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Start from the hand of morning. Okay. You start from the hand, you go all the way up to the face and neck, then down the chest, abdomen and legs finally put on the show. If you're feeling nervous, it's fine, you know, just take your confidence, try your best, at least pretend that you know what you're doing and hopefully you will do just fine. Okay. So an example of one way you can introduce yourself for this examination is um you can use the following. So hello, my name's Ella and I am a medical student. Can I confirm your full name and age please? Today, I've been asked to perform an examination of your abdomen. What this will involve me is having a general look of you examining your hands, face, neck abdomen in lex, I will also have a feel and listen to your tummy. Does that sound okay? Do I have your consent? Just to let you know I will be talking out loud to the examiner while I perform the examination to let him or her know what I'm looking for. Are you in any pain at the moment? And if the patient says Yes. Where is the pain? The examination should not be painful. But if you feel any discomfort, please let me know. Okay. So, before I get started with the examination, I've got a quick spot diagnosis questions. So say you examine the patient and on examination, the patient has by the knee vie on his chest and gynecomastia, the palpitation of the right upper quadrant reveals a nodular liver edge and splenomegaly. So, in the chart, what do you think the diagnosis is because we've got bad cellular carcinoma, liver cirrhosis. Any other differentials do you have? So, I've got chronic liver disease about solar carcinoma. Okay. So these are all really good answers. What I had was a liver cirrhosis, which I'll tell you more about its clinical signs later on. So, patient presents with fever and confusion on examination. There's generalized abdominal tenderness, moderate abdominal distention and shifting dullness. So, what do you think your diagnosis is? So, patient's basically has abdominal distention and shifting dullness and suddenly they present with confusion and the fever. Okay. So yes, the patient does have a society's, but I'm looking for something else. Somebody has a scientist and suddenly they have confusion and fever hepatic encephalopathy. I think that's a good answer. What else? I'm looking for a particular infection, spontaneous bacterial peritonitis. That's what I'm looking for. Yes. So basically a one of the doctors told me that if you've got a patient who's known to have a site is as shown by this patient's clinical sign. And suddenly out of nowhere they present with fever, altered mental status and abdominal tenderness. Then chances are it's almost always spontaneous bacterial peritonitis. But you can always check by doing an aesthetic fluid analysis. Okay. So on examination, the patient has generalized abdominal tenderness. There is evidence of aphthous ulceration inside her mouth and erythema nodosa um on her shins. What kind of gi pathology would that be? Ok. Loads of answers in here related to IBD also difficult litis or crones. More answers are coming in. I think Crohn's is more popular and well done. Crohn's would be the correct answer. So everything mono dose um and the ulceration of those ulcerations are more related to Crohn's disease rather than you see. Finally, this one might be a bit hard, but the patient presents with sudden severe abdominal cramps on examination. He has a soft and nondistended abdomen which is very tender on palpation throughout ABG reveals acidosis with raised lactate. What do you think that one could be? Oh, I'm sorry, let me just pull my phone. Okay. Lots of answers coming in. Uh MS in Turkey ischemia. Okay. So yeah, lots of answers. Ischemic colitis, MS entering ischemia. Well done. MS in Turkey ischemia is the correct answer. So the thing with acute mesenteric ischemia is that it is quite distinctive in the sense that the abdominal pain can be out of proportion to the physical exam. So the patient could be screaming in pain, but the initial abdominal examination can be unremarkable or just show, just tell you that the patient is tender throughout. And that is because the ischemia is within the hollow viscous of the intestine. And it does not cause the same peritoneal signs as you would get in more localized processes such as appendicitis and colecystitis. All right. So now moving on to the actual abdominal examination. So this is the abdominal examination, basically everything you need to know, summarized into one slide. And I'll go through each part in detail, starting with general inspection. So we're going to inspect and we're gonna start with the patient's bed site. And some of the things you might note could be a vomit, a bowl, a storm, a bag and you might want to note the location of the storm a bag. So for example, if it was in the right iliac fossa, it could, it could indicate that the patient had an ileostomy and if it was in the left iliac fossa, then it would indicate that the patient had a colostomy uh feeding tube. And you might might want to comment further on the feeding tube, whether it's a nasogastric or nasal regional parenteral nutrition, acidic train and the surgical drain. And you might want to comment, comment on the location and the type and volume of the contents inside the surgical drain. So inside there could be blood Kyle or pus. Okay. Now, inspection of the patient themselves. So things you might comment on is, is the patient comfortable addressed. Do they have any obvious scarring around their abdomen or anywhere in their body? Because that could indicate that they could have had an abdominal surgery? And I'll go through the different types of the abdominal abdominal incisions on the next slide. Okay. A patient could present with a sign that looks like this uh in the chat. What is shown here? Does anybody know? Okay. 60 I ask the patient is cachectic, well done. Yep, the majority of you are correct. Amazing. So patient is presenting with cachexia and this is basically ongoing muscle loss. It is commonly associated with malignancy. So in terms of the g eye examination, it can be associated with pancreatic cancer, bowel cancer, or gastric cancer, but it's also associated with advanced liver disease. Okay, you might want to comment on the patient's skin color. So in this case, the patient is jaundice and this can indicate a whole range of pathologies such as hepatitis cirrhosis, Collinge itis and pancreatic cancer. The patient's skin color can look like this. Does anybody know what is shown here or what diseases this associated with? Ok. Got bit of answers. Addison's Wilson's hemochromotosis, bronze skin, hemochromotosis, brown skin. Yeah, basically these are the answers I'm looking for. So the patient here has hyperpigmentation or bronzing of their skin. And in the it can be associated with hemochromotosis which is abnormal iron processing by the liver. Ok. Patient can have power or they can have and they can have severe abdominal distention, which can be caused by a whole range of things such as societies, bowel obstruction or organomegaly. And finally, the patient can present with peripheral Adema which can be associated with the liver cirrhosis. Okay. Uh At this point of the examination, if you find the patient has abdominal scars, feel free to comment further on the type of scarring or the type of abdominal incision or you can wait until you do a focused abdominal exam later on. But for now, I'll go through the different types of abdominal incisions. So this one right here is a is a culture or a sub costal incision and the main indication is open cholecystectomy. A patient could have an abdominal incision that looks like this in the chat. Does anybody know what this one is called? It's got an interesting name. I think Mercedes Benz. Yes, there is a Mercedes Benz incision. If you didn't know the name, I doubt you'll forget it now because it is literally looks like the logo and the main indication that for this one is liver transplantation. But it can also be used for other things such as also if ejecta me gastrectomy and bilateral adrenalectomy, okay. A patient could have an incision in the middle like this one. Does anyone, does anyone know what this one is called? You can take a guess I mean, big incision in the middle. What could it be called mid gastric? That's a, that's a good guess. Midline midline. Yeah, that's pretty much what's it called? It's basically a midline laparotomy incision. So if that one is a midline laparotomy incision, then what would this one be called? Which is a bit more lateral. Does anybody know? Yes, that is a para median incision. So that's a paramedian laparotomy incision. So midline laparotomy incision is used for inter abdominal access. The para medium incision is used for lateral abdominal access. Okay. A patient could have an incision like this one and this one is called a Ruth Report Morrison incision and it's used for renal transplantation. Okay. Another incision the patient could have is this one right here. Does anybody know what it's called? It's location might give you a clue. Lance incision, inguinal lands. Okay. Lance is more popular than inguinal. Understandable because it is in the exact same location. But yeah. So this one is a mcburney's incision and this one is a lance incision and both of these are used for appendicectomy. The main difference between the two is the island's incision is cosmetically better. Finally, a patient can have an incision right here. Wait, wait a second. So yeah, finally, the patient could have an incision right here. And this one is called, if I can pronounce it correctly. It's called a finan finance steal incision. And it's used for either pelvic surgery or S A section. Yes. Somebody commented C section. That's why it can be used for. Yeah. All right. So moving on to the actual abdominal examination, I'm pretty sure most people use the same system. So you start on the hands, you go all the way up into the neck and face, then down the chest, abdomen and legs. And that's just one way to look very systematic and slick. And remember it's always inspection, palpation, percussion auscultation. All right. So we're gonna start with the hands and arms. Okay. Starting with inspection of the hands and arms. And you might want to start by commenting on the finger and nail signs the patient has. So a patient can present with something like this. Does anybody know what this is called? All right. So few answers in Leukonychia, Leukonychia, basically, a lot of leukonychia is here well done. That is leukonychia and it is associated with hypoalbuminemia. And since the liver makes albumen you, you can, it can indicate and stage liver disease where basically the synthetic function of the liver is impaired causing hypoalbuminemia. Other uh pathology it can be associated with. It is a protein losing enteropathy. Alright. Operation can present a patient can also present with flattened the nails like this one. Does anybody know what this is called? Okay. Lots of Koilonychia as and yeah, you would be correct. That is Koilonychia. So these are flattened nails and they are most commonly caused by an iron deficiency anemia. So in terms of uh an abdominal examination, this one can be associated with IBD causing malabsorption in the gut. Finally, a patient can present with finger clubbing. So you ask the patient's to bring their fingers in like this and you look for the gap in the middle if they don't have it, chances are they've got some finger clubbing and some of the gi causes of finger clubbing includes malabsorption as you can get in. For example, celiac disease, IBD, uh like all sorts of colitis and Crohns, a lymphoma and cirrhosis. Okay. Now inspecting the patient's palms and some of the signs you can find include palmer erythema, which is associated with chronic liver disease, pallor which can indicate underlying anemia or it could be that the patient is naturally very pale. So this can be normal for them. A patient can present with palmer thickening like this one causing. Um this sign. Does anybody know what is showing in this image? Well done? Yes, that is to patrons contractor if I can pronounce the word correctly. So yeah, this is Dupuytren's contracture. There isn't a particular cause for it, but some of the risk factors associated with it include genetics, increasing age, excessive alcohol consumption, being male and having diabetes. Finally, a patient can present with if I can zoom in on the image, actually, they can present with yellowish or whiteish deposits around their hands. Does anybody know what sign is shown here. Okay. So yes, that's the matter. That's the most answer I'm getting. Yeah, you would be correct. So the patient is presenting with xanthoma and this one is associated with high cholesterol levels. And basically these are cholesterol rich deposits around the hand. Okay. Finally, you want to inspect the patient's arm for the following needle track marks because IV drug use is an important risk factor for viral hepatitis patient's could have excoriations due to condemn, constantly picking their skin and scratching their skin to relieve pruritis. And in terms of an A G eye exam, this could be due to underlying college stasis patient could have bruising around their arms. Now, this can be caused by a range of things. If this was an inpatient and they constantly have their blood taken, then it could be due to the blood tests. But in terms of thinking of some gi pathologies, the liver makes clotting factors. And if you bruise very easily, then it could underlie it could indicate uh clotting abdomen. Uh for God's sake, clotting abnormalities due to um severe liver disease, partly the patient's could have an arterio venous fistula. And if you have all the time in the world, feel free to assess their ab pistola. So by commenting on its location, is it brachycephalic or radio cephalic? You want to palpate it for thrills, lift the patient arms and uh auscultate or bruit. But g eye examination is already very long exam. So feel free to just comment what you see and move on. Okay. Now, you want to um assess the patient's hand for asterixis or flapping tremors. I've COVID you here showing you how with the risk extended. Just so you ask the patient's to stretch their arms out in front of them and then you ask them to cook their wrists back or you can do it for them as shown in this video and then you observe for 30 seconds. Um And yeah, the following shows this is a sign of asterixis or flapping chamber. So, some of the underlying causes of asterixis include Urania, secondary to renal failure, hepatic encephalopathy due to increased ammonia and carbon dioxide retention, uh secondary to type two respiratory failure. All right. Finally, you want to palpate for bias for temperatures. So you place the dorsal aspect of your hand onto the patient's and Paul paid for the radial pulse. Comment on the rate rhythm and volume. Finally offered to measure BP on both arms. Okay. So, moving on to the face and the neck. All right. So now we're gonna start by inspecting the face and neck and we're going to go through some of the signs you can see on the eyes. So a patient could have conjunctival conjunctival pallor. This could be due to underlying anemia or iron deficiency and this can be caused by I IBD causing malabsorption. A patient could have scleral icterus and the way you can check for that is asking the patient to look down and you lift their upper eyelid. And the reason why you do this is because the John, this tends to be more prominent at the superior aspect of the eye. A patient could present with something like this. Does anybody know what this ring structure is called or what disease it's associated with? So Wilson's disease? Well done. Does anybody know what the rings are called? Yeah. Case you're Fleischer Kayser Fleischer rings. I can never pronounce this. But you guys are all correct. Well done. Amazing. So those are case of Fleischer rings and they're associated with Wilson's disease, which is abnormal processing of copper by the liver, which causes accumulation and deposition of copper in various tissues, including the liver itself, which causes cirrhosis of the liver. Okay. So, if that's a Kaiser pleasuring, then what is this ring? Cold? This one looks more grayish or white. Sometimes it can be a lowish as well. And it's very common in patients who are over 60 years old. So, what is this ring? Okay. So, I've got corneal arcus, well done. That is correct. And it's used and it indicates underlying high cholesterol levels. All right. Speaking of cholesterol, a patient could have xanthelasma, which is also cholesterol deposits around the eye. Finally, the patient could have perry limbal injection, which is a sign of the anterior uveitis and this is associated with inflammatory bowel disease. All right. Now you want to inspect the patient, uh the patient's mouth. So a patient could present with a sign like this one. Does anybody know what this is? That is angular stomatitis. Well done. So, yeah, that's angulus dermatitis and it indicates are in deficiency. Um So patient could have aphthous ulceration inside their mouth, which can be associated with Crohn's disease. A patient could have smooth and arithmetic enlargement of the tongue. This is no one else. Glossitis and it can indicate iron folate or B 12 deficiency. Ok. Patient could have oral candida and they can also have these brownish or black spots in their mouth. Does anybody know what these spots are called or what disease they're associated with? So, yeah, this is, this is associated with its Jager syndrome. Went all done. So this is hyperpigmented macule is and they're associated with bits Jager syndrome, which is an autosomal dominant condition that causes formation of polyps in the gi tract. And someone asked how to differentiate between oral candida and glossitis. Glossitis is basically when the tongue is very red and enlarged and it's due to um b 12 or iron deficiency. Oral candida. Is this like whitish or yellowish um thing around the patient's mouth due to candida infection? Okay. All right. So, in your Oscar station, you can be presented with a data interpretation question like the following. So you can be giving an endoscopic image or colonoscopic image and you would be asked to talk through it and tell present with a diagnosis. So say that your patient was a 35 year old male who presents to the gastro clinic with a history of chronic abdominal pain, diarrhea, and weight loss. On physical examination. The patient is noted to be pale with para limbal injection in his eyes, after ulceration inside his mouth and his abdomen is standard to on population of the right lower quadrant. A colonoscopy is performed which shows the following. What is the most likely diagnosis? Okay. So the majority of you are answering crone's disease, we'll end up on right there. So most people have answered scrums disease. Well done. That is the correct answer. Now, from this image, what is the main feature shown here that supports your diagnosis? Well done. Yeah, most of you are answering correctly. So that is cobblestoning. Yes. So as I said in the Oscar's station, you're expected to talk through the image. If the image was any better quality, you can probably commentate there's deep ulceration, skip lesions and most most obviously here there is cobblestoning which is associated with crone's disease. Well done. Okay. Now, we're going to examine the patient's face and neck and you want to start by palpating the patient's lymph nodes. So this video here shows you how to do that. You start with the submental and submandibular lymph nodes, then the tonsil er and provided lymph nodes, preocular and post ocular lymph nodes, superficial cervical and super clavicular. And don't forget to palpate behind for the posterior cervical and occipital lymph nodes. Okay. So it's really important to pulpit for work shows burke shows lymph node which is also known as the left supraclavicular lymph node. And that is because it receives direct lymphatic drainage from the abdominal cavity. Therefore, if it's enlarged, this can be one of the first clinical signs of metastatic intra abdominal malignancy. Most commonly stomach cancer. The right supraclavicular lymph node receives the lymphatic drainage from the thorax. And therefore, if it's enlarged, this can indicate metastatic esophageal cancer. Finally examine the patient's JVP. All right. So, moving on to examination of the chest and this is basically mainly inspection of the chest for the following signs. So the patient could have spied an IV I which is caused by increased estrogen levels and it can indicate liver cirrhosis. This is because the liver is supposed to to metabolize circulating estrogens more particularly estrone. And if it's damaged due to cirrhosis, then circulating estrone czar gonna increase and they're going to cause vasal dilation which can present as spider angiomas. Okay. A patient can have hyperpigmentation and thickening of their uh axillary skin. So this is known as acanthosis nigricans and it can be a normal finding in dark skinned individuals. Uh but hyper keratosis and hyperpigmentation can also indicate um insulin resistance as you would see in type two diabetes. It can also indicate gi malignancies such as stomach cancer. All right. Finally, patient could have gynecomastia due to increasing estrogen's because of liver disease. Um, it can also be caused by medications such as the Jackson and spironolactone. Don't forget to check for hellos in the chest and exhilarate. Uh This can indicate again, increasing estrogen or malnourishment in some patient's okay. We're going to have a two minute break. I understand this is an early break, but this is kind of a long and intense session. So we'll have a two minute break for now. And the next section is gonna be detailed abdominal examination. All right. Uh huh. All right. So that was a two minute break. The next section, I'm gonna go through abdominal examination. All right, before I do so, it's just some quick spit spot diagnosis questions. So say it is an examination on this patient and you find that the patient has tendinous with guarding in the right upper quadrant. She also has a fever, deep outpatient of the right upper quadrant causes respiratory arrest. This is also known as a positive Murphy sign. Where is your diagnosis? Basically, everyone is going for acute cholecystitis. Well done. Okay. So that was acute cholecystitis. Ok. Patient presents with fever and jaundice on examination. There is Claire Electors and right upper quadrant tenderness. What's your diagnosis? Okay. Now everyone's going for a sending Collinge Itis or accused Collinge Itis well done. That is the correct answer and this is because the patient is presenting with shock coats triad and that is right upper quadrant pain, fever and John tous. So, acute cholecystitis and acute Collinge itis, they've got similar symptoms in the sense that both present with right upper quadrant pain and fever. The main difference is that acute Collinge itis would also present with jaundice and that makes up shock coats triad. Alright, patient presents with sudden onset epigastric pain that radiates to the back on examination. The upper abdomen is tender with voluntary guarding. This is a classic presentation of which pathology. Amazing. Yes, acute pancreatitis. All right. Finally, patient presents with abdominal pain and low grade fever. On examination. There is tenderness and the left lower quadrant. So what do you think this might be? This question is a bit hard in the sense that it's a bit more vague. But what do you think? Never mind. It's not that hard after all, the diverticulitis is the correct answer. Okay. So now we're gonna go into examining the abdomen and we're gonna start with inspection of the abdomen for the following signs. So the patient could have abdominal scars due to uh incisions from surgery and have already gone through some of the abdominal incisions. Patient can have car but medusa I this is caused by portal hypertension secondary to liver cirrhosis because portal hypertension causes engorgement of the paraumbilical veins which will present with medusa's head or car. But medusa I OK. Patient could have abdominal distension. This can be to do a whole range of things. But um pneumonic for you to remember causes of abdominal distension is the six f so fat fluid as an ascites feces flay tous foetus because the patient can be pregnant and fulminant max. Ok. Other things you can inspect for is abdominal stray, which can indicate a range of things such as cushing's or rapid weight gain or abdominal distension. Due to a scientist or organomegaly patient can have superficial hernias which can be visible. Like in this example, this is an epic gastric hernia. Okay. A patient can have bruising around there umbilicus. This can be a sign associated with hemorrhagic pancreatitis. Does anybody know what this sign is called? The first, the first letter is already given here, Helen sign. Yes, that is correct. Okay. A patient can also have bruising around their flanks. The what is the sign called? It's also associated with hemorrhagic pancreatitis, greater and a sign. Amazing. You guys know your stuff. Wonderful. So, yeah, both of these signs are late signs associated with hemorrhagic pancreatitis. Okay. If the patient has a stoma and you've got the time you can do a stoma assessment and that is by commenting on its location. Um I mentioned at the beginning if it's in the right iliac fossa, it's an ileostomy. If it's in the left iliac fossa, it's the colostomy, you might want to comment on the contents. So if there's stool, it's an ileostomy or colostomy if it's urine, it's a urostomy consistency. So, if the stool inside is a bit more liquidy, then it's an ileostomy. If it's a more formed or semi formed. So it's a bit more solid. That's a colostomy. Finally, if there's a spot present, that's at least an ileostomy or close or urostomy, if there is no spout and this is probably a colostomy. All right, moving on to palpation of the abdomen and you want to start by palpating the nine abdominal regions, the patient should already be lying flat on the bed. You start with light palpations it. And before you do so ask the patient if they're in any pain or if they've got pain anywhere around their tummy. And as you lightly palpate, look at the patient's face because they can tell you that they're not, they're not in any pain. But they can, if you palpate an area that is quite painful, they might like scrunch their eyes or make a face. So monitor their face. As you're palpating the abdomen. And during light pal patient assess for tenderness, guarding and any superficial masses like hernias. Then you want to do deep palpations of the abdomen before you do still warn the patient that you're gonna press deeper into their tummy. And this time apply more pressure or use two hands during deep palpations, try to identify any deeper masses. And if you do so, assess their location, size, consistency and pulse, italic e and remember, always palpate away from painful areas first. Okay. Now, palpation of the liver. So you ask the patient to breathe I/O and you palpate in during inspiration, you start in the right lower quadrant and you move your way up into the right upper quadrant or the right costal margin, try to identify the liver border at the right costal margin. And if you do so, assess the following degree of extension below the costal margin, if it's more than two centimeters below the costal margin, then that indicates hepatomegaly, assess for consistency because if it feels quite nodular in my, indicate liver cirrhosis, um assess for tenderness. So this can indicate hepatitis or colecystitis as you would be palpating the patient's gallbladder and pulse it al itty because pas it'll hepatomegaly is associated with severe track hospital regurgitation or pericardial disease causing congestive hepatopathy. Okay. Some of the causes of hepatomegaly. So causes of masses, uh causes of massive hepatomegaly. You can remember with cram so that it's cancer, right heart failure, alcoholic liver disease and myeloproliferative disease. Moderate hepatomegaly is caused by all the above. Um plus fail fatty liver amelia doses iron as in hemochromotosis, lymphoma and leukemia and mild hepatomegaly is caused by all of the above plus clearly duct obstruction, infection, autoimmune hepatitis tricuspid regurgitation. There's also other causes such as, but Chiari syndrome and polycystic liver disease. There's very, basically, there's a lot of causes of hepatomegaly. Okay. So we're gonna have a data interpretation question as a bit of a break because again, you can be presented with something like this in your Oscar station say you did an examination on a 65 year old patient with who complains of yellowing of their skin upon examination. He has joined this with the yellow of the skin, yellowing of the skin is clara, abdominal examination revealed a distended gallbladder on the pulp patient but no tenderness. His laboratory investigations show the following. What is this patient's most likely diagnosis? So, if I'll try lunch the pool. Oh, sorry, didn't launched. Give you a couple of more seconds. All right. Um In the interest of time, I'm gonna move on well done to the majority, about 85% of you have gone for B which is pancreatic cancer and well done. That is the correct answer. So, um in terms of the patient's presenting symptoms, painless obstructive jaundice is a key presenting feature of pancreatic cancer. The LFTs show a cholestatic pattern and that is when A L P and N G T are significantly elevated, usually more than three times the normal range and the transaminases enzymes, they're either in their normal range or they're mildly elevated. So when you're presenting with a the following pattern, then that is a cholestatic or an obstructive pattern. So the bill Iarley duct is, the biliary system is obstructed. In this case by the pancreatic cancer. It's obstructing the common bile duct in terms of the bio Marcus cancer antigen 19 can be used as a tumor marker for pancreatic cancer because it has good sensitivity and specificity. And so is carcino, how is it was some called carcino embryonic antigen? I think this one. So, yeah, this one can also be used as a tumor marker for pancreatic cancer. All right. Now, I'm to palpation of the gallbladder. I should mention that the gold bladder should not be palpable. If it is, then that suggests that it is enlarged due to bill yearly flow obstruction as you would get in pancreatic malignancy, Goldstone disease or infection like colecystitis, assess for Murphy's sign and the way you do so is basically you place your fingers at the right costal margin in the midclavicular line. You ask the patient to take a deep breath in and you basically do put the palpitation of that area. And if the patient suddenly stops mid breath due to pain, then this is known as a Murphy sign positive and it indicates colecystitis. All right. Now, if you uh palpate a gallbladder and it is quite enlarged, but there's no pain, then this can indicate underlying pancreatic cancer, especially if the patient also presents with jaundice. But if there's tenderness, chances are it's colecystitis. Okay. Now, you palpate the spleen. So you ask the patient to breathe I/O, you palpate in during inspiration and then you start in the lie, right, lower quadrant and move up and into the left, lower left, upper quadrant or the left costal margin. The spleen should not be palpable in this region. If you can palpate the spleen at the left costal margin, then that means it has already increased three times its original size. Um So the patient has splenomegaly and some of the causes of spla comically include portal hypertension, secondary to liver cirrhosis him, a lytic anemia, congestive heart failure, splenic metastases and glandular fever. Some of the causes of massive splenomegaly. You can remember them with the pneumonic chimp. So, chronic myeloid leukemia, chronic lymphoid leukemia, every Harris a leukemia infections like malaria, milo fibrosis and polycythemia vera. Okay. Now, pal patient of the kidneys. So you place your left behind the patient's back and your right hand at the anterior abdominal wall and basically you make your hands push into each other and you this process known as balloting of the kidneys. And if the kidney is ballotable, describe it's size and consistency, then repeat the process onto the opposite side. All right. Now, palpations of the aorta, sorry if I'm going a bit fast, I've just looked at the time. That's why OK. Palpation of the aorta, you place both hands above the umbilicus and you pile and you press down with your fingertips. If you can feel the aorta, then your hands should move superior early, which with each pulsation of the aorta. If however, they are moving outwards, then that, that suggests the presence of an expansile mass as you would get in an abdominal aortic aneurysm. Okay. Now, moving on to the question of the abdomen. So you percuss the nine regions of the abdomen. And if you suspect that the patient has societies then assess for shifting dullness. So say you percuss this area of the abdomen and you think, ok, this sounds a bit dull. I think the patient might have a society's, Then you ask the patient to roll onto their side and weight pathetic seconds. Then you percuss again a chain and see if you can see note any changes of the percussion note and you can percuss either two ways. Either most people do like middle finger onto their middle finger. But if you have small hands such as myself, I usually to use two fingers on top of the middle finger and that works better for me when it comes to percussion. All right. Uh percussion of the liver. This is similar to palpations. So we start in the right lower quadrant and then you move up into the right costal margin note when the percussion note changes from resonant to dull. And this will give you an idea of the lower liver border, then keep going, keep cussing upwards until the percussion note changes from dull to resident. And that will give you an indication of the upper liver border. And the idea is by knowing the two liver borders, this can give you an idea of, of the approximate size of the liver. And it can tell you whether the patient has hepatomegaly. OK. Percussion of this plane same as palpations. You start from the right lower quadrant and then you work, you work your way into the left costal margin and you uh see if the percussion no changes from resonant to dull. Uh Normally the spleen is not identifiable on percussion unless the patient has splenomegaly. Finally, you percuss the patient's bladder. So you start in the umbilical region and you pick us downwards into the pubic synthesis to assess for a distended bladder. But ask the patient's if they need to go to the toilet first. All right. Now you assess for bowel sounds. So, um, you should listen in at least two different areas around the abdomen and normal bowel sounds sound gurgling, which I'll can play an example of in a second. If there's tingling bowel sounds, this can indicate bowel obstruction. And if the bowel sounds are absent, it can indicate complete bowel obstruction or ileus, which is when the parasol tick function of the intestine is not working very well. Do two things like a recent abdominal surgery and it can also indicate peritonitis and I'm just gonna listen to your tummy. So this is an example of what normal abdominal bowel sounds. Sound okay. Oh, okay. Hopefully, you guys can hear that. I'm fasting. So this is pretty much what my stomach sounds like at the moment. Okay. Now you auscultate for brewing um to auscultate. Psoriatic Bruit, use the diaphragm of the stethoscope and auscultate above the umbilicus. And if there's an aortic Bruit, it can indicate an abdominal aortic aneurysm, a renal arteries. So use the bell of the stethoscope and auscultate above and lateral to the umbilicus. And if you can hear a renal bruit, this can suggest renal artery stenosis and I can pray an example of what Bruit sounds like. Okay. So hopefully you guys are able to hear that. It sounds like a whooshing sound. Okay. Finally, will you examine the patient's legs? So you inspect the legs for the following uh pitting edema, pyoderma gangrenosum, which is associated with Crohn's disease and erythema no dose. Um You can remember the causes of erythema nodosa um with the pneumonic know dose. Um Becky has already gone through this pneumonic in her respiratory station, but I'll go through it again because it's very helpful. So, no, for no cause as an idiopathic d for drugs like antibiotics such as sulfonamides and amoxicillin, oral contraceptives, sarcoidosis or Lofgren syndrome, also difficult ITIS and the Crohn's and microbes and basically a whole range of infections can cause everything on a dose. Um such as hepatitis B and C HIV, salmonella, campylobacter syphilis and even parasites such as GRD aces, um streptococcal pharyngitis as well. Okay. Then you sank the patient's and restore clothing. Now, you present your findings. So this is a slide of um one example, you can present your g gastro intestinal examination findings. So you can read through this in your own time. The last section about completing your examination, you can remember it with the name with a Pneumonic does. So to complete my examination, I would like to form a digital rectal examination. I would like to take a formal history and a full set of observation. I would like to also perform your analysis. I would also consider examining the external genitalia if appropriate and hernial offices and that completes your abdominal examination. So we're going to have another two minute break. And then in the next section, I will go through uh cases of common presenting complaints that you can have on your Oscar station. Uh Just a quick reminder, don't forget to join us next week for our neurology on Tuesday and cranial nerves and Thursday session, Czarsky sessions. Um It's going to be really good presented by syringe and myself. Okay. So we'll have a two minute breakfast now. Okay. So that was a quick two minute break and now I'm going to move on to the next section of this presentation. Okay. So this is the same scenario as the beginning. So the pay your patient, you're in the emergency department and you're in a fund doctor and your patient is Miss Tammy Pain, a 32 year old female who presents with abdominal pain on examination. You find the following So there is guarding and rebound tenderness on palpation of the right, lower quadrant, palpitation of the left, lower quadrant elicits pain in the right lower quadrant. So this is a bit of a strange sign and this point right here, basically, there's a mcburney's point tenderness on the palpitation. Finally, there's reduced, bowel sounds on auscultation in what do you think is going on here? Okay. Everyone is staying up and decide is, yeah, I mean, that would be my top differentials too. Anything else it could be? Because I think usually in Oscar stations they ask you for your top three differentials. Just think left to right, lower quadrant pain. Could it be so? Yeah, topic, ectopic pregnancy is one. Ovarian rupture is a good one. Yeah, it can also be that particular ITIS as well. Amazing, well done. Okay. So when it comes to abdominal pain, it's important to note where it's located in general, right. Upper quadrant pain indicates um, things wrong with the liver or the biliary system. So for example, Goldstone's Collinge Itis colecystitis, hepatitis cirrhosis and fatty liver disease. Epigastric pain is a bit more generic. It can be things like gastritis, pancreatitis which often radiates to the back cholecystitis, biliary, colic, bowel obstruction, and IBD, right, lower quadrant pain in general, my top differential is always appendicitis. But if uh you should also think of non gi causes of abdominal pain, especially when it comes to history taking station or where the station is not obvious that is either gi or sexual health. So ask if it's a female patient, ask when she had her last period and other non gi causes of right, lower quadrant pain include pelvic inflammatory disease or very insist or Torshin left lower quadrant pain. Um It can indicate diverticulitis because it mostly affects the sigmoid colon. But there can be other non gi causes such as renal colic, ovarian cysts and endometriosis. Okay. So, the patient that was in the case, she had appendicitis and uh usually it's presents as acute abdominal pain that starts in the periumbilical region and later localizes to the right lower quadrant. And that is because when the appendix is first inflamed, it irritates the visceral peritoneum, which has poor innovation. So the pain. So the pain is poorly localized. But then as the inflammation gets more severe, the it reaches the parietal peritoneum, which has basically better innovation. And therefore, the pain is more localized in the right lower quadrant. So some of the sciences and symptoms, the patient could have include loss of appetite, nausea and vomiting, low grade fever, Rovsing sign, which is what the patient had. It's basically palpating, the left law quadrant causes pain in the um No, yeah, palpating the left, lower quadrant causes pain in the right, lower quadrant patient could have gardening and rebound tenderness, which can indicate uh peritonitis caused by a ruptured appendix and also reduced bowel sounds, which is what the patient had and that is also a sign of perforated appendicitis. Ok. Investigations always group make your investigations, bedside bloods and imaging. So bedside investigations include your analysis to rule out uti if the your analysis comes positive for red cells, white cells and nitrites or nitrites, I mean, it can, you should think of a differential diagnosis such as renal colic or uti if it's a female patient to a pregnancy test because uh the right lower quadrant pain can be caused by uh could could, could have been caused by an ectopic pregnancy. So, blood's take a full blood count. It can show increased white cells crp to indicate the level and severity of inflammation. Using these because um the nausea and vomiting and the loss of appetite, they can cause dehydration and the user knees and urine kratom can be deranged imaging. The first investigation to older is an abdominal ultrasound scan which can show a a non compressible appendix. So that has a diameter of more than six millimeters. If the ultrasound is inconclusive, then you might want to do a CT. And again, it would show an abnormal appendix with a diameter of more than six millimeters. Okay. Management. Conservative management includes uh active observation which is basically fluids, an antibiotic therapy and supportive treatment. So that's things like IV fluids, analgesia, antibiotics, keeping the patient will by mouth and the definitive treatment for appendicitis is usually a laparoscopic appendicectomy. Okay. So, acute cholecystitis and acute Collinge itis present with right upper quadrant pain and uh cholecystitis is inflammation of the gallbladder usually as a complication of Goldstone's cholangitis is inflammation of the bile ducts. It could be due to infection post and ercp procedure. And the most common positive organisms include E coli klebsiella species and enterococcus species. Both of these present with right upper quadrant pain and fever. But cholangitis also tends to present with jaundice which is known as shock coats, tryouts. So, right upper quadrant pain fever and jaundice. So more about the acute cholecystitis, it can also present with uh tachycardia and tachypnea. Memphis sign is positive. I've already talked through Memphis sign. Uh blood would show raised inflammatory markers and white blood cells. The first investigation to order is an abdominal ultrasound scan which will show um a thickened gallbladder. Basically, it has I think more than three millimeters thickness. And you can also uh see if there's any Goldstone's in there management. Basically, this is uh an emergency. So admission anil and supportive treatment including analgesia IV, fluids and antibiotics. And the treatment is a laparoscopic cholecystectomy or percutaneously. Colleagues, cystotomy, okay, acute Collinge itis, the bloods would show a rise, the white cells LFTs would show a quality static pattern which I've already talked about in one of the S P A. This is when the A L P is significantly elevated compared to the transaminases. Management includes admission and supportive treatment and you may need to do an ERCP procedure to affordability. Early three decompression, okay. You can have acute pancreatitis as your presentation. And usually this presents with severe sudden onset mid epigastric or left upper quadrant pain, which often radiates to the back. The most common causes include Goldstone's and excessive alcohol consumption. Some of the symptoms um can also be associated nausea, nausea and vomiting, abdominal tenderness and the patient can be systemically unwell. So they would have low grade fever and tachycardia investigations, website bloods and imaging. So you do an E C G because to rule out an M I, you never know. Sometimes people with an M I can present with epigastric pain, blood most important investigation to order serum lipase or amylase because if they're increased more than three times the upper limit of normal, then that is your diagnosis of pancreatitis. Okay. So, pancreatitis is usually diagnosed by raised amylase and lipase, which has increased more than three times as uh the upper limit of normal. Um The main difference between the two is that lipase is more specific and sensitive but the hospitals might not have it. So, Emily's can do just fine other blood such as useful blood count. Can you uh can show raised white cells. Um you do crp to for severity and uh of inflammation, use the knees because fluid depletion is extremely common in pancreatitis. Um you can do LFTs if it's an obstructive cause of pancreatitis and imaging. You don't really need to do because as I said, your diagnosis is mainly from the blood. But if they are, uh if you're still a bit unsure, then you can do um contrast, contrast, enhanced abdominal city ultrasound or MRC P management. So, immediate management is basically you do an initial resuscitation A B C D approach, supportive treatment, IV, fluids, analgesia. If it's an obstructive cause of pancreatitis, you might want to do an ERCP procedure to relieve familiarly obstruction. And a surgical management is indicated in Goldstone pancreatitis. So that, so cholecystectomy. Okay. All right. So, um in the interest of time, I'm gonna basically skip through uh some of the slides and try to move on to the next case. So I've got some know Monix here for you to remember the difference between ulcerative curric colitis and Crohn's. And yeah, I've got all the information you need here, investigations, bedside, blood's imaging, conservative medical management and surgical management. So, yeah, I'm gonna move on to the next case now. So, um your patient, you're in the gastrointestinal ward and your patient is Mr John Diaz, a 28 year old male presenting with jaundice on examination. The patient has Clara licked ear's right, upper quadrant tenderness on palpation and a palpable liver edge that is more than two centimeters between below the costal margin. So, basically, the patient has a bit of hepatomegaly. Um What are your differentials? What do you think is going on? So, yeah, these are really good differentials, liver cirrhosis, nonalcoholic fatty liver disease, hepatitis liver cirrhosis hepatomegaly, nonalcoholic fatty liver disease, primary sclerosing cholangitis. Yeah, these are all very valid hepatitis familiarly treat disorders. Okay. So basically we need a bit more information. So you order some lab investigations for this patient and they show the following. So out of the options, what could be the possible cause of his jaundice? Try to think what pattern of John this these LFTs show and therefore out of the options, which one would be more appropriate. Okay. The measures if you have gone for see, I'm gonna end the pole right there, Maldon, that is the correct answer. So the LFTs are showing a hepatitis hepatitic picture in the sense that the transaminase enzymes are significantly elevated compared to A LP. And out of all the options, viral hepatitis is a cause of entry hepatic join tous, which is what the LFTs are showing A M B would uh show basically normal LFTs except raised bilirubin because these are examples of prehepatic jaundice and D N er cause obstructive jaundice or cholestatic jaundice. So they would show a cholestatic pattern on LFTs. So that would be a highly elevated A LP and transaminases wouldn't be elevated as much. Okay. So the patient had jaundice and uh the joint is can be classified into three things. It's either prehepatic, which is most commonly. So if you look at the differentials, most of them are related to having hemolytic anemia because breakdown of red blood cells releases hematoglobin and then hemoglobin is then broken down and then through a series of processes. The account remember it causes a release of unconjugated bilirubin. So yeah, some of the causes of hemolytic anemia, conclude congest congenital diseases such as sickle cell anemia, thalassemia, hereditary for spare cytosis infections can also cause hemolytic anemia such as malaria. Ok, intrahepatic jaundice something wrong within the liver itself, within the liver hepatocytes. So examples include viral hepatitis, alcohol related deliver disease or non alcoholic fatty liver disease. It could be autoimmune hepatitis cancer, uh hemochromotosis and Wilson's disease, obstructive causes of jaundice or posthepatic jaundice. Basically, there's something obstructing the bile ducts. So this can be Goldstone's, it can be cancer as in cholangiocarcinoma, but also pancreatic cancer pressing onto the bile duct. All right. So this slide right here basically shows you the different types of viral hepatitis. So in general, hepatitis A and E these are usually are self limiting. They rarely ever go on to form complications. I still have examples of some of the complications they can form but the Israeli happen because they're self limiting and the management is usually supportive. Hepatitis B and C or Hepatitis. In general, they start off as being a symptomatic or they can have non specific symptoms such as um uh flu like illness, general abdominal tenderness, nausea, vomiting sometimes joined this and Hepatitis B and C can become chronic and if they do so, they can form complications such as cirrhosis and hepatocellular carcinoma, which is why it's important if the patient has it, you might need to give them antiviral therapy. Okay. So, liver cirrhosis. So this is the pathological and stage of any chronic liver disease. So, the liver is gonna basically um is damaged by chronic inflammation and fibrosis. Uh it's most commonly results from chronic hepatitis B and C alcohol related liver disease and non alcoholic fatty liver disease. Uh signs and symptoms can be arranged also, um I've already talked through most of these signs during the ab the examination. So jaundice, hepatomegaly, splenomegaly, hepatomegaly might not be, if the patient has very, very severe cirrhosis, then um their liver can actually shrink. So, uh they might actually not have that they can uh they can develop the compensated liver disease and portal hypertension which would present with the society's other examples of the compensated liver disease can include hematemesis and Molina because the patient would have also visual viruses which have ruptured and that's why there's blood in stool and blood on vomiting. So, investigations include um doing a full blood count. LFTs. So interestingly, liver biochemistry can be completely normal in cirrhosis unless the patient has decompensated. Uh liver disease. In which case, the A L T A S D L P and bilirubin are all going to be deranged. Um But what more um useful markets can be prothrombin time in serum albumin because this can indicate synthetic function of the liver. So, if the liver makes clotting factors and it makes albumin. If there is prolongation of PT or hypoalbuminemia, then it indicates the uh the synthetic function of the liver is getting worse. Um You Zinni's can be relevant because the patient can develop hyponatremia which will cause fluid retention and severe liver and it's associated with severe liver disease. And this can also be deranged in hepatorenal syndrome. Finally, if you think the patient has got hepatitis, you might need to order antibodies for hepatitis C or a full hepatitis B. Serology. Imaging includes ultrasound fiber scan, liver biopsy, endoscopy for us. Official viruses and city and MRI scan for hepatocellular carcinoma management is conservative medical and surgical. Remember on your skis. So conservative management includes high protein, low sodium diet and avoid alcohol, medical and surgical management depends if the patient is showing signs of decompensated disease. So for example, you treat viruses with propanolol. If they have societies, you can treat them Spironalactone, you may need to do elastic band ligation of paris is um you might need to do a tips procedure for ascites and parasynthesis. Ultimately, the best thing you can do for this patient is liver transplantation. Okay. So this slide shows the child Pugh score for cirrhosis and basically um it groups the type of cirrhosis, whether the patient has how compensated their liver disease is. Um So yeah, I'll quickly skip into the last case if that's all right, I've got all the information you need here. So, this is about Celia cost and normal investigations and management. Hejma lytic anemia and Goldstone disease. So, you've got some information on pancreatic cancer as well. So, yeah, I've already talked about pancreatic cancer in one of the S B A S because it's most commonly presents with painless obstructive jaundice. And uh it can also have hepatitic path know hypothetic. Um What's it called cholestatic pattern on LFTs? All right. This is the final case. Mr, heart stool is a 7 67 year old male that presents with constipation on examination. He has a distended abdomen, mild left, lower quadrant tenderness on palpations and the bowel sounds are absent on auscultation. By the way, in order to determine what the patient has absent, bowel sounds, you should listen for at least three minutes, but I doubt you'd have the time in your g eye examination. So if you say you think the patient has absent, bowel sounds just, just move on. I say okay. So what do you think? What are your differentials for this case? Patient has severe constipation, distended, abdomen, bowel sounds are absent and mild left, local 100 tenderness. Okay. So, got colon cancer, obstructive, ileus, bowel obstruction. Yeah, I would say these are, yeah, bowel obstruction. These are very valid. So, yeah, there can be different causes for uh absent bowel sounds. So it can be a paralytic areas. It can be a severe bowel obstruction or it can be peritonitis. Basically, you order an abdominal X ray for this patient and it shows the following. Now, what do you think your diagnosis is? Okay? I'll give you a couple of more seconds. All right. So most popular answers were toxic, mega colon and sigmoid volvulus. I'm going to end the pole right there. But yeah, the most popular answer was sigmoid volvulus. And if you chose that, you would be correct. That is a sigmoid volvulus. And that is because the abdominal X ray is showing the classic coffee beans sign of the twisted sigmoid colon. All right. Thank so bowel obstruction. Um I've got some information here basically of everything you need to know about bowel obstruction. Why I want to go through is how you can differentiate between small bowel obstruction and large bowel obstruction because you can represent it with the radiographic image similar to the ones shown here and you would be asked for um to talk through them and to our diagnosis. So with small bowel obstruction, um the bowel is dilated usually more than three centimeters. Usually it has a central location. But to me, the most helpful feature is seeing if the lines cross go all the way across the bowel. So I don't if I consume in. So these lines, they're not as valvular convent Azor plicate circulators, which as which are in folds of the mucosa that are used to increase the surface area for absorption. They go all the way across the bowel. All right. So this is a small bowel obstruction and it is most commonly caused by occasions, hernia and IBT right, with the large bottle obstruction, the bowel is dilated more than six centimeters or nine centimeters if it's at the cecum usually has a peripheral location. But the most helpful sign you can use is the fact that the hostel lines don't completely cross the bow. Commonly common causes include malignancy, diverticular disease or um, a volvulus. And I've got examples of uh sigmoid volvulus, uh large bowel volvulus here. So volvulus occurs when a loop of colon twists around itself and the muse injury that supplies it causing bowel obstruction. So this is what the cecal volvulus would look like. And this is what the sigmoid volvulus looks like. And the main difference shown here is the fact that the sigmoid volvulus presents with the coffee being signed literally, this part of the bowel, bowel looks like the coffee bean. So that's how you can differentiate that on abdominal X ray. I hope that was helpful because I know somebody asked a question about that in the chat. So that is it, that is the end of my presentations. Thank you so much for watching and please don't forget to fill out the feedback form. Thank you. Alright. Uh Sorry, other, um, just to answer one question and uh, you feel free to leave. You need to break your fast. Um, just, just thank you. Yeah, just a quick, uh, answer to the tinkling bowel sounds. Um, it will still be present as long as there's going to be, um, fluid intake. Um, the reason why it doesn't really happen later in the disease is number one, you get diagnosed and it gets managed because of the pain et cetera that you might find in bowel obstruction with the mainly small bowel obstruction. Um But also because the fluid has passed through the bowels and and is is waiting to be, has been absorbed or is waiting um at the edge of the, at the site of the obstruction itself. So that's why it stops tinkling. Um Yeah, if that makes sense, but ideally you're not gonna, you're not going to leave it all the way till the end um before diagnosis. Uh Sorry, this is the feedback form. I'll just get you the Kiki Medic stations that we create. I hope you enjoyed, please come down for our sessions next week as well. There you go. Um posted on social media. Um I think the Zoom link does get posted on social media. So our protocol is we post Zoom links um an hour before and about 10 minutes before the session itself on, on Facebook and on Instagram, we just post a session itself, but the link is available on a link link tree in the Instagram page. Um Yeah, I think I, I today was an exception. I tend to post the links on Instagram as well as a sort of caption. But yeah, probably the best place to look at it would be our events particularly would be um Facebook. Thanks. Thanks all for coming to the session. Please tune in next week. Next week we have prepared quite a really, really good sessions. Neurology is going to run through loads of cases and cranial nerves were going to go, uh, delve into every single cranial nerve. Um, why you examine it? What do you examine and all the pathologies associated with each of these cranial nerves? So, tune in the only thing that I won't be covering is anatomy that will be probably mrcs session in the future. Sure.