1. Environmentgeneral appearance
2. Nailshandsarms
3. Eyesmouthneckchestback
4. Abdomen inspection
5. Abdomen palpation: generallivergallbladderspleenkidneysstomachpancreasaortaboweltestes
6. Abdomen percussionascitesauscultation
7. Groinherniasrectallegs

Environment

• NG tube.
• Feeding tube.
• Cans of special food.

General appearance

• Colors:
  • Anemic (iron malabsorptionhemorrhageCA).
  • Jaundiced (liver dz).
  • Hyperpigmented (hemochromatosis).
  • See Skin Colors Reference.
• Hydration and nutrition.
• Weight loss vs. gainwasting.
• Shocked.
• Postural hypotension.

Nails

• CLUBBING (UC or Crohn'sBiliary cirrhosisGImalabsorption).
• Koilonychia (iron deficiency 2° to GI bleeding).
• Leuconychia (hypoalbuminism 2° to cirrhosis).
• Muehrke's lines (hypoalbuminism 2° to cirrhosis).
• Blue lunulae (Wilson's).
• Nicotine stains (some GI CA's).
• See Nails Reference.

Hands

• Asterixis (PSE 2° to alcoholism):
  • Pt. stretches out hands in policeman's stop positionfingers spreadout.
  • Coarse flapping tremor"liver flap"is seen.
• Pallor of palmar creases (anemia 2° to blood lossmalabsorption).
• Palmar erythema (cirrhosis).
• Dupuytren's contracture [fibrosiscontracture of palm's fasciausucontracting ring finger] (alcoholismmanual labor).
• Palmar xanthomata [yellow deposists on palm of hand] (Type IIIhyperlipidemia).
• Tendon xanthomata [yellow deposits on dorsum of handarm] (Type IIhyperlipidemia).

Arms

• Scratch marks (itch from jaundice).
• Spider naevi (alcoholism).
• Bruising (clotting factors 2° to liver damage).
• Tuboeruptive xanthomata [yellow deposists on elbowsknees] (Type IIIhyperlipidemia).

Eyes

• Cornea rings (Wilson's).
• Sclera: jaundice.
• Iritis: IBD.
• Xanthelasma [yellow plaque periobital deposits] (elevated cholesterol).

Mouth

• Temporalis muscle wasting.
• Lips:
  • Telangiectasia (Osler-Weber-Rendu)
  • Brown freckles (Peutz-Jeghers).
• Breath:
  • Fetor hepaticus (alcoholism).
  • Ethanol.
• Mouth:
  • Ulcers (Crohn'scoeliac dz).
  • White candida patches (spread down throat).
  • Cracks at mouth edges (iron deficiency anemia).
• Teeth:
  • Cavities (acid 2° to vomiting).
  • Nicotine stains.
• Gums: 
  • Hypertrophy.
  • Bleeding.
  • Gingivitis.
• Tongue:
  • Leucoplakia (smokespiritssepsissyphilissore teeth).
  • Atrophic glossitis [withered tongue] (deficienciesPlummer-Vinson).
  • Macroglossia (B12 deficiency).

Neckchestback

• Cervical nodes:
  • Supraclavicular nodes for Virchow's node (lung CAGI malignancy).
  • See Nodes Reference.
• Gynecomastia (chronic liver dz).
• Hair loss (chronic liver dz).
• Back: neurofibromas.

Abdomen: inspection

• Pt is supineabdomen visible from nipples to pubic symphysis.
• Scars. See Abdominal Scar Reference.
• Stoma from surgerytrauma.
• PEG (dysphagiausu. 2º to neurological damagelike stroke).
• Distension (fatfetusfecesflatusfluidfull-sized tumors).
• Local swellings (enlarged organshernia). See ExaminingA Mass Reference.
• Pulsations (AAA).
• Peristalsis visible (thin personintestinal obstruction).
• Skin: 
  • Herpes zoster (abdominal pain).
  • Grey-Turner's sign [discolored skin] (acute pancreatitis).
• Striae:
  • Regular striae (ascitiespregnancyweight loss).
  • Purplewide striae (Cushings).
• Dilated veins location:
  • Anterior leg (IVC block).
  • Caput medusae (portal HTN).
  • Costal margin (normal).
• Dilated vein flow direction. Test by occluding with fingers:
  • Flows superior (IVC block).
  • Flows inferior (SVC block).
  • Navel radiation (portal HTN).
• Umbilicus:
  • Sister Joseph nodule (metastatic tumor).
  • Cullen's "black eye" (acute pancreatitisextensivehemoperitoneum).
• Groin: brown freckles (Peutz-Jeghers).
• Squat to pt's stomach leveland watch for asymmetrical movement duringbreathing (masslarge liver).

Palpate general abdominal

• Warm hands.
• Ask pt if any part tender: examine that last.
• Abdominal muscles relaxedpt bends knees if necessary.
• Light palpation.
• Deep palpation.
• Note rigidityrebound tendernessinvoluntary guarding (peritonitis).
• Record mass characteristics. See Examining A Mass Reference.
• Distinguish abdominal wall mass from intrabdominal mass:
  • Pt folds arms andsits halfway up.
  • Wall mass if size is same  tenderness same or greater.

Palpate liver

• Find edge:
  • Dr's R hand held still at base of RLQparallel to costal margin.
  • Ask pt. to breathe slowly.
  • During each inspirationsee if liver edge strikes radial edge of indexfinger.
  • During each expirationDr's hand moves superiorly 2cm.
• Palpate liver surfaceedge:
  • Hard vs. soft.
  • Regular vs. irregular.
  • Tender vs. not.
  • Pulsatile (tricuspid incompetence) vs. not.
• Find top border bypercussing down R midclavicular line [normal: 5th rib in midclavicularline].
• Calculate span [normal span: 12.5cm].

Palpate gallbladder

• Dr's fingers placed perpendicular to R costal margin near midlinethenmoved medial to lateral to palpate.
• Do Murphy's sign: cessation of inspiration upon palpation.
  • Murphy's point: costal margin in midclavicular line.
  • Courvoisier's law: Stones= stays small since scarred.

Palpate spleen

• Bimanual technique:
  • Dr's L hand posterolaterallybelow pt's L ribscompressing on ribcage.
  • Dr's R hand below pt's umbilicusparallel to L costal margin.
  • Advance R hand superiorly to L costal margin.
  • 1.5x-2x enlarged spleen is palpable.
  • If miss spleenroll pt. towards Dr. (so pt lies on pt's R side) andrepeat palpation.
• Alternatively: palpate like liver edge with just R handstarting from RLQdiagonally over to LUQ.
• Alternatively: combine the two methods: start to palpate from RLQ likeliver edge with just R handbut then as get closerreach with L handaround to pt's L ribcage and pullwhile continuing advancing with Rhand. 
• Assess spleen characteristics [these also help differentiate from kidney]:
  • Size
  • Shapenotch vs. no notch.
  • Percussion dullness vs. not.
  • Moves on respiration vs. not.

Palpate kidneys

• Dr's L heel of hand slipped under pt's R loinL fingers under R back.
• R hand held over RUQ.
• Dr flexes L MCPs in renal angle.
• Dr R hand feels strike as kidneys float anteriorly. 
• Repeat for other side.

Auscultate stomach

• Perform on empty stomach.
• Stethoscope on epigastrium.
• Then shake both iliac crests. 
• While shakinglisten to splash from retained fluid.
• Audible splash called "succussion splash" (ulcer or gastric CA).

Palpate pancreas

• Palpate for a roundfixedswelling above umbilicus that doesn't movewith inspiration (pseudocystacute pancreatitisCA in thin pt).

Palpate aorta

• Palpate in midlinesuperior to umbilicus.
• Dr's 2 fingers on outer margins of aortawatch if if fingersdiverge (AAA).
• Normally felt in thin pt.

Palpate bowel

• Sigmoid usu. palpable in severe constipation.
• Whether indents (feces) or doesn't indent (masses).
• Sometimes can feel CAmegarectum.

Palpate bladder

• Ask pt when last urinatedand whether was complete emptying..
• Usually palpable if fullusually not palpable if empty.
• Look for palpableempty bladder (swelling).

Palpate testes

• Atrophy (liver dz).

Abdomen: percussion

• Liver border for loss of of dullness (necrosisperforated bowel).
• Spleen for splenomegaly.
• Kidneys.
• Bladder for enlarged bladderpelvic mass.
• Percuss masses. See Examining AMass Reference.

Abdomen percussion: ascites

• Shifting dullness:
  • The Dr's percussing finger placed verticallyso Dr's finger pointingtoward pt's legs.
  • Starting at midlinepercuss laterally to dullness on L flankand marksite of dullness with non-permanent marker.
  • Roll pt towards Dr.so pt now laying on R side.
  • Pt stays lying on R side for 30minthen repercuss while still lying onR side.
  • Ascites present if the dullness has moved medially (ie the point ofdullness is now resonant).
  • Optionally: percuss laterally on both R and L flanksand mark bothbefore rolling ptso can assess them both moving.
• Dipping: 
  • Flex MCP joint fast to displace fluid and palpate a mass.
• Fluid thrill:
  • Dr. puts hands on each of pt's flanks.
  • If obesept places pt's lateral edge of handvertically on midline atumbicus.
  • Dr. flicks hand on right flankby quickly flexing MCPs.
  • Ascites if Dr feels resulting thrill on left flank.

Abdomen: auscultation

• Below umbilicus to assess bowel sounds for:
  • Rushing sound called "borborygmi" (diarrhea).
  • No sound for 3 minutes (ileusparalysis).
  • "Tinkling" sound (obstructed bowel).
• Above umbilicus for:
  • AAA bruit.
  • Venus hum [blood flowing in caput medusae] (portal HTN).
• R and L above umbilicus for renal artery stenosis.
• Over liver for:
  • Friction rub [grating during breathing] (peritonitisFitz-Hugh-Curtisothers).
  • Bruit (CAalcoholic hepatitis).
• Over spleen for splenic rub (splenic infarct).

Groinherniasrectal

• Palpate lymph nodes: See InguinalNodes.
• See Hernia Examination.
• See Rectal Examination.

Legs

• Edema.
• Bruising.
• Tuboeruptive xanthomata [yellow deposists on elbowsknees] (Type IIIhyperlipidemia).
• If chronic liver dzSee NeurologicalExamination.
• Toenails and foot showing same symptoms as Fingernailsand Hands.

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