cmecde 789

 

GI medicine and urology

Station 22 Abdominal examination 57

Palpation of the organs

• Liver – Ask the patient to breathe in and out and, starting in the right iliac fossa, feel for the

inferior liver edge using the radial aspect of your index finger. Each time the patient inspires,

move your hand closer to the costal margin and press your fingers firmly into the abdominal

wall. The inferior liver edge may be felt as the liver descends upon inspiration, and can be

described in terms of regularity, nodularity, and tenderness.

• Gallbladder – Palpate for tenderness over the tip of the right ninth rib. Positive Murphy’s sign

(cholecystitis) is cessation of breathing on inspiration, and wincing, as the tender gallbladder

comes into contact with your fingers.

• Spleen – Palpate for the spleen as for the liver, once again starting in the right iliac fossa. Press

the tips of your fingers firmly against the abdominal wall so that your hand is pointing up and

leftwards. If the spleen is enlarged, the splenic notch may be ‘caught’ as the spleen descends

upon inspiration.

• Kidneys – Position the patient close to the edge of the bed and ballot each kidney using the

technique of deep bimanual palpation. Place one hand flat over the anterior aspect of the flank

(right hand for left kidney, left hand for right kidney), and press down whilst using the other

hand to push the kidney up from below.

Midclavicular line

Transpyloric plane

Intertubercular plane

16.1

16.6

16.5

16.4

16.3

16.2

Figure 16. Regions of the abdomen.

16.1 Epigastric

16.2 Left hypochondriac

16.3 Left lumbar

16.4 Left iliac fossa

16.5 Suprapubic/hypogastric

16.6 Umbilical

Clinical Skills for OSCEs

58 Station 22 Abdominal examination

• Aorta – Palpate the descending aorta with the tips of your fingers on either side of the midline,

just above the umbilicus. Pressing your fingers firmly into the abdominal wall, assess whether

the aorta is pulsatile and whether it is expansile, i.e. whether it causes the fingers of your right

and left hands to move apart.

Percussion

• Liver – Percuss out the entire craniocaudal extent of the liver. In the mid-clavicular line, start

above the right fifth intercostal space and progress downwards. The normal liver represents an

area of dullness which typically extendsfrom the fifth intercostalspace to the edge of the costal

margin. Beyond this point, the abdomen should be resonant to percussion.

• Spleen – As for the liver, percuss the spleen to determine its size.

• Bladder – Percuss the suprapubic area for the undue dullness of bladder distension.

• ‘Shifting dullness’ – this sign indicates ascites. Percuss down the right side of the abdomen. If an

area of dullness is detected, keep two fingers on it and ask the patient to roll over onto his left.

After about 30 seconds, re-percuss the area which should now sound resonant. The change in

the percussion note reflects the redistribution of ascitic fluid under the effect of gravity.

• ‘Fluid thrill’ – this sign indicates severe ascites. Ask the patient to place his hand along the midline of his abdomen. Then place one hand on one flank, and flick the opposite flank with your

other hand in an attempt to elicit a thrill.

Auscultation

Auscultate over:

• The mid-abdomen or ileocaecal valve for bowel sounds (Table 10). Listen for 30 seconds before

concluding that they are normal, hyperactive, hypoactive, or absent.

• The abdominal aorta for aortic bruits suggestive of arteriosclerosis or an aneurysm.

• 2.5 cm above and lateral to the umbilicus for renal artery bruits suggestive of renal artery

stenosis.

Table 10. Principal causes of altered bowel sounds

Hypoactive • Constipation.

• Drugs such as anticholinergics and opiates.

• General anaesthesia.

• Abdominal surgery.

• Paralytic ileus (absent bowel sounds).

Hyperactive • Diarrhoea of any cause.

• Inflammatory bowel disease.

• GI bleeding.

• Mechanical bowel obstruction (high pitched bowel sounds).

After the examination

• Cover up the patient and thank him. Enquire about and address any concernsthat he may have.

• Indicate to the examiner that you would normally test for pedal oedema, examine the hernia

orifices and the external genitalia, and carry out a digital rectal examination. You would also

look at the observations chart, dipstick the urine, and consider investigations such as ultrasound scan, FBC, LFTs, U&Es, clotting screen, pregnancy test, and urine drug screen.

• Summarise your findings and offer a differential diagnosis.

GI medicine and urology

Station 22 Abdominal examination 59

Conditions most likely to come up in an abdominal examination station

Chronic liver disease:

Wilson’s disease

• May result from alcoholic liver disease, viral hepatitis, right heart failure, haemochromatosis,

Wilson’s disease.

• Signs may include clubbing, palmar erythema, leukonychia, metabolic flap, hyperventilation,

bruising, jaundice, gynaecomastia, spider naevi, caput medusae, scratch marks, hepatomegaly,

ascites, pedal oedema, Dupuytren’s contracture (alcohol), tattoos (hepatitis C), signs of right

heart failure such as raised JVP and pedal oedema, bronzing of the skin (haemochromatosis),

Kayser–Fleischer rings (Wilson’s disease).

Splenomegaly:

• Causes include portal hypertension (usually complicating liver cirrhosis), lymphoproliferative

and myeloproliferative diseases, haemolytic anaemias, and infections such as infectious

mononucleosis/glandular fever and malaria.

Polycystic kidney

Renal transplant

Scars

Hernias (see Station 24)

Clinical Skills for OSCEs

60 Station 23

Rectal examination

Rectal examination is commonly indicated in cases of rectal or GI bleeding (suspected or actual),severe

constipation, faecal or urinary incontinence, anal or rectal pain, suspected enlargement of the prostate

gland, and urethral discharge or bleeding. It can also be used to screen for cancers of the rectum, colon,

and prostate.

Specifications: A plastic model in lieu of a patient.

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the procedure to him, emphasising that it might be uncomfortable but that it should

not be painful, and obtain his consent.

• Ask for a chaperone.

• Ensure privacy.

• Ask the patient to lower his trousers and underpants.

• Ask him to lie on his left side, to bring his buttocks to the side of the couch, and to bring his

knees up to his chest (Sims’ or left lateral recumbent position).

The examination

• Put on a pair of gloves.

• Gently separate the buttocks and inspect the anus and surrounding skin. In particular, look out

forskin tags, excoriations, ulcers, fissures, external haemorrhoids, prolapsed haemorrhoids, and

mucosal prolapse.

• Lubricate the index finger of your right hand.

• Position the finger over the anus, as if pointing to the genitalia.

• Ask the patient to bear down so as to relax the anal sphincter.

• Gently insert the finger into the anus, through the anal canal, and into the rectum (Figure 17).

Anal canal

Prostate

Rectum

Bladder

Penis

Urethra

Scrotum Figure 17. Digital rectal

examination.

GI medicine and urology

Station 23 Rectal examination 61

Note any pain upon insertion.

• Test anal tone by asking the patient to squeeze your finger.

• Rotate the finger so as to palpate the entire circumference of the anal canal and rectum. Feel

for any masses, ulcers, or induration and for faeces in the rectum. If there are any faeces in the

rectum, assess their consistency.

– in males, pay specific attention to the size, shape, surface, and consistency of the prostate

gland. Assess whether the midline groove is palpable

– in females, the cervix and uterus may be palpable

• Remove the finger and examine the glove. In particular look at the colour of any stool, and for

the presence of any mucus or blood.

• Remove and dispose of the gloves.

After the examination

• Clean off any lubricant or faeces on the anus or anal margin.

• Give the patient time to put his clothes back on.

• Ensure that he is comfortable.

• Address any questions or concerns that he may have.

• Present your findings to the examiner, and offer a differential diagnosis.

Conditions most likely to come up in a rectal examination station

Benign prostatic hypertrophy (BPH):

• In BPH the prostate is enlarged in size (>3.5 cm) and slightly distorted in shape, but it is still

rubbery and firm, with a smooth surface and a palpable midline groove.

Prostate carcinoma

• In prostate carcinoma, the prostate is also enlarged and asymmetrical, but this time it is hard

and irregular/nodular and the midline groove may no longer be palpable.

Clinical Skills for OSCEs

62 Station 24

Hernia examination

Inguinal anatomy

Figure 18. The inguinal canal runs along the inguinal ligament, from the internal (deep) ring to the external

(superficial) ring. The inguinal ligament stretches from the anterior superior iliac spine to the pubic tubercle. The

internal ring lies approximately 1.5 cm superior to the femoral pulse, itself in the midline of the inguinal ligament.

The external ring lies immediately superior and medial to the pubic tubercle. NAVY: Nerve, Artery, Vein, Y-fronts.

Definition of a hernia

A hernia is defined as the protrusion of an organ or part thereof through a deficiency in the wall of the

cavity in which it is contained. There are many different types of hernia but the onesthat are most likely

to be examined and discussed in an OSCE are indirect and direct inguinal hernias and femoral hernias.

Their principal differentiating features are summarised in Table 11. The differential diagnosis of a lump

in the groin is listed in Table 12.

Table 11. Principal differentiating features of indirect and direct inguinal and femoral hernias

Indirect hernia (through

inguinal canal)

Direct hernia (through

Hesselbach’s triangle)

Femoral hernia (below inguinal

ligament)

• Neck of hernia is superior to

the inguinal ligament/pubic

tubercle and lateral to the

inferior epigastric vessels.

• Accounts for 80% of inguinal

hernias.

• Irreducible.

• Can strangulate.

• Neck of hernia is superior to

the inguinal ligament/ pubic

tubercle and medial to the

inferior epigastric vessels.

• Accounts for 20% of inguinal

hernias.

• Easily reducible.

• Rarely strangulates.

• Neck of hernia is inferior

and lateral to the inguinal

ligament pubic tubercle.

• Higher incidence in females,

but still less common overall.

• Often irreducible.

• Frequently strangulates.

Femoral hernia Indirect inguinal hernia

Vein

Artery

Nerve

Muscle

Inguinal ligament

External inguinal ring

Internal inguinal ring