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Go Go Subscribe to Updates Enter your details to receive occasional helpful emails and course information that we hope will help in your exams. * indicates required Name * Email * Exam Date* Abdominal Abdominal Cardiovascular Cardiovascular Communication Communication Development Development History History Musculoskeletal Musculoskeletal Neurology Neurology Respiratory Respiratory Video Station Video Station War Stories War Stories Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin... 1 of 16 28/06/2014 15:34 Abdominal Examination Guide General 1. On approaching a child: Look around room: Any medications / nutritional drink lying on the table View from Distance Nutritional status: I would like to plot his height and weight on a growth chart ? Failure to thrive Well/ unwell: conscious level (hepatic coma) 2. Dysmorphic features (mucopolysaccharidoses) 3. Skin Colour (sallow / yellow / green / brown) - Increased body hair / facial hair (ciclosporin) - Skin rashes: Dermatitis herpetiformis , Telangiectasia (Osler Weber Rendu) - Perioral freckling (Peutz-Jeghers) - Pigmentation: Caf-au-lait spots (Neurofibromataosis 1 GI stromal tumours palpable abdominal mass), Incontinentia pigmentosa 4. Nutritional support Nasogastric tube Total parenteral nutrition PEG tube
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Subscribe Subscribe Popular Sections Cardiovascular Examination Guide Neurology Videos MRCPCH Courses History Taking Videos Abdominal Examination Guide War Stories Abdominal Videos How to use this site Video Station RCPCH Information Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin... 2 of 16 28/06/2014 15:34 5. Peritoneal dialysis catheter 6. Urinary catheter spina bifida 7. Older child in nappies incontinent (neuro/ behavioural) Hands: Finger clubbing (Cystic fibrosis, liver disease, Inflammatory bowel disease, coeliac disease) Koilonychia (Iron deficiency anaemia) Leuconychia (Cirrhosis)
Palms: Palmar erythema (chronic liver disease) Pallor of palmar crease Hepatic flat (Liver failure, renal failure, CO2 retention)
Arms Tuberous (elbow) / tendon xanthomas (hypercholesterolaemia) Bruising (Liver dysfunction, haematological disorders) Contribute! Do you want to help build the best site for MRCPCH Clinical revision? Click here for more information. Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin... 3 of 16 28/06/2014 15:34 Scratch marks Spider naevi
Abdomen Inspection: 1. Shape 2. ? Distension (central flank?, generalised/ localised, symmetrical?) - 5Fs : Faeces (Hirschsprung constipation), flatus, fat, fluid (ascities, nephrotic syndrome), fetus 3. Obvious masses 4. Scars: Renal angle scars / Laparoscopic surgery / Liver Biopsy Groins inguinal hernia repair, renal transplant (will also be palpable mass) Below right subcostal margin (Kochers incision) think cholecystectomy, especially in sickle cell disease, any liver procedure, e.g. hemi-hepatectomy for hepatoblastoma Rooftop scar liver transplant Transverse upper abdominal incision repair of congenital diaphragmatic hernia more common on the left Upper abdominal midline incision Nissens fundoplication Small right upper transverse incision Ramstedts pyloromyotomy Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin... 5 of 16 28/06/2014 15:34 Umbilicus consider gastroschisis or exomphalos, umbilical hernia repair Laparoscopy scars more common, very small and multiple (often one at umbilicus) Lateral thoracolumbar incision nephrectomy 5. Striae 6. Caput medusae (Blood flows away from umbilicus) Differentiate from superior vena cava obstruction (flows inferiorly)/ Inferior vena cava obstruction (flows superiorly) 7. Other: Stomas: Ileostomy vs Colostomy ; Mucous fistula Caecostomy tube for entergrade enemas in children with chronic constipation (MACE procedure Malone antegrade colonic enema) Mitrofanoff, Peritoneal dialysis catheter 8. Get patient to blow tummy up / flatten tummy 9. Get patient to raise head : hernia / Divarification of recti Palpation Patient should be on a supine position. However, if patient has gross ascites, you might want to ask him whether it is comfortable for him to lie flat as he might have difficulty breathing if lying flat. Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin... 6 of 16 28/06/2014 15:34 Be sensitive. Tell the child: I am going to feel your tummy. Please let me know if you feel any pain or if you want me to stop, ok? . Whist palpating, look at the childs face. If the childs winced, stop and apologise and ask the child if he is ok. If you are tall or the bed position is low, you might want to kneel down when doing palpation.
1. Superficial palpation Palpate systematically. You may start from left iliac fossa and proceed in the direction above.
2. Deep palpation (palpate deeper for deeper masses. Again, warn the child that you are going to feel deeper and ask him to tell you if he feels any pain. 3. Liver (Palpation + Percussion) Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin... 7 of 16 28/06/2014 15:34 Palpate upwards from right iliac fossa towards right subcostal margin until you feel the liver edge. Ask the patient to take a deep breath and try to feel the liver edge as it descends. If you feel a mass, describe the surface (smooth or nodular) , consistency (hard/ soft) , edge (regular/ irregular) Percuss from right lower quadrant of the abdomen upwards until the sound changes from resonant to dull. This denotes the livers lower border. Then percuss from right upper chest downwards, starting in the midclavicular line at about the 3rd intercostal space. Percuss inferiorly until dullness denotes the livers upper border. Measure the liver span in centimetres
4. Spleen Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin... 8 of 16 28/06/2014 15:34 Palpate from right iliac fossa towards left subcostal margin to feel for spleen. As you reach the left subcostal margin, ask the patient to turn slightly towards you (his right side) , and palpate in the left subcostal area.
5. Kidney Place one hand under the patient in the right flank region and the other hand on top and try to ballot the kidney between the two hands. Repeat for the left side.
How to differentiate between liver, spleen and kidney Liver Spleen Kidney Dull Dull Resonant Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin... 9 of 16 28/06/2014 15:34 Moves with respiration Moves with respiration Does not move with respiration Notch Ballotable Cannot get above it Cannot get above it Can get above it Right hypochondrium Left hypochondrium
Other (Mention that I would also like to examine the patients.) Hernia orifices 1. External genitalia 2. Back and perianal area 3. Inspect stool 4. For renal examination: BP 1. Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin... 10 of 16 28/06/2014 15:34 Urinalysis 2. Assess for signs of steroid toxicity 3.
Author: Dr. Katherine Fawbert and Dr. Huey Miin Lee
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