General examination in abd. stationBy Dr saber M. A.MRCP

I pray to my God (Allah ) to accept this work and forgive me This work is dedicated to our Prophet MOHAMMED peace be upon him.Also this work is dedicated to my mother and my father who did their best for me and also to my last and lasting wife Walaa who helped me

OSCE and PACES based general examination for Abd. Station General examination start at the first look to the patient . So be a good observerIn Abdomenal station the cases are few and u can catch an early diagnosis Cases are either CLD , thalessemia , hematological disorder or kidney CRF could be apparent by the uraemic facies , also thalessemia , CLD

Thalessemia continued

Thalasemia abd distension narrow eyes large skull

Uraemia Yellowish discolration due to urochrome pigment that give the urine its unique colorPallorPhotosensentive pigmet cause dark complexionUraemic frost (urea ppt on skin after evaporation of sweat)

CKD

Uraemic frost

Nail in uraemia

Chronic liver disease

May be evident by the first look

Wasted temporalis

Caput medosaMay disappear while lying so always ask the pt to cough otherwise u may miss

Some pt just have swelling that appear on coughing >>> by stethoscope u can catch the bruit esp when coughing bu delay this step to auscultation step U can feel the thrill upon coughing U should examine the direction of filling to differentiate it from IVC obstruction but delay this step to the end of examination

gynecomastiaDo palpation after taking permession from both examiner and pt . If tender tell th examiner

Causes of gynecomastiaCLD per se is a causeSpironolactone Other causes

Lower limbWhile u still looking at the tail of bed examine for lower limb oedemaAsk the patient if he has any pain in his legs Press gently for a while by one thumb at each leg ( about 5-10 cm above medial maloleus then see and feel for pitting No need to get level of edema Do not examine for oedema in feet Do not miss diabetic dermopathy which may reveal the cause of CKD

Purpura may give u clues

ClubbingNo grading as before Just hyperconvexity in some fingersMay be blue clubbing or pale clubbingWindow test is official now not as before( this test were forbidden by old fashioned doctors and was considered as Tahshish of egyptian doctors)Pathophysiology of clubbing is not well understood

Some said it is hypoxia as in blue clubbing with cyanotic heart diseaseSome said it is inflammatory process as in suppurative lung disease Clubbing could be familial Clubbing is one stigmata of chronic liver disease

Palmar erythema Central palmar pallor surrounded by flushed skinCauses: 1-pregnancy2-normal variant 3-CLD4-thyrotoxicosis5-rheumatoid arthritis

RHEUMATOLOGICAL surveyRheumatoid hand : may be the case is feltys syndrome (rare occasion) , may be Amoiloidosis (not station 1 case but could be station 5 case )Nail fold vasculitis (station 5 also )

PULSECould be omitted in ABDBounding pulse in anaemia Water hammer

Shunt Most commonly in cubital fossa but could be in Arm ( happened in one exam )Examine shunt for patency by thrill and auscultation You may examine the shunt for its use (punctures)If CV line is present >>>> shunt not mature . No shunt but CV line >>>>> ??????ABDOMINAL PUNCTURES>>>>>> peritoneal dialysis lateral abdominal catrheter >>>>>> CAPD or APD or tidal peitoneal dialysis

FACELook at face for any striking feature like cushenoid which signify using steroids (either Autoimmune or transplantation)Others like wasted temporalis in CLD Thalessemia CKD BLA BLA BLA

EYEFor jaundice and pallorBy index and thumb gently elevate both lids and ask the patient to look rt and left while u look tangentially for jaundice Then by each thum open both lids to see if theres pallor in the conuctival fold not the conjuctiva itself

mouth. Pallor but do not touch lips .gum hypertrophy*Foeter hepaticus

Causes of gum hypertrophyBad hygeine but in exam make this the last causeCMML (exam scenario)Cyclosporin therapy in renal transplantationPhynetoin ( a very effective drug but unfortunately cause distorted face

Gum hypertrophygum hypertrophy.jpg

Parotid enlargement

Causes of parotid enlargementSarcoidosis Hypoalbuminemia such as CLDParotitisNervosa due to nutritional defeciencyChronic worm infestation

Cervical lympadenopathyLymphoproliferative disorderSecondariessarcoidosis

Vircows node

Spider naevi

More than 5 is requiredSignify systemic vasodilatation due to hyperestrogenic stateNormal with pregnacy (less than 5)

Spider naviDistribution of SVCNot commonly seen in many CLD pt Common in Alcoholics

Do not panicU may not know the diagnosis from general examination --->>>> u will get the diagnosis in the abdominal examination.If u get the diagnosis early u can accustom the rest of examination and sequence There is some general examination topics that u should postpone to the end of examination according to clinical setting

Do not examine LN before abdominal examination Also lung bases

Hope not missing any thing