• Hyperpigmented (hemochromatosis).
• See Skin Colors Reference.
- Hydration and nutrition.
- Weight loss vs. gain, wasting.
- Shocked.
- Postural hypotension.
- CLUBBING (UC or Crohn's, Biliary cirrhosis, GI
malabsorption).
- Koilonychia (iron deficiency 2° to GI bleeding).
- Leuconychia (hypoalbuminism 2° to cirrhosis).
- Muehrke's lines (hypoalbuminism 2° to cirrhosis).
- Blue lunulae (Wilson's).
- Nicotine stains (some GI CA's).
- See Nails Reference.
- Asterixis (PSE 2° to alcoholism):
• Pt. stretches out hands in policeman's stop position, fingers spread
out.
• Coarse flapping tremor, "liver flap", is seen.
- Pallor of palmar creases (anemia 2° to blood loss, malabsorption).
- Palmar erythema (cirrhosis).
- Dupuytren's contracture [fibrosis, contracture of palm's fascia, usu
contracting ring finger] (alcoholism, manual labor).
- Palmar xanthomata [yellow deposists on palm of hand] (Type III
hyperlipidemia).
- Tendon xanthomata [yellow deposits on dorsum of hand, arm] (Type II
hyperlipidemia).
- Scratch marks (itch from jaundice).
- Spider naevi (alcoholism).
- Bruising (clotting factors 2° to liver damage).
- Tuboeruptive xanthomata [yellow deposists on elbows, knees] (Type III
hyperlipidemia).
- Cornea rings (Wilson's).
- Sclera: jaundice.
- Iritis: IBD.
- Xanthelasma [yellow plaque periobital deposits] (elevated cholesterol).
- Temporalis muscle wasting.
- Lips:
• Telangiectasia (Osler-Weber-Rendu)
• Brown freckles (Peutz-Jeghers).
- Breath:
• Fetor hepaticus (alcoholism).
• Ethanol.
- Mouth:
• Ulcers (Crohn's, coeliac dz).
• White candida patches (spread down throat).
• Cracks at mouth edges (iron deficiency anemia).
- Teeth:
• Cavities (acid 2° to vomiting).
• Nicotine stains.
- Gums:
• Hypertrophy.
• Bleeding.
• Gingivitis.
- Tongue:
• Leucoplakia (smoke, spirits, sepsis, syphilis,
sore teeth).
• Atrophic glossitis [withered tongue] (deficiencies, Plummer-Vinson).
• Macroglossia (B12 deficiency).
- Cervical nodes:
• Supraclavicular nodes for Virchow's node (lung CA, GI malignancy).
• See Nodes Reference.
- Gynecomastia (chronic liver dz).
- Hair loss (chronic liver dz).
- Back: neurofibromas.
- Pt is supine, abdomen visible from nipples to pubic symphysis.
- Scars. See Abdominal Scar Reference.
- Stoma from surgery, trauma.
- PEG (dysphagia, usu. 2º to neurological damage, like stroke).
- Distension (fat, fetus, feces, flatus, fluid,
full-sized tumors).
- Local swellings (enlarged organs, hernia). See Examining
A Mass Reference.
- Pulsations (AAA).
- Peristalsis visible (thin person, intestinal obstruction).
- Skin:
• Herpes zoster (abdominal pain).
• Grey-Turner's sign [discolored skin] (acute pancreatitis).
- Striae:
• Regular striae (ascities, pregnancy, weight loss).
• Purple, wide striae (Cushings).
- Dilated veins location:
• Anterior leg (IVC block).
• Caput medusae (portal HTN).
• Costal margin (normal).
- Dilated vein flow direction. Test by occluding with fingers:
• Flows superior (IVC block).
• Flows inferior (SVC block).
• Navel radiation (portal HTN).
- Umbilicus:
• Sister Joseph nodule (metastatic tumor).
• Cullen's "black eye" (acute pancreatitis, extensive
hemoperitoneum).
- Groin: brown freckles (Peutz-Jeghers).
- Squat to pt's stomach level, and watch for asymmetrical movement during
breathing (mass, large liver).
- Warm hands.
- Ask pt if any part tender: examine that last.
- Abdominal muscles relaxed, pt bends knees if necessary.
- Light palpation.
- Deep palpation.
- Note rigidity, rebound tenderness, involuntary guarding (peritonitis).
- Record mass characteristics. See Examining A Mass Reference.
- Distinguish abdominal wall mass from intrabdominal mass:
• Pt folds arms and
sits halfway up.
• Wall mass if size is same, tenderness same or greater.
- Find edge:
• Dr's R hand held still at base of RLQ, parallel to costal margin.
• Ask pt. to breathe slowly.
• During each inspiration, see if liver edge strikes radial edge of index
finger.
• During each expiration, Dr's hand moves superiorly 2cm.
- Palpate liver surface, edge:
• Hard vs. soft.
• Regular vs. irregular.
• Tender vs. not.
• Pulsatile (tricuspid incompetence) vs. not.
- Find top border by
percussing down R midclavicular line [normal: 5th rib in midclavicular
line].
- Calculate span [normal span: 12.5cm].
- Dr's fingers placed perpendicular to R costal margin near midline, then
moved medial to lateral to palpate.
- Do Murphy's sign: cessation of inspiration upon palpation.
• Murphy's point: costal margin in midclavicular line.
• Courvoisier's law: Stones= stays small since scarred.
- Bimanual technique:
• Dr's L hand posterolaterally, below pt's L ribs, compressing on rib
cage.
• Dr's R hand below pt's umbilicus, parallel to L costal margin.
• Advance R hand superiorly to L costal margin.
• 1.5x-2x enlarged spleen is palpable.
• If miss spleen, roll pt. towards Dr. (so pt lies on pt's R side) and
repeat palpation.
- Alternatively: palpate like liver edge with just R hand, starting from RLQ
diagonally over to LUQ.
- Alternatively: combine the two methods: start to palpate from RLQ like
liver edge with just R hand, but then as get closer, reach with L hand
around to pt's L ribcage and pull, while continuing advancing with R
hand.
- Assess spleen characteristics [these also help differentiate from kidney]:
• Size
• Shape, notch vs. no notch.
• Percussion dullness vs. not.
• Moves on respiration vs. not.
- Dr's L heel of hand slipped under pt's R loin, L fingers under R back.
- R hand held over RUQ.
- Dr flexes L MCPs in renal angle.
- Dr R hand feels strike as kidneys float anteriorly.
- Repeat for other side.
- Perform on empty stomach.
- Stethoscope on epigastrium.
- Then shake both iliac crests.
- While shaking, listen to splash from retained fluid.
- Audible splash called "succussion splash" (ulcer or gastric CA).
- Palpate for a round, fixed, swelling above umbilicus that doesn't move
with inspiration (pseudocyst, acute pancreatitis, CA in thin pt).
- Palpate in midline, superior to umbilicus.
- Dr's 2 fingers on outer margins of aorta, watch if if fingers
diverge (AAA).
- Normally felt in thin pt.
- Sigmoid usu. palpable in severe constipation.
- Whether indents (feces) or doesn't indent (masses).
- Sometimes can feel CA, megarectum.
- Ask pt when last urinated, and whether was complete emptying..
- Usually palpable if full, usually not palpable if empty.
- Look for palpable, empty bladder (swelling).
- Liver border for loss of of dullness (necrosis, perforated bowel).
- Spleen for splenomegaly.
- Kidneys.
- Bladder for enlarged bladder, pelvic mass.
- Percuss masses. See Examining A
Mass Reference.
- Shifting dullness:
• The Dr's percussing finger placed vertically, so Dr's finger pointing
toward pt's legs.
• Starting at midline, percuss laterally to dullness on L flank, and mark
site of dullness with non-permanent marker.
• Roll pt towards Dr., so pt now laying on R side.
• Pt stays lying on R side for 30min, then repercuss while still lying on
R side.
• Ascites present if the dullness has moved medially (ie the point of
dullness is now resonant).
• Optionally: percuss laterally on both R and L flanks, and mark both
before rolling pt, so can assess them both moving.
- Dipping:
• Flex MCP joint fast to displace fluid and palpate a mass.
- Fluid thrill:
• Dr. puts hands on each of pt's flanks.
• If obese, pt places pt's lateral edge of hand, vertically on midline at
umbicus.
• Dr. flicks hand on right flank, by quickly flexing MCPs.
• Ascites if Dr feels resulting thrill on left flank.
- Below umbilicus to assess bowel sounds for:
• Rushing sound called "borborygmi" (diarrhea).
• No sound for 3 minutes (ileus, paralysis).
• "Tinkling" sound (obstructed bowel).
- Above umbilicus for:
• AAA bruit.
• Venus hum [blood flowing in caput medusae] (portal HTN).
- R and L above umbilicus for renal artery stenosis.
- Over liver for:
• Friction rub [grating during breathing] (peritonitis, Fitz-Hugh-Curtis, others).
• Bruit (CA, alcoholic hepatitis).
- Over spleen for splenic rub (splenic infarct).
- Edema.
- Bruising.
- Tuboeruptive xanthomata [yellow deposists on elbows, knees] (Type III
hyperlipidemia).
- If chronic liver dz, See Neurological
Examination.
- Toenails and foot showing same symptoms as Fingernails
and Hands.