Abdominal Exam Algorithm

Abdominal Exam Algorithm

Neck flexion – Layer of abdominal mass

Cough – Hernia

Liver & Spleen

Main etiologies: CLD, Malignancy, Hematological, Infection/Inflammation, Infiltration

Approach

1.  Central & Peripheral signs

Jaundice / Anemia only / None
Hepatomegaly / Chronic Liver Disease
Malignancy
-  Primary
-  Secondary
Infection
-  Viral: Hepatitis, EBV, CMV
-  Bacterial: / Any cause of Hepatomegaly with
-  Blood loss
-  Anemia of chronic disease / Chronic Liver Disease
Fatty LIver
Malignancy
-  Primary
-  Secondary
Hematological
-  Myeloproliferative (PRV)
-  Lymphoproliferative
Venous congestion
-  Cardiac (CCF, TR)
-  Hepatic Vein Occlusion
Infection
-  Abscess (Bacteria, Parasite)
Infiltrative
-  Amyloid
-  Sarcoid
Hepatomegaly + Spleenomegaly / Chronic Liver Disease w Portal HTN
Malignancy (w Portal HTN/Portal vein obstruction)
Infection
-  Viral: Hepatitis, EBV, CMV
-  Parasite: Malaria
Hematological
-  Hemolytic anemia with extramedullary hematopoiesis / Chronic Liver Disease w Portal HTN
Malignancy (w Portal HTN/Portal vein obstruction)
Infection:
-  Viral: Hepatitis, EBV, CMV
-  Parasite: Malaria
Hematological
-  Hemolytic anemia with extramedullary hematopoiesis
-  Myeloproliferative
-  Lymphoproliferative / Chronic Liver Disease w Portal HTN
Malignancy (w Portal HTN/Portal vein obstruction)
Infection:
-  Viral: EBV, CMV, Hepatitis
-  Parasitic: Malaria
Hematological
-  Myeloproliferative
(PRV)
-  Lymphoproliferative
Infiltrative
-  Amyloid
-  Sarcoid
Splenomegaly / Chronic Liver Disease (w Portal HTN + Cirrhosis)
-  Includes malignant transformation
Infection:
-  Viral: Hepatitis, CMV, EBV
-  Bacterial:
-  Parasitic: Malaria
Hematological
-  Hemolytic anemia / Chronic Liver Disease (w Portal HTN + Cirrhosis)
-  Includes malignant transformation
Infection:
-  Viral: CMV, EBV
-  Bacterial
-  Parasitic: Malaria
Hematological
-  Hemolytic anemia
-  Myeloproliferative (Myelofibrosis, ITP with bleeding)
-  Lymphoproliferative / Chronic Liver Disease (w Portal HTN + Cirrhosis)
-  Includes malignant transformation
Infection:
-  Viral: CMV, EBV
Hematological
-  Myeloproliferative
(PRV)
-  Lymphoproliferative
Infiltrative
-  Amyloid
-  Sarcoid

2.  Mild, Moderate, Massive

3.  Peripheral supporting signs

-  Stigmata: CLD

-  Cancer: Cachexia, Lymph Nodes

-  Myeloproliferative: Plethora, Bone marrow aspiration marks

-  Lymphoproliferative: Diffuse Lymphadenopathy

Why virus – leucopenia?

Kidney/Renal

Possible sites of Renal Mass

-  Anatomical site (Unilateral vs. Bilateral)

-  Transplant site

Approach to Mass

1.  Unilateral vs. Bilateral

2.  Pre-renal, Renal, Post-renal

Causes

Adults

Unilateral / Bilateral
Single functioning kidney (compensatory hypertrophy)
Clot
Cyst
Acute pyelonephritis
Pyonephrosis/Abscess
Renal Cell Carcinoma (Clear cell)
Hydronephrosis / AD (Adult) Polycystic Kidney Disease – Polycystic Liver
Amyloidosis
Acromegaly
Angiomyolipomata (tuberous sclerosis)
Angiomatosis (VHL disease)
Renal cell carcinoma (Papillary)
Hydronephrosis

Paediatrics

Unilateral / Bilateral
Renal Vein Thrombosis
Nephroblastoma (Wilms Tumour)
Hydronephrosis / Renal Vein Thrombosis
AR (infantile) Polycystic Kidney Disease – Hepatic Fibrosis
Tuberous Sclerosis (Angiomyolipomata)
Nephroblastoma (Wilms Tumour) – Less common
Hydronephrosis

Scars on inspection

-  Parathyroid scar

-  Tunneled catheter

-  Fistula: is it functioning? Are there recent needle marks?

-  RIF scar - J shape

-  Linear - PD scar

Complication of Kidney Disease: Chronic Kidney Disease/End Stage Renal Failure

Condition & Complications

1.  Features of ESRF on abdominal examination

-  Sallow appearance

-  Pruritus

-  Asterixis

-  Conjunctival Pallor

-  Pedal Edema (Fluid overload?)

Causes

-  DM - Dermopathy? Ulcers? Neuropathy?

-  HTN - Fundoscopy? Urine dipstick for Hematuria? BP measurement

-  GN - Rash? Arthropathies? (Young patient)

-  Polycystic Kidneys

-  Renal Artery Stenosis (Renal bruit)

Control

2.  Features of Renal replacement therapy

-  Hemodialysis: No BP Taking sign, AVF (needle marks?), AV Graft, Tunneled Catheter

-  Peritoneal Dialysis: Tenckhoff catheter in situ, Linear Scar (previous PD)

3.  Features of Renal Transplant

-  Transplanted kidney in RIF (Overlying J-shaped scar)
(a) Bruit? – Renal Artery Stenosis

(b) Tenderness? – Infection/Thrombosis of vein, Acute graft rejection

-  Features of immunosuppression

(a)  Steroids – Cushingnoid features

(b)  Cyclosporine – Hypertrichosis, gingival hyperplasia

4.  Parathyroidectomy scars

Complete examination by:

1.  BP measurement (Secondary to CKD or Stenosis/Thrombosis of transplant artery/vein)

2.  Urine Dipstick – Hematuria/Proteinuria/Pyuria (Ruptured cyst, Renal disease)

3.  Fundoscopy (complications of HTN, DM etc.)

4.  Input/Output chart (Fluid balance, Monitor for oliguria/anuria)

Adult Polycystic Kidney Disease

Complications

1.  Local

-  Cyst

-  Malignancy

2.  Systemic

-  Berry aneurysm

-  Cardiac (MVP, AR/MR/TR)

-  Cysts in other organs (Liver, abdominal/pelvic organs, lungs, thyroid, CNS)

-  Diverticular disease in colon

-  Renal HTN/ESRF (Common to all CKD)

Jaundice / Anemia Only / None
Hepatomegaly
Hepatomegaly + Spleenomegaly
Spleenomegaly

Hernia