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Uh My name is Urs DEA. I'm 1/4 year medical student at Imperial College. And today I'll be delivering a 45 minute lecture on central and lower abdominal pain. Uh which uh as I'm pretty sure you understand, are very critical topics for these but also for your education going forwards as the key, not only in surgery, but also in medicine. And they are pretty easy to figure out if you have a structured approach in your history, taking an examination. Uh So uh this is in partner with GS and there is a code to get 20% 10% off Osk flaco and stations. And you will be using this in the latter part of the lecture which consists of some mock practice for the Os. Uh So the learning objectives uh is to recall and use uh the structure of a gi focused history to include the red flag symptoms so that you are able to generate list of reasonable differentials, but also to perform a clinical examination of the abdomen in a way that it's timely structured and confident for you to be able to laser the important signs, but also to be able to comment on the appropriate pathway to diagnosis, investigation and management of some very common conditions that are presenting with syndrome and lower abdominal pain. So some more of questions if you can pop it in your answers in the chart. Um I generally have an understanding. So which is the diagnosis is least expected to present with lower abdominal pain. So, here we have a malfunction actually. Um So neither of the three sets are the least expected. So they are all expected to present with syndrome and lower abdominal pain. So, appendicitis very classically IBD, uh IBS uh bowel perforation, all um can present place and lower abdominal pain. But actually, what wouldn't present is gastritis, uh go and peptic ulcer disease, which uh include the uh upper gi system. So typically they wouldn't present with pain uh lower than the epigastric region. Um And this comes to the first and very important part, which is that everything that happens relates to uh a structure and function. So, if you think about uh which organs are um referring to the region of the central and lower abdomen, then you're pretty confident in making a diagnosis. Uh Whereas when someone is presented with central or lower abdominal pain, um organs such as uh the stomach, uh the pancreas and the spleen or even the liver, which lie in the upper portion of the abdomen are least relevant. It's not necessary that they cannot present, but they're least likely to present with standard lower abdominal pain. So just by starting with someone that presents with that type of pain, you are pretty confident in that excluding some diagnosis or not having them very high in your difference, at least when you begin your history and examination. Um and also that relates to uh because the gastro system is not the only one that can present in the abdomen. Um usually everything else that might present with the abdominal pain will present in the upper abdomen. So that's also something that's least relevant in this uh scenario. So we have a scenario of a 19 female unique pressure which which presents to the A&E which uh and the worst period cramps ever. Um She says that this is not what your typical period looks like. And even though there is no much bleeding, uh she has to take painkillers which she never had to do before. So in this scenario, which non gi system is important to consider. Um And let's just from, it's very important to always keep in mind when you're dealt with clinical scenarios, who the patient is and what the demographics are because that's various um moving forward. So in this scenario, we are in the A&E and we have a nice female univer, so a young female um and in the A&E signifies that something that uh is pretty acute in its nature. Uh So chro more chronic diagnosis are least likely. Um and also it's very important to consider the age and gender this condition. Um the pain is located in the lower abdomen, um feels like fluid cramps, uh but it's much worse as per the patient's des description. And the symptoms include that spotting, it starts to point towards the uh fe reproductive system more than any anything else. And so less likely in this condition would be something with the since there are no systemic or urological symptoms. Um and gi um also because there are no specific gi symptoms and then Gyne um from Gynae, something that's more severe, such as torsion would present probably with something more uh sinister and then endometriosis is much chronic. So it would be unlikely as now that come up in the A&E as the first presentation. So most likely in this scenario is an ectopic pregnancy which uh is something you should always keep in mind for uh any uh female patient presenting with uh abdominal pain and then also some more uh critical conditions which are however least likely. So the first thing to always remember is that common things are common when you're presenting with when you have a patient. And there is a diagnosis which is common. Um It is as important as something that you have to exclude. Uh so always keep this in mind and do not uh go straight into the uh emergency or the rarest form that can present in that way. Always think about the commonest form and the more difficult presentations. Uh So uh beginning with what we've clarified so far is that beginning with anything that's clinical? You should think who the patient is. So before you ask in touch, who do you have in front of you and where are you? So if you're in a hospital setting, um and as an inpatient, you might be dealing with a complication or in the a with something that's of an acute nature. Whereas when you're in a GP setting, you might be making a diagnosis of more chronic conditions. Um and also who you have, you are you, do you have a young patient or no patient? Uh Do you have a female or a male? Do you have someone who has some diagnosis or previous surgery? Someone who is on medication? Because ultimately all that can lead to um some very important signs on where you should focus your history taking and also your examination. Um So starting off with a history taking, um of course, you need to do a very good introduction and build the report for your patient. First thing you always want to do in no station is wash your hands no matter what you're doing, even if you have no patient interaction with the patient, uh wash your hands because it's a very critical step. Um And then you have to introduce yourself, which includes your name, your role, what you have to do and why you need to do it. So if you need to take a history, you have to explain that someone has appointed you to do so. And what type of questions will be asked on that respect? Moving on, you should proclaim that everything will remain confidential between you the patient and the team of care. So it's not something you have to clarify that the patient um that you are part of the team and that the patient, whatever surgery you can be made note to the rest of the team. And that's very important because sometimes patients might be more inclined to say something with a medical student because they might feel that that will not be communicated to the doctor if you don't wish it. But that, that's not the reality of the medical student, you're working within the team. So everything you um get out of a patient interaction, uh you should communicate. Uh So make sure to communicate at across before you start your history taking and then you should uh get verbal consent. Um And then you have to start your history taking in most cases with the golden limit. So with the opportunity of the patient uh sharing as much as they will sincerely and willingly want to. And even in the aus scenarios, uh the reality is that because actors are given a patient to memorize or enact, um they will naturally give a lot of information with you without you having to do anything. Uh But you have to give them the time, not give them much time, but starting off with allowing the actor or the patient to give you some information is very important and will save you much time uh in the greater history taking. Uh And this is also an opportunity for you to show higher order skills. So it's your opportunity to show that you're actively listening, that you are so easy in yet that the, that you are there for the other person, which are all very integral parts in the l. So it's not just about asking the questions, but it's also about asking them in the right way. Um So let's take a scenario of someone who says that their, their wife has made them come after a trip to Bali because they were feeling very ill. Um But now, um even though it feels like they're, they're feeling better, um this started six days ago and they still have symptoms. So even by what they've said so far, uh just in one sentence that probably took them some seconds, you got out some things about their social history, some things about their um ideas and concerns and expectations for, for example, the fact that they do not um want to come. So it's something that their partner has enforced in a way um their travel history, which is very important and relevant in this scenario. Uh and some of them symptoms uh pointing towards an infective probably cause of their uh gastroenteritis. So, uh and then of course, after you do that, you start with, whenever there is a pain in the, in the presentation, you should do a. So starting off with your site, you should um ask the question to exactly point to where the pain is, ask whether the pain has always been there and whether the pain um has changed location ever since its onset because that's very important to understand which organs might be implicated, which diagnosis you should consider. So, several pain includes the umbilical region and the right and left uh lumbar regions and relates to uh media structures. Uh So anything that's uh in the appendix and after the skull might present with central abdominal pain diagnosis include acute pancreatitis, mesenteric ischemia, um small valve obstruction, sickle cell crisis, but also something from the upper um upper gi but also from the systems which are not gi but might present to the abdomen. Uh So GGA a might also present with simple pain. Pneumonia might present with uh central pain if it's low, low. So generally central pain uh relates either to me obstruction or structures that are non gi from uh which is near the upper gi. Um and then so generally think of systemic as well when you have central pain up side. This is the link diagnosis between syndrome and lower abdominal pain because it has a uh migratory pattern where it starts as syndrome, but then moves towards the uh ri right left, uh right, uh lower quadrant, um for lower pain. Uh you should be thinking of other systems, but it's not the system that you're thinking with central pain. So with central pain, you're thinking about uh pneumonia, you, so you're thinking about lungs, you're thinking about heart in interior M I for the lower gi you should be thinking about gyne uh pelvic and uterus systems. And then there is a distinct patter of unilaterality in lower abdominal pain. And it's also different between young and uh old patients. So young patients use it. So young patients often have diagnosis in the right part and all patients have diagnosis in the left part. So that's a good pneumonia to have. So appendicitis usually in young people to the right. Whereas of the old people present in the left IBD, uh Crohn's in the right is more in the young demographic and also colitis in the other demographics is chemical colitis again in the left for older people and low to growing is a very uh important thing to remember that it's usually uh if not always renal colic. Um So that's uh just to remember that everything that's on the right is usually young people and it's usually appendicitis, Crohns or renal colic. But older people will present with diagnosis in the left lower involving the descending colon. So, diverticulitis, colitis and skin of colitis or a colic in the left. Um So just a quick questions on visceral and period pain, how is the card of appendicitis explained in terms of the referral of period pain? So you have to be able to distinct, to give an answer on how does and pain differs. And in this scenario, you have to use uh the appendicitis and the way it uh migrates from the central uh abdomen to the lower, right, right, lower quadrant. And the correct answer in this case would be that the inflammation of the visceral afferent pain fibers produces a dull pain in the midline because the appendix is a structure. But as it progresses and irritates peritoneum which is closer to the wall of the abdomen, then the pain becomes localized. So, um visceral pain uh produces dull pain um and usually refers to the midline. Um but when the parietal peritoneum is being irritated, so we have pa pain, then the pain is much more localized and the patient will be able to specifically specifically pinpoint that aspect that's been uh painful. Um So, as described, uh this pain refers in the midline and somatic pain has to do with the, the dermatomes. Um and you should be able to know that pretty well because it's a very common question that's being asked um after an examination or a history taking um for gastro and also uh differentiate that between uh referred pain, which is when the pain refers to some aspects with a very distant uh pathology. So it doesn't really have to do with visceral, but it actually has to do with a very um distant uh space then moving on with the onset. You should uh establish when the pain started and when they, when the pain started what they were doing and ever since if it's been something that came on suddenly or something that has been gradually building up, uh something that's of an acute onset is more likely a rupture or, or reproliferation. Um something that might present within the hours, uh might signify infection or inflammation. And anything that has a mass length here onset, um could indicate a malignancy, uh IBD or an acute on chronic presentation. So, for example, now an IBD flare, which is a presentation of a chronic condition, Pristiq character. Um there are some distinct uh characteristics that uh patients might often describe and uh lead to some specific diagnosis. Uh For example, when the pain is described as colicky or anything that relates to colicky, it indicates that there is an obstruction in the hollow viscus. So in the, in the viscus has a definite uh biliary pain is characteristically varico uh va colicky, uh renal pain is also uh col and bowel obstruction that theology in earlier uh signs anything that's really that's described as burning, uh refers mostly to upper gi and anything that's more dull, uh umbilical pain. So, anything that presents with umbilical pain and anything that's very sharp or very hurtful, uh might signify an acute presentation in an emergency, such as, for example, an ovarian torsion or uh it's a very severe bowel obstruction for our radiation. Uh You have to establish if the pain spreads anywhere else that comes uh uh with the concept of pain that we described before. Uh So appendicitis has that migratory pattern. Uh a colleague or just refers to pain to back and plank pain low to grow is almost noren um pain and anything that uh is of renal pancreatic acid or aortic or acid and also with back pain and something that's a very uh also uh need but very characteristic uh referral pattern is the shoulder t or anything that involves pelvic uh pathology. So, an ectopic pregnancy might cause shoulder pain. So, these are just some things to have in mind because if they come up uh in those scenarios, they might be uh very useful in just saying that there is um a diagnosis is much more likely for associated symptoms. Um There are a lot of symptoms that uh might be relevant, but it's important to focus first on the ones that relate to the gi. So jaundice which includes uh which indicates hepatic and biliary causes vomiting, which um indicates gastro uh gastrointestinal upset, bloating. You should be thinking of the six S so plateau fat fluid pieces and pin mass. Um and then bowel habit changes either in one direction or another, which might be linking to different uh causes and diagnosis scatter, which include, which is fatty stools. So, something that you would see in a patient with pancreatitis, uh biliary obstruction for someone who's taking nor and then Milana, which is the um another presentation with very dark like uh tar like stools uh which indicates an average G IP. So these are all symptoms that you should ask for in that first part and related to the gi then with timely timing, you wanna um establish whether you have an episodic presentation or a continuous one. So you wanna know how long the pain has been there and if the pain has changed the same. So, perforation uh starts uh strong and just becomes stronger. Whereas an obstruction um moves along, goes mo moves along an axis and has some periods of very intense pain and then some periods where it's not even felt and exacerbating elevating factors. You should specifically ask if the patient has tried anything, if anything has wor has wor has worked to make the pain better or uh anything that has, has made, has, has been making the pain worse. Um And that's usually eating drinking positions and analgesia. So eating, uh in some cases, for example, in a gastric ulcer, it might make it worse, but it might make a biliary um pathology worse, gluten is making celiac disease worse. Uh Whereas for example, when you have a dial and you eat, it's much better. Um, some positions are also related and very characteristic. So for example, someone who's refrained that they feel better when they lean forward might be presented with the pancreatitis where someone who is saying that when they're lying down or the pain is much worse, then it might be a case of dyspepsia. And then finally, uh, on a severity scale of 1 to 10, you wanna, um, quantify, uh, the pain that is felt subjectively to what it was supposed to. So is it a very dull pain or a very severe pain? And then after you've done all that, um you want to perform a systems review. So more than just focusing on N GI which is the obvious system here. As you've seen, there are many systems that can be involved and present with abdominal pain. So you wanna do a head to toe review and just s screen some. So for some symptoms. So you do not wanna lose time with this. So just ask the patient to say yes or no so that you can have an idea of which systems might be implicated. So, other than the gi um very important is to uh establish some red flag symptoms, uh usually for malignancy. So, weight loss, appetite loss, fatigue, fever, and change in bowel habits. Uh But then moving on to other systems, ask about Gyn, ask about, ask about any skeletal musculoskeletal problems and neurological deficits. Anything that we've noticed on your skin and anything that might relate to their lungs, heart or system. And in that here, you have to be very focused. So you do not wanna ask very little but also not ask very much because that will. So when you're taking the history, you not want that. So maybe 1 to 2, um, symptoms per system is generally uh a good thing, but also, um, do not skip red flag symptoms because these are very characteristic and also very important. And then after you've done all that, um just for you to get your head around and also for the patient to feel like they're not just providing such questions. It's a good idea to do your eyes. So ask about why they think uh what they think is happening, ask about if they have any specific concerns, something that uh they are more worried about right now, but also what they're expecting from the history or they're expecting from the examination or what they ideally want. So uh at this stage, after you've done your eyes and you've taken all your primary history, uh it's a good idea to have a summary back to the patient to make sure that you've not missed anything. And also for yourself to take some time and organizing in your brain um with diagnosis, you wanna exclude on which ones you uh wanna confirm. And also as you are going to move on to further stations to further um um uh distinct parts of the history. It's a good thing to sign for. So, say that. Now I'm gonna ask questions about your family. Now I'm gonna ask questions about your living conditions uh because that helps the patient know um where you're focusing and have an idea and their mind of what they think before you ask it. So in the past medical history, um you will be specific with uh medical conditions and surgeries that they had before and for each, you have to establish how long they had the condition, if it's controlled, if they're taking any medications, if they ever had to be admitted for it. Um, how was the admission that they had? Communications? Um, many patients might be living with conditions a lot of time or might be, for example, someone who has hypertension might not consider hypertension a medical condition. So it's a good idea to also ask if they see their GP regularly for something or they take medication for something because patients might not necessarily uh understand what the medical condition is and for surgeries. Um, if there have, if there have been surgeries, you have to know when they happen, why they happened. Um And because especially for someone who's presenting with pain, if there's been a recent surgery, then it might be related to the pain. Um, these are just some very, uh characteristic uh patterns that you might say histories and usually direct you, um, towards the appropriate diagnosis. For example, someone who might say that have uh IBD um might presenting with a flare up or someone who has uh cardiovas, someone who, for example, says that I've had an Mr two months ago. Um it means that they have uh CBD risk and if you have a CVD risk, um you are the high risk for vascular pathology as well. And so they presented to the A&E with very severe pain in their abdomen, they might be having either bal ischemia or a AAA. Um, moving on to the drug history. Um, when you think of drug history, you should really be thinking of three things, prescribe medication over the counter medication and allergies. So, allergies are a very, very important part to not miss in your drug history. For prescribed, uh, medication. You should just establish, um, uh, what medication you are taking. What's the dosing, the frequency, the form the route and the indication. And if they have any side effects also a occurrence is a very important thing because in many cases, they might be given medication which they are not actually taking. Um, and for over the counter, uh, specifically it takes something on your own something, um, from your pharmacies without your doctor has without your doctor's advice. Um, and because in many cases, uh, these over the counter medications might provoke some pathology and for allergies, it's important not only to ask about if they have allergies, but also allergies to what, what type of reaction that was. And when that happened, because narrative that a 70 year old man might have in their childhood and might have been arrested might not be relevant if the benefit of giving antibiotics. For, for example, an appendicitis might outweigh the danger of provoking a mild allergic reaction that's not relevant or continuous. Some medication that can cause abdominal pain. That's a very um good thing to have a grasp on, especially for your exams. Um So usually, uh it's over the counter iron supplements. Um that might cause also uh gastro uh opiates. Uh al almost always cause constipation even in the hospital. And that's a very critical um aspect of uh surgical patients management that you give opiates for the pain. But that's uh constipation which is not pleasant and in many cases, it might also be dangerous. Antibiotics are also common to cause abdominal pain uh due to gastrointestinal up again and then also the most friendly uh DPP four inhibitors are like the common Ozempic, um which is in which is uh has been associated with the risk of pancreatitis. So, these are all very important to have in mind, ask about them and keep them in mind because they might be causing abdominal pain without any other organic issue for family history. Uh Your focus should be on bowel and ovarian uh cancers. Um And also IBD because these are the systems that are most relevant uh but also anything that's open autoimmune or hereditary pathology in the gi is also important to ask either specifically or you might have, have it as an answer already. Um, be mindful making a question that's, uh correct in the way that it's phrased. So, did, did anyone in your family ever have any problems with their bowels, um, avoid using the words cancer, um, and death, uh, and try to phrase it in a way that's appropriate. Uh, especially if the patient is not having a diagnosis of any that because that might cause them stress. But if they volunteer uh any sort of information, but likely ask about, I'm really sorry to hear that. Um, can you tell me more about, uh, the relative? When did they get diagnosed? Did they have complications? Um, so you get an idea of the family history, um, for, of the patient, for social history, there are very distinct parts that you should be considering. Um, some general aspects of the housing conditions, the support network and how they manage with daily activities is very important. Then some, some factor that relate to modifiable uh, lifestyle factors. So smoking that should be impact here. Diet. Um, usually here, it's good to start with a general question of how would you describe your diet for average or good? And then ask them for what a typical, what date in a day. And also if they find something that's triggering or something that they just generally avoid because that, for example, it might be relevant to someone who has celiac disease for alcohol. It's a good idea to have an idea of the weekday versus weekend consumption. And again, you need to quantify this in units. So specifically about what type of alcohol, what quantity, what volume and how often that consumption is travel, history is also very important and very common to forget. But in many cases, uh it's the key to making a day stenosis. You should be asking very specific questions. So when did you travel? Where, where was that? Um And how are the others who we traveled with? Are they OK? Are they not because if someone tells you that everyone in the house is sick, then you might understand that. Ok, probably this is the, the reason why um and then recreational drugs, it's important to sign post here and say that we are you, are we ask this question to everyone and this is a safe space. Um And also for sexual history, all its very irrelevant and to the degree that it's relevant. So you don't have to take a focused sexual history. But for example, if you are suspecting an opic pregnancy, um you need to ask if the patient is sexually active, for example. So concluding your history uh taking um should include uh a summary to the patient um and asking for any clarification and confirmation of what you've elicited and also asking the patient if they have any questions and if they want to share something else with you, um ask the patient if they have any concerns if they have to, if they want to ask you something because as you take the history, they might have uh away um or they might have uh a new questions. So always make sure to account for that. Finally, thank the patient and wash your hands. Uh So wash your hands whenever you went to the station, wherever you and whatever you have to do, it's very, very important and it will be very much penalized for absolutely no reason. So do not lose smarts for this. Um So moving on to examination, um for examination, a good pneumonia you have in mind is wiper which applies to most examinations. Um So first thing uh is wash your hands and wear your pee pee, especially for uh anyone with abdominal pain. Um you might need to wear gloves or especially wash your hands. And even if you wash them in the beginning, it's always a good idea to wash them again because that's um the patient then uh identity and introduction. Um you might do them in either way. So you want to reduce your again yourself, what you're doing, why you're doing it. And also for the identity of the patient, you need to know that you're talking to the right patient. Um So you do this by confirming their name their name of their date of birth and their hospital number if we're in a hospital setting. Um So for example, um I your, your doctor has told me that you have pain in your abdomen and has asked me to examine you. So I will need to perform a full abdominal examination, which will involve me having a loop touch and listen to your thumb and legs. So be very specific on what you will be doing. Um I will be drug the Corin as I need you your abdomen to be exposed. And also mention what uh level of exposure the patient will have to provide for you to carry out the examination, uh permission per position and permission. So usually you start the abdominal examination with a patient sitting at 45 degrees, but then you will need them to lay completely flat on the bed. Um And after you take the consent, you uh allow them to get dressed or even pretend to get dressed, typically books described by nipples to need exposure requirement. But in reality, you just need them to uh expose your abdomen and a little bit below and above. And also then let's for the final aspect of this. And finally, uh right of the right side of the bed. Um that's also very important and very easy to not to under stress. So always remember that when you carry out your inspection and you move on closer to the patient you should be thinking that you should be on the right aspect of the bed. So then there's the second pneumonic pa pneumonic if you cared before. Um which is uh first thing is the permission. So you do not start an examination without having verbalized the consent. Um And as you have this, um the first thing to do before you because you start your examination is you should be asking for one specific thing and that's pain. So there is a way that you want to know if the patient is actively in pain, first of all, because you have to be as polite to them as possible. And also for you to have an idea of um how they're feeling and whether there is their general situation. So they have, they, they say that I have pain here, but I'm, I'm ok. Um It's different to whether they have a very severe pain. And in many cases in sy, a patient will um a AAA patient will be acting in a very dramatic way with her pain. And it's not, it do, it doesn't come across nice if you haven't asked about the pain and if you haven't so case an empathy before starting your examination and just take the steps. So for that and always so empathy before you even start and when you do that, you wanna start with an inspection, so you move away from the patient preferably to the, from the end of the bed and carry out uh an inspection around the bed. Uh You see the patient, how old are they, what's around their bed? So, something that might, might be very relevant in this presentation is Stoma drains, uh medications, prescriptions, charts, but also how the patient looks. Do they look? Ok. Do they look, uh uh what's their body type? Um Do they look or in the time? Um, and then have a brief look for scars, uh hernias, abdominal distension, pal jaundice, hyperpigmentation and lower uh in their bodies. So, in their neck, a arms legs, if you have edema, but just having a general understanding of what the patient looks like um for scars, um you probably did not need to know all those scars, the very basic ones, no, um are the midline ones, the uh in, you know, ones, the transverse ones. So, um it's very important to know because you might see them in a as they might have had surgeries and you might be asked on them. But also for the questions following your examination, you might be given a question that says the patient has a scar there. What surgery did they have? Um And also for stomas, um you should be able to differentiate between stomas. Um even if patients know, do not have them because they are actors. Um you might get questions on them. So a colostomy is usually on the uh left side. Um and then the theos is usually on the right side. Um And then, so it's uh based on what you see, uh you should be able to differentiate grossly between it. And then, and then the colostomy and loop colostomy. So loop colo colostomy is basically that the whole tube is taken out and you have two holes, whereas an end colostomy that the uh the end is projected outwards. So it's like you have a cross section, a coronal section of the colon and also something that's very easily missed. But it's very relevant because this is also the reason why this lecture has been grouped as central and uh lower um abdominal pain is that uh lung pain, um you might have a urostomy. So urostomy is the um similar thing to colostomy that relates to the kidneys and has urine as its content. This is typically what it looks like. So you might be given a urostomy and be asked to say what that is. So here you do not wanna say that it's a colostomy whereas it's a urostomy. But also if you're given something like that, you should be able to appreciate it with this a urostomy and also some signs uh you're not expected to see them among patients, but you are expected to get questions on them and you might even get pictures. Um So these are the two signs that uh relate to pancreatitis. The first one is Ken sign and the second one is great Turner, the way I remember this is that uh Ken is over the umbilical or, or surrounding the umbilicus and it's one name whereas greater is two names. So it has to do with the two sides because it really, it's, it's retroperitoneal bleeding in the sides. So you have it in both sides. So it's two names, two sides. That's my of remembering it, but it's uh both uh it both present in pancreatitis and any other sort of uh bleeding in the abdomen. Uh So after you've carried out your inspection, uh from the end of the bed, you move on closely to the right side and start off with the hands. So it's always a good idea to have a systematic approach as with your history. So here you wanna start with the hands, go to their arms, go to their face, uh eyes, um neck and then abdomen. Uh but for you start off with the hands, look at the palms um for pallor uh in anemia, for erythema, for the punctures contractures. So that thickening that someone with a liver pathology might present with, look at their nails for Kloch or Leuconychia. So, Leonia means white nails, whereas Kloch indicates iron deficiency and its spoon nails, um look for finger clapping. So, clamping is a very, very common uh exam condition, uh exam question. Um there are many different distant causes and usually you are looking for the window and when you're not able to see that you um say that the patient is presenting with clubbing and when you relate that to other findings, you are able to understand what the cause might be. Um And this is a pneumonic to remember all the different causes that might cause clubbing. Um A is uh you ask the patient to um lay their hands in front and you are observing for a flap uh which indicates CO2 retention for some for, for example, who has been having type two uh respiratory failure. And then with the dorsal aspect of your hands, assess the temperature of the hands and also take the radial pulse to establish the rate and rhythm. Um and that's for, for, for example, what the flap would be and then move on uh in the arms and axilla. Look for any bruises which might indicate Vitamin K deficiencies or chronic abnormalities. Look for excoriations secondary to pruritus, for example, who having cholestasis and look for needle track marks, which indicates uh IV tract use and increase it for pancreatitis in the axilla acanthosis neg cancer is um very important um hyper hyperpigmentation, uh disorder of axillary skin. It can be benign uh in some individuals, but uh it might also be associated with insulin resistance in type two diabetes, but also with uh stomach cancer and also assess for hair loss, which might indicate malnutrition or iron deficiency anemia. Then to the face and the eye. There are very important aspects of eye pathologies that relate to liver, pat to liver pathologies or gastro pathologies. So, conc val palor, the whitening of the eyelid indicates anemia, yellow sclera indicates jaundice corneal arcus. Um which is that uh gray blue ring around the eyelids, um might be benign over 60 but if under 60 it might indicate hypercholesteremia, so high cholesterol uh and also the asthma can present with um who indicates uh hypercholesteremia. Uh Kaiser Pfizer rings uh indicate Wilson's disease. So, Wilson's disease is um a disorder of uh copper processing by the liver. So that causes uh copper deposit in uh various aspects of the um body, including the outer part of the iris and also the liver causing liver pathology, uh asthma that we also, we've said that these are the fatty deposits usually in the eyes or the knees of people who have high cholesterol and also the uh a red eye. Um specifically uh when the, it's relating to close to the um limbus of the iris might indicate a arterial uveitis with secom pathology with diabetes. Uh That's a very common thing that comes up with exams. Um So a red eye um is usually indicating uh to someone who is presented with gastro gastrointestinal pain, usually someone with diabetes. So moving on uh with other other respect of the face of the mouth, um you might notice some anglo stomatitis. So some um infection, inflammation of the uh sides of the mouth, Burti um So, infection of the tongue, um which both relate to deficiencies and malabsorption, candidiasis, which is um a fungal infection of the tongue. It's very common in asthmatics who take um um agents uh which could include immunoseparation agents because they cause immunoseparation. So, f uh fungal infections are activated in the mouth. Um A ulceration uh al also related to deficiencies with iron and B12, but also with Crohn's disease. Um and hyper now macules. So those black spots inside the mouth, which are paop, pneumonic for pigs, joy system uh syndrome, much rarer uh but something that's very distinct in it presentation. So for the next uh part, uh after you've completed your first inspection, you're gonna palpate. Um So as you're now moving from the head down to the neck, um you're thinking that they're not many things to notice. So you have to palpate what you're, we're looking to palpate. Here is the nodes um and specifically rehearse node, uh which is responsible for draining the abdominal cavity and might indicate metastatic intraabdominal malignancy. So as always, for the lymph nodes, you should be examining from the back of the patient. So if it's um part of the examination, you might inform the patient that I'm going just behind you to have a look to have a feel of your neck. Um uh something that uh might be asked is uh what other notes other than the whose notes um might uh you examine. So the on the right aspect uh against uh opposite host. Um It's where the thorax and Aage uh regions stray. Um And that's just some no legitimate one. So case if you asked by your or end uh indication. Uh but then you also, if you think about what aspect of a patient you've been able to be examined so far, you have to do some further inspection as you're moving down from the neck. So you wanna inspect the chest, specifically look for spider nevi which indicate increased level of estrogens. Um And the reason why you have increased levels of oxygen is that you have some sort of uh liver pathology uh or pregnancy and O CB in female patients. Um So these are characters, spider Niva is depressing them and they refill uh gynecomastia. So that's the enlargement of the breast tissue in males is also associated with increased level of estrogen secondary to pathology or digoxin and spironolactone and also hair loss uh indicating malignancies and deficiencies and then further down below the abdomen. Uh At this stage, it's very important that you ask the patient to lay flat, have their arms on their sides and their legs are crossed because you will need to have a closer inspection of the abdomen in case you miss any scars, masses, distension, stoma and pulsation in your uh inspection from the end of the bed. Uh And these are the non uh areas of the um abdomen as we've seen before and you should be inspecting on all of them. So, uh just a quick reminder um on the stomach characteristics. Uh So for any stomach, you should be able to say where it is. What are the contents? How are the contents, uh consistency and if you spouted or not? So, um Ileo Iost and Urostomy are spouted, but colostomies are not. So these are just some uh things that you need to almost learn by heart when it comes to uh colostomies and urostomy and be able to comment on them in case you get questions um for palpation of the abdomen. Uh in specific, you need to again ask for any pain because you wanna start from the opposite side of where the pain is located, make sure that you look at the face of the patient because that will be able to uh help you understand when the, where the, where the pain actually is. Um And also do a side by side comparison as you go through um palpation of the abdomen is a divide is divided into two respect. So, light palpation and dep patient. Um light pulp patient is looking for some uh reflex signs and also so for some uh uh guarding that the patient might be presenting, whereas the patient um is uh allowing you to essentially feel for any masses and any characteristics of those masses. For example, why do they feel like how dense they are? And if they are PASAT. So for light palpation, you should be palpating with only one of your hands. Uh Whereas for the palpation you want to press much harder. So usually you need to involve both of your hands when doing. So. Um and then after you've done this, um you need to uh look for an organomegaly and the organs relevant here are the liver, the kidney and spleen. Um setting up with the liver. Um you uh move on from the lower aspect of the abdomen. Uh So you with the index uh in the, the index on the abdomen, you ask them to take a deep breath in and when they breathe out, you uh move your hands up and you should actually do not feel it unless it's enlarged. You should just be feeling the liver edge uh when you are approximately at the level of the costal margin. Um and the reasons why the hepato why you, why the patient might have hepatomegaly um include obviously um causes of infection and inflammation of the liver. Uh but also anything that uh might uh affect its uh um its function. Uh the bladder is not usually palpable un unless obstructed. Um but if it is, it could be at the midclavicular line on the right uh level of the of the right aspect of the gal margin. And Murphy sign is also a very important sign to know because a doctor might uh mimic that. So, Murphy sign is when the patient stops, um, taking a deep breath in because they have pain, uh when you're palpating the right costal margin. So, at the level that the picture is showing, um if you ask the patient to take a deep breath in and they stop taking the breath in because of pain, uh, that's um, a characteristic of uh log ascitis and it's called Murphy sign for the spleen. It's exactly the same. Uh it should not be felt, but the, the way that you're um uh examining for its uh um enlargement is exactly the same. So you start off from the right lower quadrant, but you're moving diagonally uh towards the side of the spleen is so it basically going towards the left costal margin. And again, reasons why the spleen might be enlarged include um portal hypertension, uh splenic metastasis and hemolytic anemia. And finally, for kidneys, uh the most common and the easiest way doing leos is balloting. So you press you put one of your hands below and one of your hands over the abdomen and you try to um press with your hand below uh against the hand up. Uh Usually you should not be feeling for the kidneys unless you are examining a patient who has a very low BM I um but again, what's important here is to understand whether it's something that you see in both kidneys or not. To understand. If you're talking, if you're, if you're having a unilateral or bilateral pathology. Because a kidney that's enlarged on one side means that it's most likely pathology of one kidney. So, a tumor, uh whereas if you can feel for the kidneys in both sides, then you think about something that's more uh genetic. So, a polycystic kidney disease or a low doses and then for the aorta um for the aorta, you go to the umbilicus and you press uh and try and have an understanding of uh its possibility. Uh Usually when you put your hands on the sides of the umbilicus, you should see them move for uh move up with uh inspiration. But if you see them moving away, that indicates that there might be some sort of exponential mass, for example, in AAA uh very unlikely to actually see, but you have to be able to appreciate this in case you are asked to it and then precaution. Uh So precaution, the common topic, um it again goes back to the same organ. So in the liver, you precast to be able to understand it's um uh limits. So below, from the uh R LQ uh to the costal margin and from just below just above uh to understand where it starts and ends, the spleen is the same thing. And most importantly, shifting dullness uh when you have ascites. So when you saw you have um an increased um uh a flat or some or like um if you want to establish uh if there is uh free fluid in the abdomen. Uh You do the c dullness test for the ki you start at the umbilicus and you tap towards the flank and then you ask the patients to roll over that side and take it to the examiner that I would wait for 30 seconds to uh assess for certain dullness, but obviously do not wait 30 seconds waiting. And what you're looking to see here is, is to note if there is a change from a dull note, if there is not one. Um, and that's why it's called, uh, shifting dullness. So, uh, if the dullness shifts then you have, uh, you can be pretty common in, in having, um, asciis and auscultation. Uh, auscultation has been carried out in the abdomen for two reasons to look for bowel sounds and make sure that the bowel is patent and for Bruits, uh, for valvular pathology, um, vascular pathology, sorry. Um, for bowel sounds, uh, you should be, uh, auscultating at least deposition, usually ascending and descending colon. Uh So the two sides are OK and you wanna see if they are, uh, present or if they're abnormal. If they're thick or completely absent, tingling, usually indicates bowel obstruction in its earlier forms and absent indicates that there is no propulsive activities on ileus. In order to confirm, you need to communicate to the examiner that you would osculate for 30 minutes. And Bruits, you listen over the aorta, um usually uh you go 1 to 2 centimeters above the umbilical um and they might be present if you have a AAA. And for renal, uh you go slightly lateral to the um region that you osculated for the uh bruise in the aorta. So a little bit on the sides of the navel. Um And if you are able to elas a bruise, usually that indicate that there is no art arteries, synosis, finally, uh you get to palpate in the legs and what you're prop in the legs is buring edema, uh which indicates hypo and that's uh the conclusion of the examination of someone who 10 with central or lower abdominal pain. Um And you need to say that the examination is not complete. Thank the patient, help him get dressed um and wash your hands. So according to the examiner, uh for this examination, uh you should be, first of all, of course, say who you examined and basic demographics, what was their complaint? And then think about everything that you did entitles and share it with the patient with the examiner. So you wanna say what you found on general inspection if they have been stigmata of uh gastro gastrointestinal disease. So signs essentially detail every region that you've examined everything that you measured. So the pulse that you measured uh make sure to communicate that. But also because you will be doing that for 15 or 30 seconds, make sure that it is a multiple of 15 or 30 say there has been uh evidence of impy and then think about everything that he did. So, palpation, hyper calcium, if they were normal or not, uh then you look at the organs. So if it was or organomegaly, then you hear it with your stethoscope. So you heard her bowel sounds. So, were they normal? No tingling where the bruits and finally in the legs was the, was the edema. So there is no uh better way to report the examiner than just following the um exact uh structure of the examination that you followed. Uh But just have in mind some phrases that examiners like to see. For example, stigma of gastrointestinal disease, organomegaly, evidence of opathy. Uh because those indicate that you have uh professionalism in communicating your findings. And then after you say of that, summarize, uh whether you had, uh you, whether what you've examined is consistent with a normal abdominal examination or whether there is a specific presentation or set of presentations that you are considering, um are linked to this uh presentation and say that for completeness, you would uh like to order or perform certain sorts of investigations or examinations, follow up investigations for anyone who's presenting with central or lower abdominal pain, of course, relate to what the patient has said in their history or what you've been able to elicit. Um, for example, uh if you had any uh signs of hernias you might wanna say that I would examine the hernial orifices. Um If you have any sort of symptomatology of Melano f stools, you might wanna do ad re um for blood. Uh you wanna think about liver function tests for any liver pathology or anything that's um related. You do U and E um special tests such as, for example, feet test to look for blood in the stools and then moving on to more um uh sort of ordering investigations, something that you wouldn't do yourself. Uh imaging uh ultrasound for the liver, um CD contrast for gastro pathology and no contrast for uropathological. Um So the reason why you order contrast for gastro actually what you got what you do not want contrast for um is that uh you do not want contrast that you're able to see if the flow is obstructed in the kidneys. Um And that's why uh you do not want contrast in a ct done for uh uropathological. And finally, any procedures that you might suggest for the patient to have including colonoscopy, sigmoidoscopy, and endoscopy. So when you're uh sharing with the examiner, what you would follow up, follow up from your examination, have a Guinness structure approach. Think about any other examinations, you would do, think about anything that you would order uh from very simple things such as labs, do special tests and imaging. And then finally, something that you wouldn't be able to do yourself. Uh And it's much more invasive with follow at the end. But so that you are thinking about the pathway and that the investigations have in order. So do not just provide three or four that do not have a certain idea of where they are leading to or how they will be in a timely way organized. Um And this concludes the um presentation. Uh You can provide feedback here on the QR and there's also the link um in the chat box. Um If there's any question that you would like me to answer, just gonna check. Uh No, OK. Me, if there's any question, I'd be more than happy to answer it. You.