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No, As I said, Today's part. Teo, uh, Gastroenterology station. My name's initials. Well, in case you wonder where, um so it's titled The Gastroenterologist Station part, too. But I really think we should rename it as just the abdominal station. Okay, because I really want to be emphasized that the abdominal examination is not a gastrointestinal examination. Okay, it's not just in examination of your gastrointestinal system. There's a whole bunch of other systems that are relevantly abdomen examination. Okay, there's knowledge that there's a lot of surgical knowledge that comes into the abdomen. There's a lot of renal stuff that goes on obs and gynie. Um, even the cardiothoracic stuff with the abdominal aorta. There's a whole bunch of other specialties to be thinking about outside of the gastrointestinal system. Okay, so it's gonna be lots of different specialties being covered today. It's not just gonna be gastro s, so it's gonna be a mix of medical knowledge mix of surgical knowledge, But we'll be I'll try and be as comprehensive as possible. As always with these sessions. Well, he loves the pictures. Lows of videos loads a spot diagnosis. Okay, there's a lot of spot diagnosis today. because there's a lot of content to get through, but really super interactive throughout on. I hope you guys really enjoy it, So we're gonna go. It started. It started with the examination station, so we've been asked to see Mr Square Pants, a 35 year old male who is presented with normal pain. We've got to perform a focus examination of his abdomen and then present our findings on, So let's get into it. And as always, we just like to give some general tips for physical examination's. So when you, as always with this patient physical examination's, it's always about taking that time of the start for your general inspection, Okay, it's such an important aspect is arguably arguably the most important aspect of your physical examination. Make sure to take a few moments to look at the patient's look around the patient at the bedside and just Milic, try and clarify it to yourself. If you can pick up anything any sort of physical findings just on that gentle inspection, okay, it's really, really important and really highlight to the Examiner that you're looking around. Okay, make a big show of it. If you're talking during the examination and you're picking Talking about physical findings are you looking for? Don't say you're looking for a physical finding. Say there is no evidence of a particular findings. Okay, for example, there's no evidence off Big club. Okay, always home white. But the start and we'll talk about what wife is and into the general bedside manner. Make sure you always examine from the patient's write down side. And, as always, with physical examination's, it's all about putting on a show for the Examiner. Okay, it's about reflexia. Knowledge is showing that your competence and showing that you can effectively do a physical examination. Okay, it's all about putting on a good show for The Examiner. It's a performance. Okay, so let's do some spot diagnosis. I'm sure you guys are very familiar with that. You guys really enjoy this stuff. So we're going to talk about some physical examination findings for common abdominal cases. So on examination patient has generalized abdominal tenderness. There is pollen and erythematosus nodules over both of his shins. There's evidence of toss standing at the ulcers and numerous abdominals guys, what do you think? So everything Mendoza is part of part of this patient's presentation. What else? What's the overall diagnosis? Yes, grows disease. Very good. So this is a very common station and very common case that comes up in abdominal stations. Okay, they can easily bring in a lot of patients with Chron's disease, and I'll have a lot of these classic examination findings. So let's talk threats. So Crone's disease, where the implantable diseases are gonna tenderness, is common. Okay, cause it's, uh, you know, it's been inflamed about collar. Why would a patient with Chron's disease have power? Like anemias? What could cause anemia and crone's disease? Yeah, but then bleeding potentially. You don't actually use that much blood with Chron's disease, lack of abductions, a big cause like a lack of iron absorption and also B 12. Okay, Always think about B 12 lack of B 12 absorption as well with Chron's disease, because they they faxed e terminal. I am I really, um particularly so Definitely. Pollens are key feature to pick up as someone mentioned these erythematous know deals over shins that's describing everything and the dose. Um, I'll show you a picture later on. That's ah, another important thing to inspect for. It's one of the extra intestinal manifestations of crone's disease. Toss staining wise toss staining. Important in a patient with Crohn disease wise smoking. Important to think about with inflammatory bowel disease in general. Yeah, good. So smoking this book is a big thing to be thinking about in any patient IV. Okay, smoking is that is worsens disease and Crohn disease and, as shown, that has been shown to be somewhat protective and also to collect us. So it's important to pick up on evidence of smoking after sources is a key feature and Crohn disease because it's it's a disease that affects from the mouth to the anus. So you can get inflammation in the mouth area you need to up the cell, says numerous abdominal stars. Why would a patient with Crone's have loads of abdominals? Guys, what explain that? Why would they have loads of stars of their abdomen? Pretty eyes doing? Yeah, So there is. There are surgical spots, right, and we'll talk about the different type of surgical scars in detail. But patient is Chron's is classically that they'll have had multiple surgeries. Okay, multiple different types of the bowel. Resections remember, surgery is not never really a curative and crone's disease. Okay, because disease can affect different parts of the bowel. A lot of patients will have had multiple different types of bolus sections, and often they'll have a lot of different types of stone bags inserted. Okay, so these are all important things to be inspecting with the abdomen. Okay, but that's a classic crone's disease patient. That's how I look at this one. On examination. Patient has a distended abdomen with Splenomegaly put Medusa clubbing, shifting Dulles, the six fighter angiomata present on his chest. And there is evidence off scleral Icterus. Yes, yes. So you guys got it. So this is cirrhosis of the liver cirrhosis, and we'll again we'll talk about liver disease and good beat up today as well. Is is classic peripheral stick motto off liver of liver disease. Okay, descended abdomen so suggestive of a site T's okay, particularly there's evidence of shipping dollars. So that's ascites Splenomegaly feature of portal hypertension on computer to say, also feature portal hypertension troubling. So cirrhosis is also cause of clubbing, Um, 65 around your marker. So how many's spider angiomata is clinically significant for liver failure? Generally, Yeah, so they have more than five. That's clinically significant for liver failure. So he has more than five. So that's also clinically significant for cirrhosis and evidence of scleral icterus as jaundice feature after big feature of liver failure. Okay, have decompensated liver disease. Okay, Next one patient has excruciating generalized abdominal pain. Same lesion was unremarkable. His pulse is irregularly irregular. Onda venous blood gush showed a raised Lucked it? Yeah, you guys got it? Said it is all sort of an ischemic picture. This is ah, acute mesenteric ischemia. Okay, so the key thing is to realize is that generally with examinations were looking for positive findings, but it's also really important realize that negative finding is also important to think about as well. Okay, so this patient has generalized excruciating abdominal pain, but the abdomen examination was unremarkable. Okay, that's suggestive of mesenteric ischemia. Because the classic feature acute mesenteric ischemia. Is this presentation off a severe abdominal pain? Okay, tenderness, but disproportionate to your examination findings. Okay, so this patient has severe pain, but the examination was unremarkable. Okay, So suggested about, you know, mesenteric ischemia and this irregularly irregular pulse. So as some of you have mentioned so suggestive of atrial fibrilation. And that's one of the big risk factors for mesenteric ischemia. Because with a if you're gonna get clot formation and those clots can embolize and cause your mesenteric ischemia, okay. And the rays lactate also suggestive off intestinal esquina. Okay, this is Ah, quite a detailed case. Okay, But there's a lot to break down, so have a good think about it. So on examination, a patient has a scar over lying the right lower quadrant with a smooth, nontender palpable mass underlying it. There's a non functioning 80 fistula and the right on. And there is evidence off gum hypertrophy. Think of prick marks and abdomen injection looks. What do you think this is? This is there's a quite a lot of stuff to think about with this patient. You got a couple of different answer you can You guys really try and break down everything that's going on with this patient, so I think a couple of you got it. So this is likely a renal transplant case. Okay, so there's a couple of reasons why renal transplant. So we'll talk about one of the key things at the start as I say that there's a Scott the right lower quadrant, and there's a non tender, palpable mass underlying. Okay, so non tender, palpable mass. That's likely the oft Okay, that's the graph that you can palpate on boats. These scar cold for a renal transplant. Also name of the surgical scar. Classically done for a renal transplant. Yeah, Ruthie Food Morrison Scar. Okay, we'll talk about all these scars later on. Okay, but the classic name for the renal transplant scars there is a defect Morrison spot on. It looks like a hockey stick s. So that's why it is likely, uh, this patient has a real transplant. Nonfunctioning a V pistola. What does that indicate? What is that suggestive? What does that mean? Yeah, so we'll talk about 80 officials in a bit of detail later on. Okay, but maybe official is classically created for hemodialysis, so this patient's likely been on hemodialysis. But I told you, this is non function is a nonfunctioning 80 Fischler. So it means that they no longer on hemodialysis on so and that so and previously been on hemodialysis. But they're no longer having hemodialysis because they had the real transplant gum hypertrophy What do you guys think about that? Yeah, and, you know, suppressive therapy. Someone said that cyclosporine. Okay. One of the common municipal of agents used a renal transplant is cyclosporine, and one of the key side effects of cyclosporine therapy is gum hypertrophy and a lot as a lot of you said these finger prick marks abdomen injection marks is suggestive of, um it's a diabetic individual. So finger prick marks fricking for glucose testing. Abdomen injection marks. So insulin subject is in into injection marks, but suggesting is said, insulin dependent diabetic. So why is it relevant to the renal transplant? So it's very diabetes is very, very relevant to kidney disease because diabetic nephropathy is super common. So this is a patient who has had a renal transplant, who has previously received Dallas at dialysis. Hemodialysis has evidence off, um, immediate suppression. Okay, so is evidence of complicated complications from immune immune suppressive therapy, and also has likely has renal disease because of diabetic nephropathy. Okay, that's a lot to break down there, but it's this is the type a very common case that might come up in your off skis. Okay. They might bring in a renal transplant case, but that's the sort of way to break it down. Last one on examination Patient Has abdominal Distention Tingling high pitch bowel sounds on auscultation and the percussion notes is tympanic. There is a non reducible and extremely tender inguinal mass. But I think, yeah, you guys got it. So this is likely obstruction. Okay, this is likely a small bowel obstruction. Eso Why obstructions wise Bowel obstructions is abdominal distention so classically about obstruction? Classic auscultation finding for bowel obstruction, which we'll talk about later, is these tinkling, high pitch bowel sounds because you're getting obstructions and about your bowels peristalsis against an obstruction is that causes a high pitch tingling bowel sound. Percussion is tympanic, so because it's filled with as a percussion, it will be tympanic, and it's non reduce full, extremely tending renal mass, as some of you said likely is suggesting a strangulated hernia. Okay, so this is likely a small bowel obstruction secondary to a secondary to mechanical obstruction by a strangulated hernia. Okay, that's a good, different types of cases that might show up. Okay, Hopefully that was useful. So let's get into the actual examination. So this is how it introduced myself. Okay, just some general sentences. Always make sure the weight wash your hands. Introduce yourself a position the patient on Dex posed them. Uh, where do you position the patient for an abdominal examination of the stock. How do you position then? You position them lying flat? Yeah. Remember you position them at 45 degrees at the start again. Then later on, when you actually get to the specific bits of the examination, then you get them to like flats. Okay, But you start off with them at 45 degrees. Uh, in terms of how you introduce this out used patient, friendly language. Okay. Instead of saying abdomen, use words like tummy. Okay, Um, in any physical examination, it's always good practice to ask if the patient is in pain. Why's it really important in an abdominal examination to ask if the patient is in any pain? Why is it very important to ask in an abdominal examination if the patient is in pain, I was going to affect the way you do your, um, examination. Yeah, very good. So you know that you're not going to touch that first. Okay, So if a patient has localized abdominal pain. Summer. Then that's the last place you're going to pop it. Okay? You always start from the non painful areas of the non tender areas, and then you come to the painful areas. Okay, that So that's why it's very important to ask if the patient is in pain. And so, yeah, that's your introduction. So let's do our general inspections about diagnosis. Um, have I'm gonna show you bunch of pictures. We'll go through this quite quickly. Okay? I won't ask you for all of the images. I'll talk to you, some of them, but it will be super interactive. What do think? I'm trying to get out with this picture. What do you guys think? I'm trying to get out with this picture. Physics head was the first good thing to look at and general infection in the patients. Are they comfortable at rest. Okay, so it's a bit of ah, a random picture, but just general thing. Look at that. Comfortable at rest. Okay. What about this patient's This is ah, bit of ah, slightly trickier to inspect, but you need to be able to inspect this. What do you use happening? Yeah, good. This is joined us. Okay, so we talked about jaundice in a bit, but this is, uh, you know, yellow discoloration of the skin. Jaundice is it can be quite hard to appreciate in a lot of patients, particularly in darker skin patients. So this can be quite hard to appreciate, okay? And particularly darkest, darker skin patients. Okay, there's no not enough pictures are out there of darkest skin patients with skin manifestations. So if you have ah, once you stopped practicing, if you ever see any of these sort of skin manifestations and have darker skin, people, please get consent, then try and take pictures of them and publish them, cause it can. It's important for education of people to actually be able to see these sort of skin manifestations in the dark skin. People is well, but they're this is joined us. What about this one? Yeah. Obesity. So brought in to pick up on. Always think about the habits of the patient. So if there's sort of evidence off, be city, just pick up on it. Still thinking about habitants. What do you guys think about this patient's? How would you describe the habit? It's of this patient could get you a very good. So this is cachexia. So generalized loss of muscle mass loss of proteins to be a loss off general muscle mass as a key. Things that's kept CIA. So it's good. Guess if it's if it's due to a particular condition that's causing this sort of loss of muscle mass loss of protein, that's that's what I get. Cachexia is what about this one about the difference in color hair? Yeah. Pollen. Okay, you get to pick up in pilots, not just the conjunctival that you look for for power. Okay? You look at systemically is welcome power. And what about the this last one? This is a tricky one. What you guys think I say, It looks like he's been out in the sun for a while. Hyperpigmentation. So as someone said, it's a bronze skin. Very good. What is this broadened skin suggestive of this sort of tan skin? If it's pathological, what do you What is this, a testicle? Yeah. You can activate plantation. You can't get Addison's disease. What about, um, condition which you have loads of iron accumulation. Hemochromatosis is very good. So hemochromatosis Another cause of this sort of brown brown bronze town skin as well. Okay, go to that stuff. Stuff we're inspecting on the patient. Now, let's talk about the bedside in terms of the bedside that I like to think of the three D. So Okay, so drips drains on drugs, so let's have a look of different instruments. So, what do you think about this image? Yep. This is a acidic drink. Very good. This is a cytic drinks. You see, collection container here. So, um, I recommend just watching how acidic drains have done, but this is showing our ascites is being drained. Uh, what All this one? This is a bit you have to be. You have to You probably have seen this. Do you know what it is? What do you think this device is? It's only and you to, uh, looks like a cap. There's not quite a capital. If I say it's this is gonna help. Uh, take suction. Any secretions? Yeah. Surgical dream. Okay, this is just a sort of type of surgical drink. Okay? I'm not gonna go into detail, different types of surgical grains, but general thing to look at is different types of dreams which people might be, which might be inserted postoperative it. Okay, so this is a surgical drink. Uh, what about this one? So someone's mentioned that area. What? What is this Indicating mg tube. So generally inspect for feeding tubes in your abdominal examination. Okay, so it might be an end you tube might be Ah, gastrostomy judging ostomies and things just look for feeding tubes in general. What about this one? This will This is very common in your Oscar. Still, that might be patients might bring with them. Kidney bowl? Yes. Oh, vomit bull. Okay, so it's gonna help collect and vomit on last one here. So still on the topic of sort of feeding if someone has bags attached to them Like which looked like this, What does that indicate? Yeah, it's a TPN bag. Okay, so parenteral nutrition. So this type of total parenteral nutrition back. Okay, So if someone's getting feeding by the intravenous truth, it'll be connected to this type of bag. Okay, So feeding tube like this, if they're getting a little feets like with an n g tube. But if they're getting it through, you know, like a cannula will be connected. Teo, This type of back a case of parenteral nutrition. Cool. So that's that's your general infection. So we looked at the patient and looking at the bedside. So, uh, this is what we did that general inspection. Remember, we positioned them at 45 degrees and doing a good inspection of both the patient and at the bedside. Okay, let's move on to the hands. I starting with the dorsal aspect of the hand to the back of the hand. So let's talk about what we're going to look for. What do you think about this picture? Yeah. Leukonychia so leukemic here. So there's very important to inspect the nails in your abdomen examination. So this is leukemic. Yeah. We'll talk about what record represents in a bit. Uh, what is? But if that's leukonychia, what is this image indicating? Yeah, so that last look in again and this is koilonychia. Okay, so they look different. So, Luke and I guess it is sort of white line across the nails, so that's leukonychia. And it's sign of low albumin level's okay, and commonly in your abdominal station that will be due to chronic liver disease. But koilonychia So this is your spoon shaped and else. So it's pulling up words. That's Colin Icky. And it's associated with sort of deficiency anemia. Um, but yeah, those are the sort of keen Ailes findings to be looking out for in your abdominal station. Uh, what about this one? I'm sure you guys have picked it up stuff. Yeah, this is Ah, clubbing. Okay, so we'll talk about the g I causes of clubbing in a bit. But remember, in your osteo boys demonstrated to the Examiner, okay? Always get the patient to demonstrate if if their club so get the patient to touch their nail beds together. And look, if there's a gap between the nail beds. Um, yeah, this is clubbing and lost in there for the back of the hand. Would you guys think What is what around all around all of these joints. So they are not doing it, But someone said it xanthomas. These are Ted's. These tendons on Domos. Okay, So cholesterol deposits. Um, but yeah, I can They do. It looked like a lot of the stuff you guys are talking about, like, rheumatoid know. Yours, galaxy toe. I they did these Nautilus stuff do look quite general quite look similar, but this is these are tendons on film was Okay, so my first sort of by the question for you guys, what are the G I causes of clubbing? You guys can just list some gastrointestinal causes a problem for me. I want four different GI I causes of clubbing. Yep. Um, cirrhosis is a big one. Ah, I'd be good else. Celiac disease. Good. And lymphomas. Well, uh, good. So, uh, there's four different causes to be thinking about. Okay, Um, might absorption. So someone has celiac disease that's gonna cause clubbing IBD. So inflammatory bowel disease, But Crohn disease and also colitis that's gonna cause clubbing as well. Lymphoma. If someone has an intra abdominal lymphoma, that can also cause cramping. And if someone has chronic liver disease or liver cirrhosis, that's also gonna goes clubbing. And you can see that I've colored in the first letters off these words because it's gonna make this nice and, um, on it called milk. So it's milk, but a c at the end instead of Okay, so that's the new monitor. Um, the GI I causes of clubbing. So over the last couple of weeks we talked to the cardiovascular causes clubbing. We've talked to the Risperdal causes of clubbing. And now we've talked through the gastrointestinal cause of clubbing. So how often? Now, you can appreciate that There are a lot of closes up clubbing on, but yeah, just trying to remember them. Sort of by system. Okay, Someone said COPD. I'm not happy with that. Remember, COPD doesn't specifically does not cause coming. If you make sure Watch last week. Say recording COPD does not cause clubbing. Yes, that's the easier of Ah, dorsal aspect of the hands. Let's about the front of the hands. The Palmer aspects of the hands. What about this? Looking at what I'm looking at, uh, Palmer erythema get so palmer erythema. It is a bit of a misnomer. Okay, Because as you can see in the picture, the actual center of the palm isn't actually a rhythm. It just okay, this is not actually right in the center of the from the Palmer erythema. The actual bits of the hand other getting erythematous is your I mean, I'm in and you're high protein, I eminence, and you're so basically the fingers. Okay, those are the bits that are getting red. Okay. About Palmer erythema again. It's one of the stigmata off liver disease. Okay, It's sort of indicative of lack of estrogen metabolism. That's your Palmer erythema. Next one. It's the picture. You should be still thinking about liver stuff. Yeah. Do patrons contracture. Okay, can you tell me? Is due patrons contractures something you inspect for mainly or something? You palpate mainly. Yeah, you palpate it. Okay, I know, I know. A lot of you will see pictures like this for do better this contraction, be it. This is sort of indicative of very severe do patrons. Because what happens in duper trains, you're getting thickening of the palm of fascia. And if it's very severe, it can cause this election deformity. Okay, which looks like this, but the key thing is that do differences that sickening off the palm of fashion. Okay, so and you can really palpate that thickening. Okay, you can help it. Things like those courts that happen in the palm of fashion with the thickening, but yeah, make sure you actually probably ate the palms for this dupixent contracture. Okay, get lost. One hits. Looking at the fingertips where these indicative off? We talked about them in the spot diagnosis. What? Yeah, You guys got it? PM marks? Yes. Blood finger prick. Glucose Mark. So we talked about them. One of the sort of signs of someone being a crime diabetic. Okay, so there's this sort of indicates someone's been pricking their fingers a lot on the same. Um, Okay, guys, please don't throw on the screen, but yeah, this is, um, finger prick. Glucose mark. Someone's been pricking their fingers for blood glucose monitoring a lot, and that's important to pick up. Um, get cool. So now let's move on to the arms. Okay, so it's not just the hands minute. Inspecting the back of the hand in the front of hands were also look inspecting the arms, So have a look at it. So I have a look at this one that we have a very dedicated osteo see from here, but you guys think about this. Picture eso the brown skin. I think it's just the filter on the patient. That's a I don't think the specialist has gone skin, but yeah, somebody said it. So this is just the tattoos get so this guy's got a ski. The shoulder tattoo. Okay, so more is more dedicated to ask. Easy than myself is going on easy tattooed on his shoulder. Uh, what do you guys think about tattoos and your belly examination? What is that sort of worry that? What do you thinking off? Meghan? Can you kick this guy hepatitis C again? By hepatitis? Yeah. So think about tattoos. So we think about sort of one of the ways of transmitting viral hepatitis. So, yeah, tattoo is important to inspect. Similarly thinking about sort of viral hepatitis transmission. What is What are they looking for here? Yeah, track marks. Okay. So again, there's all sorts of indicating looking for sort of ways in which hepatitis might be transmitted. Skate so truck marking suggestive of intravenous drug use. Important to look for. What about here? What am I looking at here yet? Bruising. Very good. What am I thinking about with bruising in an abdominal station? Yeah, very good. So coagulopathy. Okay. One of the another important beach off chronic liver disease. Okay. Decompensated thing. Uh, lost on here. This has been trickier. So let's say this is These are the arms, but one of these. Uh, what are these different, Um, lesions particular. Yeah. If I say that, um, sort of due to excessive scratching. Yeah, actually. Excoriation. So these are sort of bags, but you describe those excoriations. So why would someone be scratching themselves a lot if you think about your abdomen examination? What? My cause. Excessive ritis you have Someone has liver disease, so coolly Stasis. So there's excessive bile salts accumulating in the skin. Uh, someone said PVC. That's a very important condition that causes generalized correct. It's okay. So? So if someone scratching themselves a lot that might cost, sits and skin manifestations such as it's excoriation so again, important to just pick up on. Okay, cool. Now we're gonna talk about this finding in a bit of detail, but what do you think about this one? Aybe Fischnaller. Okay, on. And we're going to see him. This is a surgically created A Be Officially, this isn't a sort of a b malformation. We'll see him. This has been created in the patient I want to be created for We took another set of shots. Yeah, he even else is very good. So that's about 80 fischelis in a bit of detail and make sure you guys are really confident and talking about hemodialysis in your skin. So I'm gonna ask you a bunch of different. Examine a style question about dialysis and make sure you guys are confident in understanding the different expects of 80. Fischler's and chemo dialysis. What are the different types off? Renal replacement therapy? The very common example. Questions you got hemodialysis. What else? There's peritoneal. The house This? Yep, Renal transplant. Good. So there's three major types of renal patient their business hemodialysis, peritoneal, dialysis. And, as we know, transplants. Okay, 80 official issue. Creating a be fissures. That's the type of hemodialysis. Um, so that's the major way in which human house is done. But you can also do it through a central line, so we'll talk about central lines as well. And in a later on. But 80 fissure is the main way. Hemodialysis is. No, I didn't. But can you tell me what is an A B picture? What? Why am I going to connect an artery to have been What? How is that going to help me do dialysis? What's the point of connecting our tree to a vein good increased blood. Okay, So any official is basically you're connecting the artery to the pain, because for dialysis, you need a slow flowing bank. You need the vein to be moving slowly, but also need that to be enough blood to create an effective circuit for thousands. Okay, So, as I said it, and anastomosis of an artery and vein to create a safe, large bore basket access for hemodialysis. Okay, so by connecting the arteries in the vein, they're increasing blood flow into that being. And so and then you could just puncture that vein to create be Dallas a circuit. Okay, um, so if you see in a be officially and you're off ski, how do you assess it? What are the different things you should do with the, um maybe officially? Yeah. I'll pay to osculate auscultate. It's What about? What should you look for? You feel full and feel for the thrill, yet needle marks. That's important to look for. Okay, there's a lot of recent needle marks as well. That indicates that they're they've been It's been recently used and things, so it's functional. So these are all different things to be looking out for with a Navy base for okay, So I mentioned some important things to look at the location of it. Okay, if it's located, typically will be located head sort of. And because it's a connection between the radial artery and this back up cephalic being on book A. The integrity if there's any sort of rushes. If there's any evidence of swelling, I would theme around the 80 Fisher and and in terms of power patients are carpet for a thrill. As you can imagine, there's gonna be turbulent blood flow going through the official A. So you should be able to pump it for a thrill. It's a functional fistula. Um, Bray's the arm is that should make the Fisher collapse okay, because of gravity on auscultate for a bruit gets a few auscultate the ab Fischler because it's terrible in blood flow and and if it it's functional, you should hear a bruit over the ab. Fisher. Okay, these are all the different things you should do in your osteo. You see an 80 pistol. Okay, look, uh, feel for the thrill and make sure you also take for a bruise. Okay? Very, very important. If you see it in your skin as a couple of more things. So, yeah, I haven't listened to the BRUIT on a Navy Fisher. Okay, it's update again. Okay. Okay. Hopefully, you could have that for their That's the sort of sound for a bruit often 80. Fisher. Okay, so just make sure you auscultated ah, last question here. What are the complications of chemo analysis? And let's talk about let's say it's humid out cysts with the navy fistula inserted infection. Yep. Arrhythmia is year tension. Someone's got heart failure. Potentially at my toe redness. Hypertension is a big one yet. What sort of the ones he sort of really rare complication that you might get with human houses through a Navy fisher. Really? With medical problem that you might get. It's got a bit of a longer name type syndrome. Give you a hint. I'll assist. Disagree with disequilibrium syndrome. Very good knowledge. Yeah, it's very, very rare. Complication of human dialysis to an 80 fish liver. Yeah, uh, let's talk through the eight complications, so there's complications you can get with the 80 Fisher so we can get from bows. Get stenosis on gum. Get infected. Okay. You also get something called a steal syndrome as well. There's official is directing blood away from the hand that's called a steal syndrome, and you get muscle cramps, high potential, someone said. And you also get this very weird. Ah, be right. Complication called dialysis disequilibrium syndrome. If you have time at the end, I can talk through it. Okay, But let's just that sort of hemodialysis, okay? This sort of keep clinical knowledge to be thinking about with him a Dallas. Uh, let's move on. Oh, quickly. Another question. Hemodialysis. That's very commonly asked one of the indications for emergency hemodialysis have you tune into our final season? Siris will be very familiar with these indications. Yeah, eh, I use very good. They're very keen, your monitor to remember the different causes, the different indications to do emergency hemodialysis is the pneumonic a year. You know, someone has severe metabolic acidosis, refractory and electrolyte imbalances. Any sort of ingestions off certain toxins if they're fluid overloaded and you're not able to get fluids if you're not able to drain fluid with things like throws mind and if they have any feature of uremia, these are all indications for emergency hemodialysis. Okay. Very common examiner Question. Make sure you know these indications. Okay. Still still on the hands? Okay. There's a lot to do with the sort of hands. Have a lot of this video. Yeah. Asterixes bear against. So this is Yeah, this is asterixis the liver flat. Okay, so make sure you check the asterixes. Get them to put the hands out called, got their respect and check for that flap. Okay. This asterixis which this patient is demonstrating, What are we thinking about with asterixis in your abdominal examination? Yeah, I Patrick and careful. Opti. Okay, very so the mechanism isn't that well understood for it. But if someone has a Patrick and careful ah, pretty sort of do to, um, liver failure. Often they might have this asterixis. Okay. And last week, in the respiratory station, we talk about another course. Also asked her access What causes what we think about with the respiratory station about asterixis? Yeah. So to retention. Okay. So just make sure, you know, make sure you're familiar with which stage which type of examination you're doing with them. Which cause of asterixis is for that specialty. Yeah, for the abdomen examination, it's about it. And careful a p. Okay, So what does hepatic encephalopathy indicates if you're thinking about liver disease in general? What is the indicated for patient has developed hepatic encephalopathy. If you think about liver disease, what does that indicate You remain on day? I'm thinking, sort of as a concept of liver disease. What does that indicate? Yeah, Decompensated liver disease. Okay, so I just want to sort of cover so quickly some concepts and liver disease. So can you tell me what does decompensated Liver disease? Me. If an Examiner asked you that in your ski, what does it actually mean? If someone has decompensated liver disease no longer able to make it to function, so uh, you could use more specifically is no longer able to maintain function right? That's the sort of key thing with thinking about. It's no compensate liver disease. Liver is his disease, so there's something some insult to the liver, but the liver still functional like as and it's still able to maintain normal function. But decompensated liver disease. That means that there's been such damage to the liver that the liver's no longer able to maintain normal him from your city says, and it's that that's led to dysfunction. Okay, Um, please watch are happy. Told you the Hepatologist final session I gave a couple of months ago. We talked. I talked to you this and a lot more detail. But there's a sort of a diagram. A meat for that session. So we're compensated. Liver disease delivers still functioning, but and patients are typically asymptomatic. But if they decompensated, that means that the liver is no longer able to maintain their normal demands on. But that's where you start getting complications, okay? And we'll talk through some of the complications as well. Key thing is, with both compensated and becomes a liver disease. They can still have stigmata off liver disease. Okay, that if they did compensated, that means that that a rat's high risk of getting certain complications. Okay, in terms of the cause of decompensation. So So for someone to actually developed decompensated liver disease, really? Common causes are listed here. One of the most common ones is infection. Okay, so someone has got any feature off be compensated liver disease. Always think that they've developed some infection. Okay, So in that patient with hepatic encephalopathy, you definitely be working that patient up for certain infections. Okay. Uh, could be another sort of definition question. Can you guys define liver cirrhosis for me? What is the definition off liver cirrhosis? It's fibrosis, but you need to be more specific. What is what about What is that? Fibrosis? Irreversible fibrosis. Good. So the key definition again? We talked about this during a hepatology or final session. But cirrhosis, it's irreversible. Remodeling off the liver duty fibrosis. Okay, so there's fibrosis. But the key thing is that the actual remodeling, the huh that's happening in cirrhosis. It's irreversible. Okay, that's the key difference between chronic liver disease and liver cirrhosis. Okay, if you say that a patient has liver cirrhosis, it means that they have irreversible liver disease. Okay, if someone has just chronic liver disease, there might be some reversibility that But if someone has cirrhosis, it's, you mean is that their disease is irreversible. Yeah, And then that high risk of complications such as cancer as well Good. So that's what we're inspecting with the hunts. Okay. Also, remember to check the pulse. Okay? And remember, assault ways when you're checking pulse, Don't use your thumb Okay, out page with your 2nd and 4th fingers. Not here. Thumb. And also remember the three things we always comment on it. The pulse. Comment on the rate rhythm and the body. Okay. With all these with the Risperdal examination and the abdominal examination, make sure you always offer to check the patient's BP. Okay. You don't actually need to, um, check BP. Okay? With any of these physical examination's you just you always just offer it to the Examiner. So just offer to examine her and just say, at this point in the examination, I would check the patient's BP in both arms. Okay. Um, yep. So that was our hands and arms. Okay? There's quite a lot to be thinking about with the hunt, so it's actually hands and arms. They said that that different things we were doing, we were expecting for a bunch of different stuff. We were palpating for duper trains. We palpated the radio course. We checked for the liver flat, and we also offer to Jack the BP in both arms. Okay, That's a different stuff for the hands and arms. Let's number one to the sort of face, So we'll start with the ice on here. We got some spot diagnosis. So what do you think about this patient? This is Ah, hopefully a very obvious sign. You have jaundice, but yeah, as somebody saying if you see jaundice in the eyes, you should specifically call that scleral icterus. Okay, so if you see yellowing of the eyes indicative of jaundice, that's called Scleral Icterus. How about this patient? You see this brown ring around the outside? Yeah, he's a fly. Should rings indicative off Wilson's disease. Okay. Condition where you got copper overload? Uh, next one. Here. What is this little spot here? Yes, is until asthma. Okay. Indicative of, uh, sort of abnormal lipid profiles. Okay. Oh, is that it's not just for the cardio examination. You look present. The last one is also useful to look at with the abdominal examination as well, cause there's different conditions that can lead to abnormal lipid profiles. Uh, what about this one? This is again pretty. Hopefully pretty obvious. Yeah, Pollen. Like a constant type of pollen. Okay, so there you look for polyps. Stop it. Okay, But the really important you have mainly checking for the pollen. The conjunctival. So, Asa patient to pull down the eyelids and looked at that power. Okay, Schools. That's your ice. That's we want to the mouth and tongue. Couple things you want to be inspecting with the mouth and tongue. Um, So what about what is this patient have here When you got you guys type? You guys type type my foster? Yeah. Ankle. Is that what scientists? Very good. Uh, what about this one here? What is this, little lesions here? Yes, and up. This also what the cause is of up this ulcers in your abdomen. Examination. We talked. We talked about one of them at the start. Crone's disease. Good. Celiac. So another one are Someone said bash. It's disease. That's a very good, very, very good cause, Teo to say as well. But the shots disease, um, have must like this. Cool. Uh, next one. Slightly tricky ever at the pigmentation. What's worked? Is this condition indicative out in your abdominal examination? Yeah, but put you guys in a very good so yet these say these hyperpigmented macule is and the lips okay, on DA. This is a feature off, uh, Potiga syndrome. It's a type of, uh, one of the genetic Correctol cancer syndromes. Potiga is characterized by different sort of polyps, but a as a skin manifestations, you can get these perioral hyperpigmented macule cool. Well, that's when we talked about this in the spot diagnosis. But what is this sign? What is this? Picture shows good gum hypertrophy. Okay. Or if you want to be technical, is gingival hyperplasia on. And as we talked about other starts, if you see this in your examination, definitely be thinking about immunosuppressive therapy is particularly cyclosporine. So if someone's are had a solid organ transplant such as a kidney transplant, they might have this complication off cyclosporine therapy. Good. What about this one? This is Ah, pretty obvious, I think. Um, yeah. Uh, yeah. What I think about about the tongue. Yeah. I've got another picture of Canada loss itis get here. This is a scientist. So there this is Got sight is so big time feature off sort of B 12 deficiency or in deficiency on some of your Imagine that to look for candid isis. So this is definitely kind of die, sister, um or or thrush. Um, why? Why would I look for kind of isis in a abdominal station. What? What kind of isis tell me. Yeah, I get immuno suppressing. Okay. Again. It's someone's immune. Suppressed. They could be at a higher risk of getting fungal infections such as kind of isis. Okay, so just like I got my poetry kind of isis can also be injected in indicative off complications off immunised depression. Okay, so we talked about 80 fischelis as a way of giving hemodialysis. I quickly wanted to talk about central lines as well. So one of the ways to do hemodialysis is to give is to use a be official is other ways is do central lines in the neck. Okay, So can you tell me what type of line is this? What type of a venous cap? It is this. How would you describe this catheter in the neck mainly. Is this a tunneled capita or a non tunnels capita? No, this is a non tunnels central venous captor. Okay, so this is a non tunnel central venous capita. And this picture here's a sample of a tunneled central venous captain. Okay, so this is a tunnel central venous capture. This is a non tunnel central venous captor. Okay, so these are both ways off. These are both types of central lines, okay? Used for many different things, not just hemodialysis, but these are different types of lines that might be inserted into the neck. And someone said, Hitman line. So, yeah, there's different types of tunnel central venous capitals. One example is a Hickman line so that in terms of the fl tunnels, the tunnels referring to it being basically cuffed underneath the skin here so you can see it's actually covered underneath the skin for as this one be actual ports are actually wide open. Okay, It's not very comfortable. Need to skin. Um, So what's the benefit off? Tunneling the catheter. Why is that useful? Why? Why is this? Why would you Very the line underneath the skin. Yeah. Good. So it's a lower infection risk if you bet very it, and it needs the skin. And also, it's harder to displaces. Well, so it's much more stable if you actually put it on, leave the skin like this. Okay. So, I mean, it makes it much more stable, much more longer lasting. Okay. These non tunnel central venous capitals, they only lost sort of up to 10 days. Okay, Whereas these tunnel central venous catheters, they can last a couple of months. Okay? Or even years. Okay. So important to just recognize if it's a tunnel central disc after are non tunnels. Um, CAFTA. Okay, cool. So still on the next. So make sure you always look at the DVD as well. So I've shown this video of a couple of times over the last few weeks, but make sure oscillation to look towards the left and check of the JVP is in the correct position. So have a watch. Remember, we're looking for that inward movement. Double pulsation. Okay, that's your baby. Be cool. And rather always probably lymph nodes as well. Okay. Another important aspect of your abdominal examination is your lymph node exam. Which note is really important to pop it in an abdominal examination, which know Do you have to pump it? Yeah, very cars notes say left supraclavicular notes. So she got this picture here. So I always make sure you you make a big show of palpating your left supraclavicular node your Birkavs note and you can see this enlarged Birkavs note here. What is then enlarged backups. Note a sign up in your abdominal examination. Yeah, Gastric cancer. Very good. Okay, if someone has an enlarged because notes okay, it's very concerning for gastric cancer. Okay. Gastric cancer has a couple of different signs. Okay. But definitely enlarged. Broke off snow. It is a big one to be looking out for. Cool. And also just I just want to give you a quick tip, okay? Because when you're when you're when you still got the patients stopped up, right? Um, the next day, just the osteoporosis and lie down, and often people sort of ms and stuff on the back with the abdominal examination. So I'd say at this point, make sure to just do a quick inspection of the back and make sure you don't miss any sort of surgical scars on the back as well. So you never tell me what is this sort of sky indicative out there? But like this guy indicates. So it has a scar said about these sort of renal angle here? Yeah, The nephrectomy start. Very good. So this is sort of a sign of nephrectomy scar. So just a quick tip. The main sort of aspect of inspection is to look at the abdomen, but a lot of people miss the back, so it make sure you don't miss a nephrectomy scar on the back. Okay, um, that's a quick tip. And also, I got a quick exercise on breath odor. So a lot of people forget this, but it's also useful to check the breath odor. So I got a quick exercise to basically much the boxes to be from the breath. Smells to the condition. So let's do this pretty quickly. So, halitosis. Which one is this going to match up with? All it does is Yep. Bacteria colonization. So halitosis really foul smelling breath. That's ah, addictive bacteria. Colonization in the oral cavity or in the G I t. Alcohol is a feature of alcoholism. Okay, Someone's been binge drinking. What are frequent breath order? Yeah. Bowel obstruction. Very good. Okay. So if someone has severely obstructed the actual breath order might smell of feces. Okay. So important to pick up feet. Patacas. I'm sure you guys gonna pick up. It's a feature of chronic liver disease. Okay. It's in the name, um, similar to it's very so, uh, it's a comedy I've never smelled it myself, so I don't know how to describe it. But Peter Patacas is a sign off. Chronic liver disease and the last one ketotic breath is a feature off DKA. Okay, key top here. So a d k a. You can get this sweet smelling breath because of the acid on on, but yeah, that's another type of breast small. So just say you look, you're unlikely to pick it up something like this in your osteo. But it's just something to be able to just be aware off to be thinking about when you're doing an abdominal examination. Cool. So we just did the neck, the face. We we did the eyes, face and neck. And so these are there different things we did. Okay, so we inspected the eyes, inspected the face and mouth, and we also palpated the lymph nodes again. We also examined the JVP as well. I forgot to put down the slide, but remember always in examine the DDAVP as well. Well, we'll do this stuff on the chest and then we'll take a quick break. So when we went to the chest quickly and talk about what we're inspecting So, what is one of these little lesions here for these little lesions there? Yeah, Spider need by ago. Spike's spider angiomata. Okay, these are quite small despite anyway, but definitely spite. Uneven. And we talked about that mother start. So peach up, Um, suggestive of liver disease. Particularly if you see more than five. It's a more than five spider. Need I tell it's a significant for liver failure. What about this one? This is a very subtle sign. Okay. What? What do you guys think? I'm trying to get out with this picture? Yeah. Lack of her, like a lack of just, uh um so lack of chest isn't useful. That is a very subtle Sinemets. It's suggestive of liver diseases. Well, chronic liver disease. So it's a very subtle sign of chronic liver disease. Uh, what all this? This guy here? What do you think about this guy? Yeah, Gynecomastia again? Gynecomastia Another part of the stick martyr for chronic liver disease. Um, I get feature of lack of estrogen metabolism and other than liver failure. What other? What drugs? My cause. Gynecomastia. Okay. Can you have a list with some drugs? Have the exam to ask you. Spironolactone is a big one. Samantha Dean. Digoxin. Ison eyes. It ketoconazole, um, Easter gyn. Um, yeah, there's a There's a bunch of different drugs that can cause the gynecomastia. Okay. Uh, what? All this guy here? What is this? What is happening? The XL ahead. Yeah, you can't Doses night becomes What is it? A sign off? A cantos is not a cancer. This is this sort of document, Doc and Bell. But actually, typically in the axilla, the insulin resistance is common. But what's the most worrying cause off a condos is never comes. Yeah, gastric cancer, like a gastric adenocarcinoma is a is a very worrying course for an eight count doses. 90 cans. But there's other common ones, like type two diabetes, Cushing sitting room, obesity just situations off insulin resistance as well, but definitely the most worrying causes Gastric adenocarcinoma. I got one more picture here. This is again is quite subtle. Thinking about the sort of hair in the exam. Yeah, is ah, it's an expected. So there's a loss of exhilarate hair here. Okay, this is very subtle sign I gave you need to be quite experienced to be able to pick this up accurately. But if you pick, see loss off exhilarate hair, what does that sort of indicate? What might that indicates if you're inspecting the Exelon. So Addison's disease. Okay, if someone has lost of exhilarate, okay, if there's, um so if it's pathological loss of exhilarate head, that's actually quite sensitive. Sign for Addison's disease. Okay, uh, cools, that's sort of stuck inspecting for on the chest. I want a quick video of spider Niva that I think is really useful to look at. So the key thing with spider knee by is that their central billing? So if you press on despite an IV, I you'll see that it fills from the center outwards. Okay, So look really closely, and you can see that the actual where they compress it, it it blanches. But as soon as you release the pressure, you can see that be blood fills from the center outwards. Okay, so have a close watch of it. Okay. So hopefully you could really appreciate that that a Suzy put pressure on it. It disappeared. Okay, Blanched. But since he released pressure, it was central feeling okay filled at the center. And then it's still of the other sort of spider legs. Okay. It's central feeling spite anyway, So always palpate any spite of me by to make sure it's ah, it's a truce. Fight. Anybody Okay, Cool. That's up. Just okay. So quickly in terms of the chest we just inspected. Remember that after we did the neck, make sure you get the patient to lie down, okay? And, uh, then do your inspection. So we inspected for different things and yeah, that was Ah, we did up to the just that We're gonna move on to the abdomen after the break, so we'll take a five minute break we got you can put out the form A magazine. Let's get started. Cool. So you're gonna say and move on to the abdomen again. Obviously, you're going to do a gentle inspection with the abdomen. Are closer. Inspection of the abdomen, the absolute most not is probably the most important, but absolutely, very commonly tested topic with us keys is surgical scars. Okay. You absolutely need to know your abdominal different types of abdominal incisions for your skin is so I've got I've made this sort of interactive diagram, so we're gonna draw some lines on this guy, and you guys are going to tell me the surgical scar on the indication for that particular surgery. Okay, so I'm looking that Scott, what do you think coaches got? Very good. What's the indication for a coach? Your incision? What does that indicates? Open cholecystectomy. Very good. That's a very common indication for a culture incision. Okay. Specifically is to gain a lot of access to the biliary tree and things. Yeah, they said Coach, uh, incision. Okay. Also, also, there's a sub cost the incision, but the main indications to do an open cholecystectomy. How about this one? So we got basically an extension off the hook culture incision. So to the other side. And we got a bit good incision upwards as well. Yeah, it's a miss eighties bend scar. So if you you know your car logos, hopefully you'll be very familiar with this shape, but that this is a type of Mercedes Benz car. Uh, I should have asked you about, um say he's Ben Scar. Classic indications is for liver transplantation. If someone's needing. Teo, if you need both of your adrenal glands to be removed, feed gastrectomy subject to me. That's a very common reason for Sadie's Ben Scott. Okay, but the absolute you need to remember one. Make sure you remember liver transplants. Okay, that's the main incision to do a liver transplantation. Uh, cool. What about this one? What's the yellow and I just run back Midline incision Yet? What's the what of a surgical operation might there they have had? Yeah, laparotomy. Okay, so is a midline laparotomy decision. Okay. And with laparotomy scars, the main thing to think about is if they have had major abdominal surgery. Okay, It's this type of incision. It's fall to gain good visualization of the entire thing. Entire abdomen. Okay. To gain big interrupt online access off if they need to have emergency surgery for Triple A, for example, that's the sort of indication for a lot of proteins. If you see it, it means that they've had some major operation. Cool. What about this incision here? So still sort of Ah, same direction as the midline. But how do we describe it? Paramedian incision. Very good. Paramedian decisions are still a laparotomy scar, but it's it's if you need to gain more lateral mistral access. If he needs access to like the kidneys. Um, they might need to a paramedian incision. Okay, it's not. This is a quiet is quite a rare surgery now to do paramedian spots, but yeah, it If you need to get access to more of the lateral organs, you might see it. Well, this shape here, what about just don't looks. You could argue. It looks like a hockey stick. Yeah. So you we talked about this at the start, so that's hockey stick. Incision is known as a routine food. Morrison's car. I was that indicative of what common procedures? A root for most and start on for. Yeah, real friends. My Very good. Okay, So remember that you can have a root from most. It's got this side as well. Okay, that it's, you know, maybe for a renal transplant. Um, so you make sure you, you know, the shape prevent. So it's a hockey stick shape saw. So unless we want to this one. So this is, uh, sort of still looks quite similar to it. What do you think about this one? Yeah, Lanschot. Very good. So what is that? What? The landscaper. Useful. What? Well, if you think about the anatomy here. What is located right behind this line here? Yeah, just the lungs incision, classically classics. Surgery for appendicectomy. It's okay. And open appendicectomy. So that's your lancets incision. Similarly. Still think about Pentostatin knees. What if someone had this type of incision? So this is a still appendicectomy scar, but it's going in a different direction to your land scar. Good. You're on scar, also known as your McBurney and city. Okay, so this is so they both incisions for open dependence activities. But can you tell me which which surgery is generally preferred? Is that the lungs? So the really wrong? Which one is generally done? So it's that kind of Yeah. The lung scars, the main one. Okay. Why Lanschot? Why's the lance car generally better than your really on McBurney incision healing. So it's mainly the cosmetic outcomes. Okay, so the land sensation is cosmetically better, Okay? And yeah, I just said, because the last scarring. So the cosmetic outcome with the land sensation is generally better than your real, Your own incision. Okay, but both of them are done for a pen. Distracted? Um, last one. Yeah. Finance. Steel incision. What is the final still incision. You spoke PT If you just look where the incisions being made. What is it gonna be done for? C sections. Good. What other type of surgery might be done in the pelvis? What type of made? What other type of major surgery might be done in this area? Hysterectomy is good. So, Okay, it's a major operation. C sections open hysterectomy. He's so that's your fun and steal incision. Okay, So any type of pelvic surgery or some time in a C section? This is a common incision, which they might have. Okay, So is that your abdominal scars? Okay. Make sure you can recognize them. Make sure you know the major indications for them eso we get just We're just going to quickly review that with some actual pictures of these scars. So this is gonna be pretty rap, but fire. But we're going to quickly revise all those scars again with some actual pictures of them. So what? What what is this type of scar here? What do we just say? This type of scar schools? Yes. It's a midline laparotomy sticker. Uh, what about this one? So it's not quite midline? Yeah, so that's a paramedian laproscopic laparotomy, Scott. Uh, or this one. So this is the sort of underneath the rib said, Yeah, absolutely. A coach A or sub costal incision. Okay. Uh, what about this one here? You guys know you guys definitely know this shape now? Yeah. This is your Mercedes Benzes car classic for liver transplantation. How about this one here? So this is the sort of in general, um, ligaments? Sort of trajectory? Yes, it is. Your Lanschot. Okay, this is your Lanschot, okay? They followed the it once sort of like this. That would be your grade. You're on scupper. This is going directly, horizontally. So that's your land scar. Okay. Ah, the last one. So what about this one Here? You have a look here. Yeah, that's fine. And steal incision. Okay. So plastic for tacitly don't see sections for distracting this. Okay, so hopefully you guys are very confident in your abdominal scars now. Okay? So be able to recognize all these different types of us. Let's go. Let's keep going. And it was still on inspection. So can you guys tell me what is this representing here? Just still looking at general inspection ascites good. But if you see this type of ascites and your osteo, how would you describe it? Is that low volume ascites are medium bala volume ascites are high volume ascites. Yeah, this is definitely high volume of ascites. Okay, so it's going to say how scientist, but really characterized and say it's high body. Um ascites. Okay, this is huge. Okay, this is grossly distended abdomen. This is a high volume ascites. Uh, similarly, what? You know? Not quite not similarly. But what is this abdomen representing here? Pregnancy said this is a pregnant abdomen. What is this line here? Coast. Yeah, this is your linea nigra. Okay. I'm sure if you've ever seen any pregnant patients, you're able to appreciate this. The linea nigra I'm seeing in pregnant abdomen. So we're talking about different causes off abdominal distention, any eye. Tell me what All the different causes off abdominal distention. What can cause a distended abdomen? Talk about sight, ease. You talk about pregnancy. What else might cause abdominal distention? You have to have a must. Ah, a lot of you're saying they're different than you, Monica. Very good. So, in terms of the way to remember it. So you can remember the five s See a lot of you excited. So facts. Okay, Someone's be still have a descended abdomen. Fluid society is like this society's here. Feces. So someone, um, obstructive bowel obstruction that could lead to a distended abdomen. Uh, flatter. So someone has been constipated for a long time. That can cause distended abdomen. Fetus. So pregnant abdomen, another cause of abdominal distention. And lastly, a full minute mass. Okay, so if someone's got a huge mass somewhere that can also cause abdominal distention cool. Still talking about inspection. Now, what do you think about this time here? Everything's some bruising around the umbilicus. Yeah, this is Colin's time. Okay? We'll talk about in a bit. Uh, what about this sign here? Yes, and this is great tennis sign. Okay, so what about these In indicating, what about these sort of signs off pancreatitis, specifically hemorrhoid hemorrhagic pancreatitis or get very severe pancreatitis, which is leading to necrosis hemorrhage on be sort of with pancreatitis. If if they've got these signs, it means that they're bleeding into the retroperitoneum. Okay. Behind the Claritin, A parody paratonia cavity on the color, The signs So periumbilical bruising great tennis sign. So flank bruising. Um, I always tend to mix them up. But the best way to remember is basically, if you say, in order to see the great turn assign, you need to actually turn the patient to actually see it effectively. So that's the way I tend to remember it again. But, yeah, these are both signs off severe acute pancreatitis. Okay, cool. So examiners, and now ask you what are the causes of acute pancreatitis? And I want to see a lot of new Monix come up in the chat. Yep. I see a lot of scope. Ian's for some reason. Yes. There's a lot of courses. I see the eye gets my school. So if you ever got asked this in your thirties is actually it probably a dream question to be asked, cause I'm sure most medical students know this new monitor, But your Monica's I get smashed. Okay? I'm not gonna go through it. But this this sort of pneumonic to think about with the cause is of acute pancreatitis. Really? Really. Common ones are things like Goldstone's and alcohol. Okay, so make sure if you if you ever need to remember any causes. Make sure you say Goldstone's and alcohol. Okay, but these are all the It's pretty exhaustive list of the different courses off pancreatitis. Okay, um, scorpions things. Ah, you can mention it. Okay, but it's definitely not the most common one. Make sure you mention Goldstone's and alcohol. Okay. Similarly, still on the topic off acute pancreatitis. If the Examiner asks you what are the complications of acute pancreatitis? What might you say? Yeah, odds. Acute respiratory distress syndrome. Definitely. Yeah. So in terms of when, if you're going to present your answer, I present my onset saying, divide your aunt in to talk about the early complications of acute pancreatitis and the late complications off acute pancreatitis. Okay, just to sort of help structure your answer. So, in terms of the early complications are useful to you. Monitor, remember? Is grass. Okay, So, uh, vehicles elevated, you might get a high glucose levels, you know, failure, acute respiratory distress syndrome, sepsis shock. Okay. These are your sort of immediate complications of acute pancreatitis, your emergency presentations and terms of your later complication. So sort of delayed complications off acute pancreatitis. You can use the pneumonic not so and for necrosis. Okay, Frank, running across sister, we get complications like hemorrhage A for obsess and the final piece for studio cyst formation. Okay, so just when you're presenting your answers, always trying to find a way to structure your answer. So a good way to structure it is to talk about the early complications and the late complications. Okay, Cool. So I think it was still on inspection. So what do you guys think about this video here? So I have a watch of this video. What do you think? So a lot of using computer Medusa's that Coumadin is specifically for when you see visible on the like, 11. But this is there's a lot of this is severe. You can see a lot of beans around the abdomen here. So this isn't just compute Medusa. So these are all sort of. I just say portal systemic anastomosis because it if you just take a poop Medusa. And you're just talking about these umbilical veins. But you see these gross, uh, visible Baines around the entire abdomen. Okay, so this is indicative of severe portal hypertension. Okay. Yeah. They're definitely complete. Medusa, is there? What about this video here. This is a very interesting video. Look, very closely. No, it's not a Triple A this This will be a huge Triple eight. There was No, this isn't a triple eight and yeah. Yeah, Well, what type of urine yet? So, actually, this is an incisional hernia. Okay, this is a patient who had surgery. Okay? And this is an incisional area and yet so weakness in the abdominal wall. Getting a hernia like this. If you see this in your house kiosk the patient to cough again and see if that brings about the union. But this is a type of incisional hernia. Uh, what about this image here? We'll see what all these lines here stria gets, but the these are very specific strike. Okay, So if I show you this image here, what do you think about this image here? Yeah, So this is still stride, but this is strong. I suggestive of Cushing's syndrome. Okay, So when you think when you look at straight a, it's important to really, really look close in, try and analyze what type of stray it is. Okay, So he had destroyed a destroyer, hear much more much thicker. Okay, They're much more violations. That's more indicative of Cushing's syndrome. Okay, whereas here destroy A is not is a lot thinner. Okay, they're not as violation. And that's more indicative of sort of obesity related striae or normal aging striae. Whereas this is actual Cushing's syndrome strike. Okay, sort of due to high levels of cortisol. Uh, finally image. Um, so we talked about we were talking about Sort of. Dallas is at the start, worked. Is this patient receiving here? So this patient is at home as well. What do you think? Yeah, Tonio dialysis. Okay, So being make sure you're familiar with the different types of renal replacement therapy. Is this an example of peritoneal dialysis? So they dialysis circuits been created. The tubes we inserted directly into the peritoneal cavity I One of the big advantages for peritoneal dialysis is that it can be done at home. You can see the patient was reading a book at home. I'm sort of big advantage of paratonia dialysis on, but yeah, make sure you able to recognize them. Last image here. What do you think this is a really quite tricky. This is a tricky one. if I say hey, these are Let's say this is a diabetic patient. Yeah, Injection march. So these and if you're really looking closely, these are lift. This is evidence of lipodystrophy. Okay, so he's both signs of these are common sites for insulin injections. Okay, for subcutaneous insulin injections. But if they if they're not rotating the places they inject enough okay, they can get this complication off lipodystrophy. Okay. So you can see the actual sink. The skin looks a bit sunken here. Yeah, this is called lipodystrophy. So looking at insulin injection sites, we'll talk about lipodystrophy and the diabetic stuff and a lot more detail during our diabetes station in a couple of weeks, but yeah, let's keep going on. Okay. Well, let's talk about this stuff in a bit of detail. What do you guys think about this? This patient And what is this patient wearing? Yeah, it's a stoma. Okay, so we're gonna talk about so much, but based on the location off the stoma bag, what type of stoma is this patient likely wearing? Yeah, ileostomy. Because right now, the ostomy is classically located in the right lower quadrant. Okay. Colostomies classically locate in the left lower quadrant. So I got this summary side on Stoma, So Okay, just basically pretty much the most important stuff to remember about stomachs. Not going to go through it completely. Okay. I just told you the key things. Make sure you're able to differentiate between ileostomies and Colostomies to remember ileostomies typically located in your right eye iliac fossa colostomies typically located in your left iliac fossa. In terms of the contents of the ileostomy, it's typically loose. Okay, because it's been basically an opening from your ileum. So the the actual contents, their bowel contents well, wouldn't have had time for tea become solid. Okay, not enough water will have been re absorbed to actually become solid and to become formed. So most of the contents of the ileostomy will be loose a liquid, whereas the colostomy bag, because it's you're draining the contents a little more distantly in the gastrointestinal tract has been more time for the bowel contents to have water re absorbed and actually become more solid. Natural stool character is much more formed. Right? We'll be self semi formed. Okay. Uh, can you tell me what Just spouted me. What does that mean if a stoma bag is about it? Flush a lot, Yes. Oh, keeping the stories you want to know. Is that a spouted stoma bag or is it flush with the skin? Okay, so if it's flush with skin, that means that the actual bowel contents can just openly touch the skin. Okay. Whereas if it's spelt it, it means that there's a protective barrier over where the stomach over where the storm is inserted to prevent the actual bowel contents from irritating the skin. Okay, so very important within ileostomy because, um, you have a lot of corrosive chemicals, and that's in your small bowel contents, which can damage the skin. Whereas with the colostomy bag beers that most of this stuff has been absorbed and it's not the actual chemicals aren't gonna be as corrosive to the skin. Okay, so typically with a colostomy bag Oh, be flush with skin where ileostomies will be spotted with the skin. Okay. And I've got this picture showing the different types of resections. Okay. And I've made this little a flow chart to help you determine what type of surgery has been done based on the type of stoma Okay. So hopefully ah, this slide will be useful to help you picture what type of surgery has been done based on the stoma. Have a read of this when you get the slides on. If you have any questions on this, we can go through it at the end on directly in terms of stomach. Always look for complications of stomach. Okay, so I've got all these pictures. They're showing different complications of stomach. Um, so just be aware of the different complications of stones as well. So I have a read, and hopefully these pictures are highlighting these different complications as well. Okay, we're gonna move on. Certainly. Still, we've only been talking about General about inspection so far. Okay? But we're gonna move on to the actual technique. So in terms of the examination, finding spoke chrome disease. Can you tell me some common examination findings? We talked about a lot of them at the start in terms of generally in the crone's disease patients. What are the different exam patient findings that you might see? We've already talked to a lot, most of them so. But this is a basically quick revision of most of the stuff. Surgical scars, very important mouth All says at acumen. A dose, um, Costain ing up. This all says, Yeah, the whole bunch of examination findings for Crone's disease patient. Okay, so I've listened a lot of them here. Okay. Is that pretty much most of all the classic examination findings from Crone's disease patients. So make sure you're very familiar with this case. Is a very common because these patients are very common and they can easily bring them to your ski. Okay, cool. So we're going to move onto palpations now. Recession might run on for sort of finish up corporate 10 past nine past nine, but we'll try and power through a script as I can. So we got some quick spot diagnosis for you guys based on palpations. So let's let's go through this quickly. A patient complains of right upper quadrant pain rates radiating to her right shoulder. 10. The pain began began shortly after she ate a p A slice of pizza on examination there is inspired here arrest with deep our patients off the right upper quadrant. Yeah, this is a cute colecystitis. So acutely societies of inflammation of the gold better classic presentation. Zar up right upper quadrant pain radiating to the right shoulder. 10. Because of irritation to the dye from, uh, it's really made it related to meals. Okay, she's eating a bunch of carbohydrates. What is this sign here? Inspired to arrest with Depo Patient off the right upper quadrant? Yes, Murphy's sign. So if we'll talk about movie sign in a bet. But if someone this is describing someone with a positive Murphy sensitive, inspired to arrest during deep palpation of the right upper quadrant on that's movie sign positive, Very indicative off. Cute colecystitis. What about this patient here? So this patient also has right upper quadrant pain. She has increased adiposity scleral icterus and has been complaining off fever and intermittent chills at home so slightly different today. Other one. So somebody is saying bile hepatitis so I can see why I say about hepatitis. I say this is I tried to describe it. I would think of ascending colon judges when I'm writing this, but I can see why you say about hepatitis A swell. But what's the classic triad for ascending colon? Justice was a classic triad of symptoms. You get shock goes, try a very good, So fever, right upper quadrant pain on square electricity. Well, and I guess the chills or something that makes it more like to get sending cholangitis. Okay. Yeah. This is that classic Charcot's tried, which is? Ah, part of the, um, plastic features for sending cholangitis next door. Here. Patient complains of pain in his back and umbilicus on examination. There's any gastric tenderness and periumbilical discoloration. There are decreased breath sounds and a positive frost. Exciting. Yes. So we talked very talk through a lot of this. So this is again we talked about the two pancreatitis, So epigastric pain, very suggestive of pancreatitis, radiated the back as well. Very suggestive. Very classical. Acute pancreatitis. Periumbilical discoloration. So we talked about it. Sign of Collin. Sign on. Da. What is this positive Chvostek sign. What does that indicate? Hypocalcemia. Very good. So we said hypocalcemia is one of the complications of acute pancreatitis. What about decreased breath sounds? Why might someone with a key pancreatitis have decreased breath sounds? Yeah, You disappeared. You distress and, um, definitely. So if someone has comedy, if they have pulmonary edema because of the pancreatitis, that can definitely cause decreased breath sounds. They might also have your infusions. Well, so why? Why? Why Might somewhat with pancreatitis get a little effusion? Yeah. Fistula. Very good. So acute pancreatitis. You might, you might. You might create official into the lung cavity s. So that might cause a little effusion. So I can also cause decreased breath. Sounds good. Next one are on examination and 83 year old patient complaints off left lower quadrant. Pain on examination, he has left lower quadrant tenderness to palpation rebound, tenderness and gardening. What do you think about this patient? Yeah, this is Ah, diverticulitis. So classic presentation of diverticulitis. Elderly patients left lower quadrant pain. Um, very suggestive diverticulitis. What is this? What is rebound? Tenderness and guarding a sign off. What is that indicating? Yeah, Peritus. Um Okay, well, we'll talk about what these terms actually mean in a bet, but yeah, these are both of keratin. Is, um okay, this is a bit of ah, longer one. But ah, just quickly wanted to highlight some key points. So patient has worsening abdominal pain. Pain started in the periumbilical area and now in the right lower quadrant, tenderness wanted a distance from the aces to the umbilicus as well as guardian ready bun tenderness. Just pain in the right lower quadrant with palpation of the left, lower quadrant and pain in the right lower quadrant with our patient off with passive X extension of the right hip. Yeah, you must be going. This is I wrote this a bit longer for a couple of reasons. So this is a classic presentation of appendicitis, so that we pretty much got most of these signs of keep appendicitis in this scenario here. So with appendicitis, classically, when where the patient will complain of periumbilical pain, and but eventually it starts to really it towards the right lower quadrant. Um, she has right lower quadrant. Pain is one third of the distance from the ASIS to the under, like a So where is what's this location describing here? Yeah, McBurney's point. Okay, So the anatomical location from a response is one third of the distance from the eighth. Says to the umbilicus We talked about guarding, rebound, tenderness, the beaches off erotism a pain in right local don't want palpations off the left lower quadrant. What is that song called? Yeah, Rose, Rose things Rob sing sign. Okay, so if you pop it on the left lower quadrant and they complain of pain in the right lower quadrant, that's called rubs and sign. Um, also one of the signs of a coupon. Appendicitis. What's this last time here? Pain in the right lower quadrant with passive extension of the right hip. Yeah. So, uh, so I'm very good. Okay, So, uh, there's a whole bunch of different signs for appendicitis. Okay, so we talked about the Casodex. Is the pain in the right lower quadrant and McBurney's point. But this patient also has a positive. So a sign and robs inside is Well, okay, last one. Here, a two year old has lower abdominal pain. On examination, the legs are drawn up to the abdomen. A sausage shaped abdominal masses palpated in the right upper quadrant. So that's that examination on a baby unit. It's not new unit. Just infant. Yes, Intussusception. Okay. Some classic examination findings, for instance, with interception. Okay, The key thing, if you ever said if this comes up in your empty, your SPF sausage shaped mass in the right upper quadrant. Very classic interception. Classically, babies will be crying a lot and they'll have their legs drawn up to the abdomen again. As someone said classically, they'll have this red current jelly stool is Well, okay, so I got another question for you guys. What are the signs off Peritus? Um, what are all the different signs of keratin? Is, um, on examination. So tenderness in itself is not a feature parasitism. The specific things we're looking at with tenderness, guarding, good rebound, tenderness. Anything else? Uh, abdominal rigidity gets so let's talk through themselves. Let's so it's important, actually. Know what these terms means? So going So this is where they're involuntary Test tensing up your donald your muscles when you pop, it's okay. So when you pump it them and if they if your muscles around their start contracting to prevent you from palpating further because your body knows it's it's causing severe pain that's got be okay. So again, it's that muscle contraction that involuntary contraction and tensing of abdominal muscles to prevent you from palpating to deep that's guarding whereas rebound tenderness is what happens when you sort of remove pressure from the abdomen. Okay, so if you remove pressure on the abdomen and that causes worst pain. Then when you actually put pressure itself, that's called rebound tenderness. Uh, board like rigidity. So if you have A if you have parents in is, um that means your abdominal wall. It's not going to be moving with respiration. So typically your your tummy should be moving up and down with respiration, right. But with parasitism, it means your abdominals not gonna be moving very much, and your breathing becomes very thoracic. Okay, that's another feature of parents, Aniston and finally, percussion tenderness of the Percocet. And they have pain. That's also in the sign of puritanism. A swell. Okay, so these are all the important features, Really? Make sure your you can appreciate what guarding is and what rebound tenderness is. Okay, these are the absolute, really important clinical signs to be able to pick up on Onda. Okay, so let's talk about the rest of the examination now, and I know when you're doing the abdomen examination, people always get confused about which fit. I need to only palpates and which but I need to only percuss. Okay, so I have a really cool trick to show you guys to help you guys remember which, but you need to palpates, which picks you need to both palpates and percussed. So it's called the 222 routes. So and it's because there's two different things for each aspect of the examination. So in terms of percussion and palpations, there's two different bit. So you need to percuss and palpate the liver and the spleen. You only palpate the kidneys and the aorta. You need to only percussed the for ascites and blood and the bladder. Okay, so the cuts for shifting dollars and because the bladder as well okay, so you don't need to palpate You don't need to palpates the blood necessarily or auscultate the bladder. Okay, so only percuss in the for ascites and bladder, and you're only auscultated for breweries and bowel sounds. Okay, so bruit is for renal artery buoys and also the abdominal aorta bruise as well. Okay, so that's a very it's a quite a neat trick to help you guys remember which. But you need to how many things you need to because and palpate and auscultate. So hopefully that's useful for you guys. Just move on to palpations. And so, in terms of palpations areas, we need to palpate the general abdomen. How they deliver. How about the go butter part of the spleen? Help with the kidneys and we need to palpate the water. Okay, so there's six different areas we need to pop it. So it seems up our general abdomen, these this is the way to pump it to remember, with palpating. General abdomen. We need to do a superficial palpations and a deep palpations on. Make sure you're you know, you're different quadrants in your abdomen when you're palpating your It's this sort of motion with your hands. Okay, so you're really trying to fold your fingers into the abdomen on down. Always look at the patient when you're populating. Okay. Very important. The exam will be looking at this from when you're palpating the abdomen. Make sure you're looking at them to check for tenderness, okay? Or check for guarding and rebound tenderness as well. But always when you're palpating look at the patient's base on Once you've done your superficial pal patient, then you can do your deep palpation so deep outpatient but your other hand and stop and president deeper. Okay. Um but yeah. So superficial and deep. Our patient for the abdomen. I have a quick video to show you guys to have a watch and let me know what you guys think the diagnosis is. Wow. Oh, it's worst. Worst there. Oh, okay. Very interesting video. What do you think? Yes. Appendicitis. Okay, but the obviously we talked about pesticides. This signs a lot. Okay. So, classically, this patient was complaining of pain and that sort of McBurney's point area. But the key thing learning point I want to use for pickup from that video is too always palpates from non painful areas. Okay, so you can see here because the baby the physician, he was palpitating and all these non painful areas first, But then he was moving towards the painful area on because he started with the non painful areas. First, he was able, the physician was able to appreciate exactly where the painful areas were. Okay, so that's my big learning learning points always palpate away from the painful areas first and then moved to the pain Flares lost. Okay, So video demonstrates why it's really important to do that. Okay, so we did our general abdomen. Now let's move on to the liver. So with liver palpations. This is where you're getting the patient to breathe I/O. So, um, observation. Breathe I/O. And this is the technique. So you're palpating with your edge of your index finger weekend starting from the right lower quadrant and moving upwards on. So the key thing is, you want to move in during inspiration for your liver palpations. Can anyone tell me why? What? Are you more likely to feel the liver during inspiration? Yes. So the when you breathe in your diaphragm is gonna push down on your liver. Okay. So that's why when you actually you squeeze them during inspiration because the dye friend's gonna push your liver done. That's gonna increase the likelihood of you actually being able to catch the liver edge when you palpate it. Okay, so that's why I squeeze in during inspiration. And if you are able to feel the liver edge comment on the consistency of the liver edge commentator If they have any tenderness, make sure you you check patient's face and check if this has any evidence of pulsatility. Okay, So can you tell me some stick mater of chronic liver disease? So exam is and I'll ask you some. What are the stigmata? Chronic liver disease? He has to give you some different stigmata. So a size isn't It's. Technically, it's not part of the stigmata. Okay, is that is one of the complications of photo hypertension. So stick Martin's. These things were looking peripherally. Yeah, you guys were pretty much talked through all of them so far. But I've got this table for you guys to basically put everything in the same slide on. We talked about this during a hepatology final session. But this slide basically covers all the different stick multi conclude disease. And we can see that other feature these sort of peaches are signs off be compensated liver disease, which we talked about as well. So make sure you're very clear on one of the stick matter. One of the complications on because that's very important aspects of understanding liver disease. And also I got another question for you guys about liver disease. How is the severity of liver disease graded? What is the way we grade the severity off chronic liver disease? So it's not the meld score. Okay, Melts goes ah is useful for determining prioritizing patients for France months. So some of you said it's so It's the child Pugh school. Okay, so the child Pugh suppose don't think that determines the severity of decompensates cirrhosis again? We talked about this during our hepatology final session, and the recording is still available on metal. So if you want to learn more about that, make sure to check out that weapon. I did. Yeah, but make sure you can talk about the child Pugh score. It's the main way we grade the severity off chronic liver disease. Okay, so we did a liver palpations. Now let's we want to go. But so with the gold bladder, there's two main signs to be looking out for. One of them is the Murphy's sign, which we talked about. Okay, it's that inspired to arrest during inspiration. And the other side is the Corboz. A sign. Can you tell me what is called beyaz? A sign? What is that? What? How do you describe what I see? A sign. Okay, Very good. So palpable mass in the right upper quadrant with the, uh, pain. Okay, so that's the main thing. So it's a palpable gold bladder without pain on as someone said So it's mainly it indicates that the public, if there's no pain, it indicates that the public algo butter is not due to Goldstone's. Okay, that's the main thing is indicated. Okay, it means that there's no Gold Stones and because it's not due to Goldstone's and makes it more likely to be things like cancer. Okay, particularly pancreatic cancer. So if you feel like palpable gold, better like this patient like this exam is palpating here, and the patient doesn't actually have any pain as very suggestive of pancreatic cancer. Okay, And make sure you check from Murphy Sinus. Well, so again, just pop it in the right upper quadrant. And if there is inspired to see if they stop breathing like if that breathing because of the pain, they out of this sort of inspired me arrest that suggestive off colecystitis again. Cool. That's what about the spleen now, So in terms of spleen palpations, So we're going to start in the right lower quadrant and move to the diagonal. Okay. Move, Dagney to the left upper quadrant. Um, again, you're moving up during inspiration because similar concept of liver, because that was gonna push down um, but yeah, that's your spleen propagation. Can you don't tell me what this CT scan is showing here? So this is a, um, Corona section ct some? Yeah. This is Ah, splenomegaly here. Okay, this is a huge thunder, Maglie. So can you guys tell me, what are the causes off? Massive splenomegaly infections going. What's happened? Infections. Malaria is a big one. See? Ml Very good. Chronic myeloid leukemia. Sickle cell doesn't sound one cause massive splenomegaly you might. You'll get Botox plan is, um, with sickle cell anemia. But least when I says yeah, EBV gets you the it's not gonna cause massive splenomegaly. Okay, I'm trying to be very specific in what's going to cause huge amounts of splenomegaly mile A fibrosis. That's the other big one to be thinking about. And lymphomas. Well, so are you. Still pneumonic is chimp. So see for CML cll. So chronic myeloid leukemia and chronic lymphocytic leukemia age for Harry Cell leukemia. So, um, it's one of the non Hodgkin's lymphoma I for infection. So a lot of you mentioned a lot of the infections, particularly things like malaria can cause massive splenomegaly and for my fibrosis. So if someone's bone marrow is fibrosis completely. That's going to lead to things like the spleen taking over the matter paresis and that can cause very enlarged spmeans And finally pee for polycythemia Vera. Okay, so again, one of the types of myeloproliferative syndromes. So that's a useful pneumonic. So I've been examined, ask you one of the causes. A few splenomegaly may actually you comment on all of these different conditions? Okay, so we did our spleen. That's not we're going to the kidneys. So in terms off kidney power patient, this is where we're starting to talk about bloating and things. So in terms of your kidney population, way to do it is watch a couple of videos. Okay, Josh, be learn the technique of balloting, the kidneys. But there's one under the top one and posterior on bush, down from the top and bottom. Just trying to feel if you can feel the kidneys between your hands and if you can, That's called polluting the kidneys. Um, make sure your hand on top is a bit more medial. Okay, because your kidneys are not actually completely to the sites. Okay. Make sure the top and is a bit more medial towards the umbilicus, but yeah, this is the technique for allotting the kidneys. So I got a question for you guys. One of the differences between the left kidney and splenomegaly on palpation. So, basically, how do you differentiate this spleen from the kidney? Yeah, if you can get underneath it. Very good. Splenomegaly crosses the midline. Good. That's a good thing to take up on and feel on the Yeah. Oh, good. Thanks to pick up on. So in terms of keyed differences, So I've listed the key things here. So the spleen has a palpable notch. Okay. On the medial surface of the skin, if you really if there's actual splenomegaly, you can feel a palpable much You can't get above the spleen. Okay, But you can get above the kidneys. Um, thinking is during inspiration. Your spleen moves diagonally. Okay. Your kidney doesn't move that much during inspiration. The spleen is not a lot of all. Okay, you can palpate this plane from your between both your hands, but by someone. Has he big kidneys? That might cause a lot of work in that. Might that those would be ballotable on. As someone said, the spleen crosses to the midline. Okay, so the spleen enlarges to the right iliac fossa. Uh, when someone tell me, what is the main cause off ballotable kidneys? What might cause someone to have really big kidneys bilaterally had enough process? I'm thinking bilaterally. What? My cause. Really big care. Need a lot of our kidneys. Yeah. Polycystic kidney disease. Very good. Okay, that that's one of the major causes off. Um, a lot of kidney. So I recommend just go to a real award in the hospital and try and find these patients. Okay, cause they're it's actually about quite cool to actually be able to block the kidney's polycystic kidneys is cause a little redness. Okay, Last bit of our patients have a paint, the aorta. So in terms of the way to pop it, the ilter located between the umbilicus and the zip easterner. Okay. And then press down with your fingertips. Okay, Um, and you could see this image here if it's outwards and pulse it up on that suggestive of a triple A. Okay, so So if you can, if you're feeding the posts and you can feel the post moving outwards and it's very positive that could be suggestive off triple A. Okay, Although it is quite a difficult sign to pick up clinically. I'm using that probation technique, but yeah, make sure your technique is good. Okay, so we did that palpations. And I'll let's move on to our percussion. So in terms of percussion, start without percussion off the general abdomen because all nine quadrants of the abdomen and in terms of your percussion technique, make sure you're aiming for the distal phalanx of your finger on. Make sure you practice it. Practice as much as you can. Okay? Is percussion is something you just absolutely need to practice as much as you can. So demonstrate shifting, Dulles. So what is shifting dollars to sign off? Just as a concept about is shifting dollars to sign up? Yeah. Ascites. So I got this really cool video to show you guys off shifting dullness. So have a watch. So really, really pay attention to the do this guy's technique. Yeah. Yeah. Have you roll this way? Okay, so I was shifting dullness. Okay, Now I'm going to use the water bottle analogy to explain this. So if imagine ascites So imagine ascites so there's fluid in the abdomen. So if the patients lying down flat like he was here, it's Diflucan. The acidic fluid is at the bottom. Okay, so when the exam it was stopping at the top. It's only a rather talks. That is because a rice is in the top. So when they cut panic, Okay, but then the exam, it starts tough for cussing to the site on because the flu is gonna accumulate towards the blanks, it becomes dull towards where the acidic, fluid ISS Okay, so the topics and plan it. But then he starts cussing to the side, and it becomes dull where the air fluid levels. It's okay, so it's dull in the blanks. So then the examina ask them to roll to the site and then by going to the side that eso So you hold your finger where the fluid level is of keep your fingers where you first feel adult, and then you ask the examiner to roll the patient towards you. With John still staying in the same position on down you can imagine because you ask the patients roll over the flu is gonna move downwards. Okay, because you've moved our situation to roll over. So because the fluids moved away, the area which you had your hand on is gonna be sympathetic. Okay? Because the flu is actually moved away from your hand. So when you because over that area again, it becomes tympanic. Okay, so when it was when they were lying down, it was dulled to the sides. Get them to roll over. It comes to panic because that's the sort of concept of shifting dullness. So just because from the midline to the side find out where it becomes dull an oscillation to roll over. And if it becomes tympanic in that area or residents, that indicates shifting boneless. Okay, eso that's your ascites. Okay, it was a quickly and ascites. We're going to run through this pretty quickly, but I got some quick spot diagnosis questions on spot on the site. East Avago. So patient has shifting dollars. There's evidence of do patrons contracture palmer erythema and cook Medusa. His sock is high. What do you think? What's the cause of the ascites in this patient? Yeah, product. Liver disease. Okay, so we got sick matter of chronic liver disease here, and it's Saugus High If you want to learn about saga, please watch. Ah, hepatology for final session where I talk about it in detail But this is suggestive of chronic liver disease. Until that this patient, uh, patient of shifting dollars periorbital edema, photosensitive rash from the urine and the catheter bag and a low side. What is the cause of ascites in this patient? Yeah, So Lupus s So it's not the Lupus that cause Pacific causes the ascites. It's the What's the complication of Lupus that causes ascites? Yeah, Lupus nephritis. Specifically, we think about nephrotic syndrome. Okay, So is it specifically the Nephrotic syndrome which leads to drop in albumin? And that's what's causing the ascites. Okay, so way got nephrotic syndrome head. There's periorbital edema. Sign of low albumin. Photosensitive rush. Okay, so peach of Lupus. Okay. Systemic Lupus erythematosus, onda frothy urine's of feature of protein urea. And the losartan is typical for ascites due to nephrotic syndrome. Um, but yes, that's why Nephronic syndrome is the cause of shifting dollars here. What about this one? Uh, shifting on this raised JVP third heart sound course crackles in both long bases. High sock. What's the cause of ascites in this patient? Yeah, Heart failure. Very good on blast one here. So patient has shifting dullness. Evidence of asterixis fever and altered mental status. Acidic fluid showed 500 neutrophils spare millimeters Acute. Yeah. So this is a complication of ascites. So this is suggesting that the ascites has become infected so spontaneous, back to your peritonitis. So the infection in the ascites is likely cause other complications such as hepatic and careful opathy, which is causing altered mental status as well. And the patient also has a fever suggestive off infection. Okay, what's the numbers for SPP Harmony? Neutrophils four millimeter cubes is needed to diagnose SPP. Yeah, greater than 2 50 neutrophils familiar to Cuba is diagnostic for SPP. Okay, so I'm not gonna go through this week went through the mechanism of soggy in hepatology final session, So just watch that And is a little table summarizing the different parameters for acidic fluid analysis. Again, we talked about it during a hepatology of a final session and in terms of the management of ascites again have summarized I talk about all of this stuff during ah hepatology for final session. But here the sort of key aspects of managing ascites. Um, finish up finishing off with the percussion. So make sure you because the liver so starting from the right lower quadrant move upwards again. First, find that area becomes don't. Okay, so as you because upwards assumes becomes dull. That's when you hit the lower margin lower quarter of the liver and then do the same from the ribs downwards to find the upper margin of the liver. So that's gonna help you determine if there's any evidence of a pattern megaly. So we got a picture of huge hepatic megaly here on my next question for you guys is one of the major causes off the pattern megaly. Yeah, give me some other causes of pattern megaly cancer. Yeah, So, in terms of the major causes, remember that three See, so one c for cancer vaccine for cirrhosis on the third C for congestive heart failure. Okay, remember these three causes These are the three common causes of a pattern Ugly on have listed some other ones here, but these are the three major common cause is off the bottom, actually, because the spleen in a similar way to the liver. Okay, so start from the right level. Quadrants go to the left upper quadrant. Okay, so it's still in that diagonal motion. And also because the bladder as well. But remember, when you're going to just about it, tell the patient in first. Okay, Ask them if they need to use the restroom before if they need to empty their bladder beforehand. Okay, because it can be very uncomfortable. Uh, yeah. Make sure you press the bladder as well. Cool. So we did a percussion. Let's finish up with auscultation. So in terms of auscultation, we need to listen for bowel sounds. So in terms of the key bowel sounds really looking for, remember, we also take It's in the sort of ileocecal valve area, so sort of in the ileocecal valve that's about commonplace to listen for bowel sounds so normal. Bowel sounds very good. Link bowel sounds okay, especially if someone's just eaten at that are very good in bowel sounds. It's known as about obstruction. They'll get these very high pitched tinkles bowel sounds okay, because there's an obstruction. So there's Paracelsus against an obstruction that causes high pitched tinkles bowel sounds. If someone's got peritonitis or if they're 1000 up moving a toll. They have some kind of a list, and they're not gonna have any about since. Okay, absent bowel sounds indicative. Off. I'll ius or peritonitis. Uh, so that's your bowel sounds. Okay, so your bowel sounds remember, you listen with the diaphragm. In terms of bruise, you're gonna listen for bruises in the aorta and in the renal arteries. Okay, so with bruises, it's best to use the belt. Okay, cause they're all low pitched sounds the bruise for the aorta. Auscultate It's in this area. So just above beyond below cas, um, that's the best place to auscultate for the abdominal aorta and then for the renal arteries. Also, they just laterally to where your auscultated for the triple A. Okay, so auscultated these locations. So lateral leads to the, um, to above the umbilicus on so that the middle one is for the abdominal aorta and then auscultate just the side of it for your, uh, renal arteries. Okay. I'm gonna sound for renal artery bruit. So I have a listen. Oh, it's outside sort of renal artery bruit. Okay, so it might be suggestive of some kind of potentially being a lottery stenosis but yeah, make sure the list of the bowel sounds and listen for bruises. Cool. So we just did the abdomen. Okay, That was a huge chunk of the examination there. So in terms of the abdomen, we did a whole bunch of different things we inspected. Be palpated be percussed. We performed shifting Dulles. We also take it for about sounds and for bruises. Now, let's quickly finish off with the legs so quickly. Can you guys tell me, what am I looking at here? If I say this is the pistons leg? Yeah. Pitting edema. Very good. Okay, um, so pitting edema in your abdominal station thinking about liver failure Nephronic syndrome as well. Uh, what about this picture here also. But how do you just describe the what's the name for this type of also? Yeah. Pyoderma gangrenosum because it is sort of ulcerative necrotic lesion in the legs. That's pyoderma gangrenosum similar to everything. Minute dose. Um, which we talked about. It's what it can be. An extraintestinal manifestation of inflammatory bowel disease. Um, final image here. What's this image here, which I just literally just said every three minutes is, um okay, So this is every time on the dose. Um, we talked about this last week, but can you guys give me some major causes for everything on the dose? Um, apart from IBD, what else can cause everything you know? Dose? Um stop. Yep. Stuff infections yet sarcoidosis. Yeah, TB cool. So attempted the pneumonic the pneumonic to remember the cause of human dose. Um, the pneumonic is no dose. Um, so no drugs? No. Because so, if it's it can be idiopathic be for drugs or sulfonamide amoxicillin. Oh, for the combined a little contraceptive pill. As for sarcoid you for hospitalitis and chrome disease. So IBD and M for microbes. So it says in infections like strep infections. Okay, so those are your major causes off erythema nodosa. So that's in terms of the legs. So we basically just inspected and look for I loaded Lower limit. Dema look for 30 minute dose. Um, like a part in the communism on be? Yeah, that's your legs. And then we're done, So make sure you've done that. Done the patient and restore your restore clothing, and that is your abdominal examination. Okay, so I hope this light is gonna be useful for your revision, we pretty much work through the examination in each different stage. So to finish off with present, you're finding. So I presented here a normal exam abdominal examination. So have a read Ah, useful pneumonic to remember the investigations for for your abdomen exam is in your Monica dough. So, in terms of investigations that you can offered to do after your abdominal examination, you can say D for digital rectal examination. Oh, for basic observations. You for your analysis, GI for examining the external genitalia if it's appropriate and at age for her annual orifice is okay, so you can use that. And you want to go to remember their major investigations you need to do for the abdominal examination. That's it. Thank you guys. Are you guys enjoy the session? That was a very long session, but very content. Heavy session. But have you guys enjoyed? Um, the abdomen is very topical. Organ does. It makes a medical knowledge mix up surgical knowledge. We talked about a lot of different specialties at the same time. Um, maybe has enjoyed it. Good luck for your ask is if it's if you if they're coming up soon. Ah, yeah,