Abdomen examination

Hand rub!!! Ask for a chair

Introduce to patient
 Selamat pagi, encik/puan. Nama Saya_______, saya pelajar perubatan unimas. Saya nak periksa
badan sekejap. Kalau ada sakit, sila bagi tahu.
Position the patient at flat!!
Expose the patient
 Male: take off shirt, put at aside nicely and tell patient: saya akan letak baju di sini, kalau rasa sejuk,
sila bagi tahu.
 Female: best if can take off shirt & and cover up for courtesy when not checking.
After proper exposure, go to the end of the bed and look for
 Jaundice? Sallow? Polycythemic (erythropoietin injection in PKD pt)
 Malnourished? Cachexic?
 Abdomen full flank? Distended?
 Any obvious tatoos
 Any device: tenchkoff catheter
Go back to right side of the bed, ask any pain in the hand? Sila ikut saya buat (outstretch hand)
 Dorsum: Check for clubbing (eye same level with nail), leuconychia(hypoalbuminemia)
 Flapping tremor (hepatic flap/uremic flap)
 Palmar: check for palmar erythema, dupuytren’s contracture (alcoholism)
Arm
 AV fistula
 Tattoos
 Bruises (coagulopathy)
 Needle injection mark
 Scratch marks (bile salt deposition/ uremic symptoms)
Eye
 Jaundice
 Kayser-fleirscher ring
 Pallor/polycythaemia
 xanthelasma
Mouth
 gum hypertrophy (in renal transplant pt with long term cyclosporin)
 Parotid gland swelling (alcoholism)
Neck
 JVP: signs of fluid overload
Chest
 Spider naevi
 Gynaecomastia
 Loss of axillaries hair
 Hypertrichosis (excess hair d/t long term cyclosporin in renal transplant pt)
Abdomen
Inspection
 Distended? Full flank?
 any surgical scar(don’t miss the lateral & back)
 Any prominent dilated veins (caput medusae)
 Scratch marks?
Palpations (asks for a chair if not yet ask & SIT DOWN!!!!!)
 Soft palpation: soft? Tender? Any obvious swelling?
 Deep palpation:
o Liver: soft/hard/ Firm? Sharp edge? Smooth/nodular? Size? Liver span?
 o Spleen: soft/hard? splenic notch? traube space dull? Size?
o Kidney: size?
Percussion
 Ascites: shifting dullness?
Auscultation
 Liver bruit
 Splenic bruit
 Renal bruit
 Bowel sound
Turn the pt with back facing you
 Check lymph nodes : Virchow’s node (Upper GIT malignancy)
 Any spider naevi at the back
 Any surgical scar (nephrostomy? Nephrectomy?)
Leg
 Edema
Complete examination by checking the BP/urinalysis for haematuria
If suspect is PKD case: I would like to check for BP, cranial nerve examinations specifically look for CN3 palsy
dt posterior communicating artery aneurysm

Presentation
This pt is comfortable. He is otherwise pink/jaundice/ cyanosed. He is not cachexic.
There was no clubbing, no other peripheral stigmata of chronic liver disease except loss of axillary hair. There
was no sign of hepatic encephalopathy.
The parotid glands were not palpable.
There was no gum hypertrophy, no palpable cervical lymph nodes.
On inspection
There was no scar, no dilated veins. The abdomen was distended with stretched umbilicus/ full flank
It was soft and non tender.
The liver was palpable, ____cm below the coastal margin, smooth surface and sharp edge.
The spleen was palpable, ____cm below the coastal margin, not tender (splenic vein thrombosis).
The kidneys were ballotable
There was no clinical evidence of ascites
There was no bruit and bowel sound was normal
In conclusion, this pt is having hepatosplenomegaly with jaundice./
In conclusion, this pt is having bilateral kidney enlargement, most like dt PKD & in failure evidence by AVF.

Investigation
 Child pugh’s criteria: Albumin level, total bilirubin level, coagulation profile,
 if suspect PKD,
o USG Kidney to confirm diagnosis
o Kidney biopsy
o USG liver, pancrease& spleen for cyst
o CT scan/ MRI brain for aneurysm

Management
 Liver
o prevent decompensation by making sure adequate hydration, make sure bowel output
good
o Specific: antiviral medication, stop alcohol if drinking alcohol
o Non specific: lactulose if constipated or uremic, surveillance by monitoring the LFT & USG
 PCD
 o USG if more than 20years old, genetic screen if less than 20years old
o Screen for complication
o Erythropoietin injection
o Kidney transplant
 Thalassemia
o Genetic screen & screen family
o Give folate
o Transfuse FFP if needed
o Monitor the complication of the disease & treatment side effect
o Biohazard screen 6 monthly
 Hepatic encephalopathy
o Treat underlying causes
o Lactulose
o Oral neomycin to eradicate gut flora
Complication of Thalassemia
 iron overload
 DM
 Short stature
 Pseudogout (calcium)
 Heart failure

Causes of splenomegaly
CHINA
Congestion: portal hypertension
Hemolytic anemia: Thalassemia, hereditary spherocytosis
Infection- typhoid, typhus, malaria, IE
Neoplasia- myeloproliferative, lymphoproliferative
Autoimmune-CTD

Causes of massive splenomegaly

3M
Malaria (chronic)
CML
Myelofibrosis

Complication of chronic liver disease

HEPATIK
Hepatic encephalopathy
Portal hypertension
Ascites
Tumour (hepatoma)
Infection (spontaneous bacterial peritonitis)
Kidney failure (hepatorenal syndrome)

Precipitating factor for hepatic encephalopathy

HEPATICS
Hemorrhage Surgery
Electrolyte (hypokalemia) Constipation
Protein rich diet Infection
Alcohol/analgesia
Trauma