• Environment, general appearance,

• Nails, Hands, arms

• Eyes, mouth, neck, chest ,back

• Abdomen inspection

• Abdomen palpation: general, liver, gallbladder, spleen, kidneys, stomach,

• pancreas, aorta, bowel, testes

• Abdomen percussion, ascites, auscultation

• Groin, hernias, rectal, legs

Environment

• NG tube.

• Feeding tube.

• Cans of special food.

General appearance

• Colors:
  . Anemic (iron malabsorption, hemorrhage, CA).
  . Jaundiced (liver dz).
  . Hyperpigmented (hemochromatosis).
  
  Hydration and nutrition.

• Weight loss vs. gain, wasting.

• Shocked.

• Postural hypotension.

Nails

• CLUBBING (UC or Crohn's, Biliary cirrhosis, GI malabsorption).

• 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).

Hands

• Asterixis (PSE 2° to alcoholism):
  . Pt. stretches out hands in policeman's stop position, fingers spread out.
  . Coarse flapping tremor, "liver flap", is seen.

• Pallor of palmar creases (anemia 2° to blood loss, malabsorption).

• Palmar erythema (cirrhosis).

• Dupuytren's contracture [fibrosis, contracture of palm's fascia, usu contracting ring finger] (alcoholism, manual labor).

• Palmar xanthomata [yellow deposists on palm of hand] (Type III hyperlipidemia).

• Tendon xanthomata [yellow deposits on dorsum of hand, arm] (Type II hyperlipidemia).

Arms

• Scratch marks (itch from jaundice).

• Spider naevi (alcoholism).

• Bruising (clotting factors 2° to liver damage).

• Tuboeruptive xanthomata [yellow deposists on elbows, knees] (Type III hyperlipidemia).

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's, coeliac 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 (smoke, spirits, sepsis, syphilis, sore teeth).
  . Atrophic glossitis [withered tongue] (deficiencies, Plummer-Vinson).
  . Macroglossia (B12 deficiency).

Neck, chest, back

• Cervical nodes:
  . Supraclavicular nodes for Virchow's node (lung CA, GI malignancy).
  
  Gynecomastia (chronic liver dz).

• Hair loss (chronic liver dz).

• Back: neurofibromas.

Abdomen: inspection

• Pt is supine, abdomen visible from nipples to pubic symphysis.

• Scars.

• Stoma from surgery, trauma.

• PEG (dysphagia, usu. 2º to neurological damage, like stroke).

• Distension (fat, fetus, feces, flatus, fluid, full-sized tumors).

• Local swellings (enlarged organs, hernia).

• Pulsations (AAA).

• Peristalsis visible (thin person, intestinal obstruction).

• Skin: 
  . Herpes zoster (abdominal pain).
  . Grey-Turner's sign [discolored skin] (acute pancreatitis).

• Striae:
  . Regular striae (ascities, pregnancy, weight loss).
  . Purple, wide 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 pancreatitis, extensive hemoperitoneum).

• Groin: brown freckles (Peutz-Jeghers).

• Squat to pt's stomach level, and watch for asymmetrical movement during breathing (mass, large liver).

Palpate general abdominal

• Warm hands.

• Ask pt if any part tender: examine that last.

• Abdominal muscles relaxed, pt bends knees if necessary.

• Light palpation.

• Deep palpation.

• Note rigidity, rebound tenderness, involuntary guarding (peritonitis).

• Record mass characteristics.

• Distinguish abdominal wall mass from intrabdominal mass:
  . Pt folds arms and sits 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 RLQ, parallel to costal margin.
  . Ask pt. to breathe slowly.
  . During each inspiration, see if liver edge strikes radial edge of index finger.
  . During each expiration, Dr's hand moves superiorly 2cm.

• Palpate liver surface, edge:
  . Hard vs. soft.
  . Regular vs. irregular.
  . Tender vs. not.
  . Pulsatile (tricuspid incompetence) vs. not.

• Find top border by percussing down R midclavicular line [normal: 5th rib in midclavicular line].

• Calculate span [normal span: 12.5cm].

Palpate gallbladder

• Dr's fingers placed perpendicular to R costal margin near midline, then moved 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 posterolaterally, below pt's L ribs, compressing on rib cage.
  . Dr's R hand below pt's umbilicus, parallel to L costal margin.
  . Advance R hand superiorly to L costal margin.
  . 1.5x-2x enlarged spleen is palpable.
  . If miss spleen, roll pt. towards Dr. (so pt lies on pt's R side) and repeat palpation.

• Alternatively: palpate like liver edge with just R hand, starting from RLQ diagonally over to LUQ.

• Alternatively: combine the two methods: start to palpate from RLQ like liver edge with just R hand, but then as get closer, reach with L hand around to pt's L ribcage and pull, while continuing advancing with R hand. 

• Assess spleen characteristics [these also help differentiate from kidney]:
  . Size
  . Shape, notch 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 loin, L 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 shaking, listen to splash from retained fluid.

• Audible splash called "succussion splash" (ulcer or gastric CA).

Palpate pancreas

• Palpate for a round, fixed, swelling above umbilicus that doesn't move with inspiration (pseudocyst, acute pancreatitis, CA in thin pt).

Palpate aorta

• Palpate in midline, superior to umbilicus.

• Dr's 2 fingers on outer margins of aorta, watch if if fingers diverge (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 CA, megarectum.

Palpate bladder

• Ask pt when last urinated, and whether was complete emptying..

• Usually palpable if full, usually not palpable if empty.

• Look for palpable, empty bladder (swelling).

Palpate testes

• Atrophy (liver dz).

Abdomen: percussion

• Liver border for loss of of dullness (necrosis, perforated bowel).

• Spleen for splenomegaly.

• Kidneys.

• Bladder for enlarged bladder, pelvic mass.

• Percuss masses.

Abdomen percussion: ascites

• Shifting dullness:
  . The Dr's percussing finger placed vertically, so Dr's finger pointing toward pt's legs.
  . Starting at midline, percuss laterally to dullness on L flank, and mark site of dullness with non-permanent marker.
  . Roll pt towards Dr., so pt now laying on R side.
  . Pt stays lying on R side for 30min, then repercuss while still lying on R side.
  . Ascites present if the dullness has moved medially (ie the point of dullness is now resonant).
  . Optionally: percuss laterally on both R and L flanks, and mark both before rolling pt, so 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 obese, pt places pt's lateral edge of hand, vertically on midline at umbicus.
  . Dr. flicks hand on right flank, by 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 (ileus, paralysis).
  . "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] (peritonitis, Fitz-Hugh-Curtis, others).
  . Bruit (CA, alcoholic hepatitis).

• Over spleen for splenic rub (splenic infarct).

Groin, hernias, rectal

• Palpate lymph nodes

• Palpate hernia.

• Palpate Rectal.

Legs

• Edema.

• Bruising.

• Tuboeruptive xanthomata [yellow deposists on elbows, knees] (Type III hyperlipidemia).

• If chronic liver dz, See Neurological Examination.

• Toenails and foot showing same symptoms as Fingernails and Hands.