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Alway start by looking around the room for any clues that the patient has bought- like medications

 

General examination-

  • Level of consciousness- Alert/ Oriented/ cooperative
  • Decubitus (position in bed)
  • Gait
  • Built- Average/ small or large for age
  • Nutrition- Average/ undernutrition
  • Dysmorphism

 

Face

  1. Eye  – Kayser- Fleischer Ring
  2. Skin- Pallor/ scars/ Telangiectasia / Incontinentia pigmentosa/ Café-au-lait spots
  3. Lips – Perioral freckling (Peutz-Jeghers)
  4. Gums- Hypertrophy (myeloid leukaemia, ciclosporin, phenytoin)
  5. Mouth- Ulcers (Aphthous ulcers: Crohn’s disease, ulcerative colitis, coeliac disease, behcet’s disease)
  6. Tongue- Anemia, Cyanosis/ large tongue (hypothyroidism, Beckwith-Wiedemann, mucopolysaccharidosis, Amyloidosis)
  7. Breath- Halitosis

 

Hands

  1. Pallor
  2. Clubbing/ Koilonychia
  3. Oedema- Present/ absent

 

Arms

  1. Bruising
  2. Scratch marks
  3. Petechiae
  4. Tuberous Xanthoma in hypercholesterolemia

 

Neck and chest

  1. Scars
  2. Birthmarks

 

Examination of the abdomen

 

Inspection

  1. Shape
  2. Flanks
    • Full or not
  3. Venous prominence
  4. Umbilicus
    • Position- central/ to side
    • Inverted/ everted
    • Midway between xiphistertnum and pubis symphisis
  5. Venous prominence
  6. Hernia
  7. Granuloma
  8. Bluish discoloration around umbilicus
  9. Skin
    • Ulcers
    • Striae
    • Pigmentation
    • Scars
  10. Localised swelling
  11. Movement with respiration
  12. Pulsations
  13. Peristalsis
  14. Hernia sites
    • Inguinal
    • Emoral
    • Umbilical
    • Epigastric
    • Incisional hernia
  15. Ask patient to cough to see impulse in hernial orifice
  16. Inspect the groin after permission from patient and examiner

 

Palpation

 

Superficial

Superficially run your hand from the left iliac fossa in anti clock fashion.

The purpose is not to feel for deeper structures, but the following

  1. Temperature
  2. Superficial tenderness
  3. Consistency- guarding/ rigidity
  4. Localised lumps
  5. Fluid thrill
  6. Direction of flow in blood veins
  7. Divarication of recti
  8. Pulsations

 

Deep palpation

  1. Liver
  2. Spleen
  3. Gallbladder
  4. Kidneys
  5. Palpation of tests (Ask Permission)
  6. Tenderness in the following areas
    • Mcburney area
    • Epigastric area
    • Renal angle
  7. Rebound tenderness
    • Palpate the abdomen and suddenly release the pressure.
    • The patient will complain of pain on rebound.
    • Generally seen in peritonitis.
  8. Examination of hernial areas
  9. Urinary bladder

 

Percussion

Done from resonant to dull area

For liver

  • Percuss from 2nd intercostal space on the right side and percuss downwards until you feel dull at the upper liver border.

For Spleen

  • Similarly percuss from 2nd intercostal space of the left side downwards for the upper border of the spleen

Shifting dullness

 

Auscultation

  1. Listen for Peristalsis
  2. Hepatic and splenic rub
  3. Venous hum
  4. Bruit
  5. Per rectal examination – not always necessary in examination

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