Alimentary: Examination
  1. Environment, general appearance
  2. Nails, hands, arms
  3. Eyes, mouth, neck, chest ,back
  4. Abdomen inspection
  5. Abdomen palpation: general, liver, gallbladder, spleen, kidneys, stomach, pancreas, aorta, bowel, testes
  6. Abdomen percussion, ascites, auscultation
  7. Groin, hernias, rectal, legs
Environment
  • NG tube.
  • NG TUBE
  • Feeding tube.
  • Cans of special food.
General appearance
  • Colors:
    Anemic (iron malabsorption, hemorrhage, CA).
    Pale Nails
    Jaundiced (liver dz).
    Yellow Abdomen
    Hyperpigmented (hemochromatosis).
    hyperpigmentation
    See Skin Colors Reference.
  • Hydration and nutrition.
  • Weight loss vs. gain, wasting.
  • Shocked.
  • Postural hypotension.
Nails
  • 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.
Hands
  • 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).
Arms
  • 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).
Eyes
  • Cornea rings (Wilson's).
  • Sclera: jaundice.
  • Iritis: IBD.
  • Xanthelasma [yellow plaque periobital deposits] (elevated cholesterol).
  • Xanthelasma
Mouth
  • Temporalis muscle wasting.
  • head_temporal_wasting
  • Lips:
    Telangiectasia (Osler-Weber-Rendu)
    Telangiectasia
    Brown freckles (Peutz-Jeghers).
  • Brown freckles
  • Breath:
    Fetor hepaticus (alcoholism).
    Ethanol.
  • Mouth:
    Ulcers (Crohn's, coeliac dz).
    mouth ulcer
    Crohn's disease
    White candida patches (spread down throat).
    White candida patches
    Angular-stomatitis: Cracks at mouth edges (riboflavin deficiency anemia).
  • Angular stomatitis
  • Teeth:
    Cavities
    teeth cavities
    Nicotine stains.
  • Tobacco Stain on teeth
  • Gums: 
    Hypertrophy.

    Bleeding.
    bleeding gums
    Gingivitis.
  • Gingivitis
  • Tongue:
    Leucoplakia (smoke, spirits, sepsis, syphilis, sore teeth).
    leukoplakia tongue
    Atrophic glossitis [withered tongue] (deficiencies, Plummer-Vinson).
    Atrophic glossitis
    Macroglossia (B12 deficiency).
  •  macroglossia
Neck, chest, back
  • 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.

Abdomen: inspection
  • Pt is supine, abdomen visible from nipples to pubic symphysis.
  • Scars. See Abdominal Scar Reference.

  • Stoma from surgery, trauma.

  • PEG (dysphagia, usu. 2 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).
Palpate general abdominal

    Position of Patient for Exam of Abdomen


  • 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.
Palpate liver

Video of Palpation

  • 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].
Palpate gallbladder
  • 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.
Palpate spleen
  • 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.
Palpate kidneys

  • 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.

Auscultate stomach

Sound Clip of Audio of succussion splash

  • 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 pancreas
  • Palpate for a round, fixed, swelling above umbilicus that doesn't move with inspiration (pseudocyst, acute pancreatitis, CA in thin pt).
Palpate aorta
  • Palpate in mid line, superior to umbilicus.
  • Dr's 2 fingers on outer margins of aorta, watch if if fingers diverge (AAA).
  • Normally felt in thin pt.
Palpate bowel
  • Sigmoid usu. palpable in severe constipation.
  • Whether indents (feces) or doesn't indent (masses).
  • Sometimes can feel CA, megarectum.
Palpate bladder
  • 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).
Palpate testes
  • Atrophy (liver dz).
Abdomen: percussion
  • 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.
Abdomen percussion: ascites
  • 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.
Abdomen: auscultation
  • 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).
Groin, hernias, rectal
Legs
  • 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.