Tag: flapping tremor

In patient assessment, following the process of history-taking, we’ll be looking into performing a thorough examination of the abdomen.

Examination of the Abdomen Outline

1. general considerations
2. examining the hands
3. examining the eyes
4. examining the mouth
5. palpating the cervical lymph nodes
6. examining the patient’s chest
7. examining the abdomen

1. General Considerations

• ensure your hands are warm – patient comfort
• during palpation check for signs of pain in patient’s face eg. grimacing
• expose the abdomen including the inguinal regions (not the genitalia) while the patient is lying flat with one pillow
• if patient has a nasogastric tube notice the aspirate
• if patient has a urine catheter notice the urine bag
• if patient has an IV line notice what is being administered
• if patient has a drain following a laparoscopy check drain for massive amount of blood, urinary output, IV fluids, NG tube aspirate, and pain relief administration

2. EXAMINING THE HANDS

FINGER CLUBBING

• check for finger clubbing caused by interstitial oedema and dilation of the arterioles and capillaries
• assess for finger clubbing by checking for the loss of the normal angle between the nail and the nail bed, and fluctuation of the nail bed
• advanced finger clubbing may be featured through swelling of the subcutaneous tissues over the base of the nail causing the overlying skin to become tense, shiny and red, increase in the curvature of the nail especially in its long axis, and swelling of the pulp of the finger
• finger clubbing causes may include gastrointestinal issues such as inflammatory bowel disease (a term for two conditions – Crohn’s disease and ulcerative colitis, that are characterized by chronic inflammation of the GI tract), and liver cirrhosis (scarring of the liver caused by continuous, long-term liver damage)

KOILONYCHIA

• thin concave spoon-shaped nails commonly found in anaemia due to iron deficiency

LEUCONYCHIA

• white discolouration of the nails (possibly totally opaque) commonly found in patients with a low serum albumin a.k.a. hypoalbuminaemia

BROWN LINES

• a brown line close to the nail’s end may be present in patients with chronic renal failure

PALLOR

• pallor of the skin creases may be a sign of anaemia
• thalassemia major (a severe recessive genetic disorder of hemoglobin structure with hemolysis or rapid breakdown of red blood cells resulting in anemia and iron overload in the heart, liver and other organs), sickle cell disease (red blood cells become hard and sticky and look like a C-shaped farm tool called a “sickle”), iron deficiency (due to malnutrition or heavy menstrual bleeding or IBD, celiac disease, Vitamin B12 deficiency, folic acid) and leukaemia (malignant progressive disease in which the bone marrow and other blood-forming organs produce increased numbers of immature or abnormal leucocytes which suppress the production of normal blood cells) may all lead to anaemia and consequentially pallor of the skin creases

PALMAR ERYTHEMA

• redness involving the heel of the palm, and occasionally the fingers; symptoms include non-itching, symmetrical, painless, and slight warmth in redness areas
• common in patients with liver disease, thyrotoxicosis (a clinical state of inappropriately high levels of circulating thyroid hormones T3 and/or T4 in the body), rheumatoid arthritis (chronic inflammatory disorder), but also possible in pregnant women due to hormonal changes

DUPUYTREN’S CONTRACTURE

• thickening of the palmar fascia which causes flexion contracture commonly affecting the ring and little finger
• commonly found in patients with chronic liver disease

FLAPPING TREMOR

• ask patient to outstretch arms with the wrists in extension; in this position, the downward intermittent flap of the hands is exaggerated
• flapping tremor can be seen in patients with liver disease and chronic renal failure

3. EXAMINING THE EYES

PALLOR

• pallor of the mucous membranes eg. the conjunctival mucosa (happens when the haemoglobin level is <9-10g/dl

JAUNDICE

• yellowish discolouration of the sclerae, mucous membranes and skin due to high concentration of Bilirubin in the blood; easily detected in daylight but may be missed in artificial lighting

4. EXAMINING THE MOUTH

TONGUE

• assess the patient’s tongue for dehydration (dry, coated tongue which looks white and furry)
• pale and atrophic tongue can be seen in iron deficiency anaemia
• beefy red and painful tongue can be seen when the patient is deficient in B12

BREATH SMELL

• a ‘fishy’ breath smell indicates uaremia (raised level in the blood of urea and other nitrogenous waste compounds that are normally eliminated by the kidneys)
• a ‘mousy’ breath smell indicates liver failure
• a ‘fruity’ breath smell indicates presence of ketones in diabetic ketoacidosis
• a ‘wine-like’ breath smell indicates renal failure
• a ‘bad’ breath smell may also be caused by sleeping with an open mouth

5. PALPATING THE CERVICAL LYMPH NODES

• Virchow’s node is an enlarged hard lymph node which can be found in the left supraclavicular fossa; it is indicative of abdominal neoplasm (abnormal growth that occurs within the abdomen)

6. EXAMINING THE PATIENT’S CHEST

SPIDER NAEVI

• central spiral arteriole that supplies a radiating group of small blood vessels, which, if occluded by pressure, blanches
• commonly found in the upper part of the body above the nipple line especially in areas exposed to sunlight
• healthy people, including pregnant women and patients on oestrogen therapy may have one or two spider naevi, which is considered to be normal
• a large number of spider naevi is commonly found in liver disease

PURPURA

• purpura shows up when capillaries bleed into the skin
• purpura commonly shows up in patients with a low platelet count caused by haematological malignancies or patients with chronic liver disease along with coagulation defects

GYNAECOMASTIA

• gynaecomastia is enlargement of the breasts in males
• can be discovered by feeling gently around the nipples
• gynaecomastia may be caused by puberty, chronic liver disease, bronchial carcinoma, and drugs such as digoxin and spirinolactone

7. examining the abdomen

ABDOMEN QUADRANTS

SWELLING

• swelling may be caused by the 5 F’s in Abdo Distention, namely fluid, fat, flatus, faeces or foetus
• swelling may also be a sign of hepatomegaly, incisional hernia, or abdominal mass

EPIGASTRIC PULSATIONS

• epigastric pulsations can be due to aortic pulsations in a thin patient or an aortic aneurysm (a balloon-like bulge in the aorta – see further below for more information on palpating for aortic aneurysm)

DISTENDED SURFACE VEINS

• commonly found in portal hypertension, usually radiating from the umbilicus (Caput Medusae) and in obstruction of the inferior vena cava

SCARS

• a midline scar may indicate a gastroduodenal, pancreatic or spleen surgery
• a right subcostal scar may indicate a cholecystectomy or appendicectomy
• a suprapubic scar a.k.a. Pfannensteil incision may indicate pelvic surgery or cesarean section

STOMAS

• an ileostomy can be found in the right iliac fossa as a spout of mucosa protruding from the abdominal wall with a continuous flow of effluent
• a colostomy can be found in the left iliac fossa if permanent, or in the right hypochondrium or left iliac fossa if temporary; it is flat in appearance (mucosa is sutured to skin) with intermittent effluent

PERISTALSIS

PALPATION

• ask patient if any abdominal discomfort is present, and if yes, where
• ensure that your hands are warm
• to palpate, use the flat surface of your fingers and keep your forearm at level with the abdominal wall
• palpate the abdomen gently, leaving any painful areas for last; note any signs of pain on the patient’s face, rigidity, or tenderness
• repeat palpation in a firmer deeper way, feeling for abnormal masses
• if a mass is felt, note position, size, shape, surface (smooth or irregular), edge (clear or poorly defined), consistency, pulsatility, percussion note (dull or resonant), and presence of bowel sounds

PALPATION OF THE LIVER

• to palpate the liver start in the right iliac fossa; when the patient breathes in and out, move your hand upwards bit by bit until you reach the costal margin
• check for hepatomegaly (enlargement of the liver) and if present, note size in cm below the costal margin; hepatomegaly causes include metastases (eg. bowel carcinoma), congestive heart failure, cirrhosis (early stage), and infections (eg. viral hepatitis, infectious mononucleosis)
• check liver edge – smooth edge may signify congestive heart failure; knobbly edge may signify metastases
• check consistency – liver feels hard in the case of metastases
• check for tenderness – happens when liver capsule is distended; indicates congestive heart failure, hepatitis or hepatocellular carcinoma
• check for pulsatility – happens in the case of tricuspid regurgitation

PERCUSSION OF THE LIVER

• start percussion of the liver further up from the fifth intercostal space and move down to the mid-clavicular line
• the liver is dull to percussion
• normal liver does not extend beyond 1 cm below the costal margin on deep inspiration

PALPATION OF THE SPLEEN

• the spleen acts as a filter of the blood, filtering for bacteria, parasites, and fungi; the spleen has white blood cells to protect against septicaemia (infection of the blood)
• start palpating the spleen from the right iliac fossa
• as the patient breathes in and out, move your hand towards the tip of the tenth rib; on reaching the costal margin, place your left hand around the lower left rib cage and palpate with your right hand in the midaxillary line
• a slightly enlarged spleen can best be felt if the patient half rolls over onto his right side
• a large spleen would sound dull in percussion
• MASSIVE splenomegaly can be caused by Myelofibrosis, Chronic graunlocytic leukaemia, and Malaria (parasitic infection)
• MODERATE splenomegaly can be caused by Haemolytic anaemia, Chronic lymphocytic leukaemia, Lymphoma and Portal Hypertension
• MILD splenomegaly can be caused by Infections such as glandular fever, hepatitis, brucellosis (from unpasteurised milk) and infective endocarditis, Pernicious anaemia, and Sarcoidosis
• HEPATOSPLENOMEGALY is when both the liver and the spleen become enlarged; causes include Myelofibrosis, Portal Hypertension, Lymphoma, Leukaemia, and Infections

PALPATION OF THE KIDNEYS

• the kidneys are usually not felt; only an enlarged kidney or enlarged spleen can be felt
• palpate each kidney by positioning one hand behind the patient’s loin and the other just above the anterior superior iliac spine; instruct the patient to breathe deeply
• normal kidneys usually give a tympanic sound when percussed
• signs of renal swelling include: ballottable kidneys, vertical descent, moving down on inspiration, being resonant to percussion (due to overlying colon)
• bilateral enlargement of the kidneys may happen due to polycystic kidney disease
• unilateral enlargement of the kidneys may happen due to Hydronephrosis (kidney becomes stretched and swollen due to a build-up of urine inside them), simple renal cysts, or a tumour (renal cell carcinoma)
• NOTE: thin patients may have a palpable right kidney lower pole

PALPATION FOR AORTIC ANEURYSM

• aortic aneurysm is a balloon-like bulge in the aorta that can dissect or rupture
• palpate for aortic aneurysm by placing two hands along the midline, just above the umbillicus; aortic aneurysm may be present if an expansile pulsation can be felt

THE GALL BLADDER

• the gall bladder, which is situated just to the lateral side of the right rectus muscle adjacent to the 9th costal cartilage, is usually impalpable

PALPATING FOR OTHER MASSES

• palpate for abnormal masses in the epigastric region which can be a sign of a gastric carcinoma or pancreatic cyst
• palpate the suprapubic region for uterine fibroids
• NOTE: in a normal patient, the descending colon is often palpable in the left iliac fossa

ASCITES EXAMINATION – only necessary if the abdomen is distended!

• ascites is a condition in which fluid collects in spaces within the abdomen; it affects lungs, kidneys and other organs
• check for shifting dullness by percussing over the abdomen, starting centrally and moving to the flanks; note change of percussion note from resonant to dull (dull = fluid); ask patient to roll over onto that side whilst holding your hand on that same position, then percuss the area and check if area of dullness has moved…if yes, this is a sign of shifting dullness
• check for fluid thrill by asking a colleague to place the edge of his or her hand along the midline of the patient’s abdomen; flick one side while feeling the opposite side; if ascites is present, a wave-like sensation called fluid thrill may be felt hitting your hand
• causes of ascites include: intra-abdominal neoplasms, liver cirrhosis with portal hypertension, carcinoma, and nephrotic syndrome

GROIN & EXTERNAL GENITALIA EXAMINATION

• position your fingers over the inguinal and femoral orifices and feel for any masses at these sites; instruct the patient to cough and feel for a cough impulse and enlarged inguinal lymph nodes
• causes of lumps in the groin include: inguinal or femoral hernia, vascular structures such as the saphena varix and femoral aneurysm, lymphadenopathy, ectopic testis in superficial inguinal pouch, undescended testis, lipoma or hydrocoele of the spermatic cord

AUSCULTATING THE ABDOMEN

• auscultate for bowel sounds and assess pitch; bowel sounds may be absent or decreased if patient has peritonitis, or in post-operative ileus presence (temporary lack of normal muscle contractions of the intestines); bowel sounds may be increased with a tinkling pitch in the case of bowel obstruction
• auscultate along the course of the aorta and iliac arteries, and in the renal areas for any bruits (audible vascular sound associated with turbulent blood flow)

URINE TESTING

• examine the patient’s urine with a dipstix and check for protein, blood and glucose

DIGITAL RECTAL EXAMINATION

• instruct the patient to turn in the left lateral position
• reassure and explain that the procedure may be uncomfortable but painless
• wear gloves and lubricate the index finger
• examine the perianal skin for skin lesions, external haemorrhoids or fistulae
• place the tip of the forefinger on the anal margin, steadily pressing on the sphincter whilst passing the finger gently through the anal canal into the rectum
• assess tone of anal sphincter and palpate around the entire rectum; note for any abnormalities and examine any masses systematically
• in a male patient, feel for the prostate gland anteriorly; a normal prostate is smooth with a firm consistency, and has two lateral lobes separated by a median groove
• prostatic hyperplasia commonly produces a palpable symmetrical enlargement
• a hard and irregular prostate with an undetectable median groove is usually a sign of prostatic carcinoma
• after withdrawing your finger, examine stool colour and check for presence of blood and mucus
• NOTE: 50% of rectal carcinomas may be detected through a rectal examination

Liver Issues can also arise from excessive alcohol consumption, drug reaction, hepatitis A (from food), gallstone obstruction in bile duct. An Examination of the Abdomen can help detect Liver Disease.

Summary

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