ABSOMEN - SHORT CASE SCHEME
1. Intro
2. consent
3. position
4. exposure
5. General look
6. INSPECT
7. LIGHT PALPATION
8. DEEP PALPATION
9. VISCERAL PALPATION
10. PERCUSSION and SHIFTING DULLNESS
11. BOWEL SOUNDS
12. INGUINAL NODES
13. RELEVANT
• RELEVANT
1. Chest - Gynecomastia, Spider, hair, sternal tenderness
2. Face - appearence, cachexia, Puffy
3. Eyes - Anemia, Jaundice
4. Mouth - Jaundice, Cyanosis, Cheilosis, oral ulcers
5. Neck - JVP, Lymphadenopathy
6. Hands - Palmar erythema, Wasting, bruising, Nails koilo or leukonychia,
Rheumatological,
7. Precordium - specially p2
8. Legs - Edema
9. Back of chest - Crepts or Effusion
10. Nodes
• OFFER DRE AND GROIN
• – Abdomen short case we can approach in two different ways
• System based
1. Hepatic abdomen
2. Renal Abdomen
3. hematological Abdomen
4. Cardiac Abdomen
5. Obstructive Jaundice
• Finding based
1. Isolated Splenomegaly
2. Splenomegaly with Anemia
3. Splenomegaly with Jaundice
4. Splenomegaly with Anemia and Jaundice
5. Ascites with Splenomegaly
6. Hepatosplenomegally with Ascites ( with CLD stigmata and without CLD
stigmata)
7. Hepatosplenomegally without Ascites ( with CLD stigmata or without CLD
stigmata)
8. Palpable Mass/Kidney
HEPATOMEGALY
• Non Tender Hepatomegally
1. Young age
• Infective ( Typhoid, Malaria)
• Lymphoproliferative and myeloproliferative
• Polycystic Disease
2. Old Age
• HCC
• Liver Mets
• Tender Hepatomegally
1. SOFT
• Acute hepatitis
• abscess
• Alcoholic Hepatitis
• budd Chiari, CCF
2. HARD
• hcc
• mets
• Non tender + Jaundice
• Autoimmune
• PBC
• HFE
• Lymphoma
• HCC
• METS
• CLL
• *Hepatomegaly with lymphadenopathy and anemia
• Hematological - Lympho proliferative ( lymphoma, all )
• Infection ( TB, HIV, IMN)
• ISOLATED Hepatomegaly smooth
• NASH
• ASH
• HFE
• PBC
• Amyloidosis and Sarcoidosis
• ISOLATED but Nodular
• Cystic
• Cirrhosis
• HCC
SPLENOMEGALY
Splenomegaly for exam purpose
• in all cases, apply the mnemonic PHIH
1. Portal HTN
2. Hematological ( Myeloproliferative, Lympho proliferative )
3. Chronic Infection ( Malaria, typhoid, kala azar, TB )
4. Hemolytic ( Hereditary, Autoimmune, Hematological )
• – RELEVANT examination needed to rule in or rule out DDs
1. Stigmata of CLD
2. Anemia
3. Jaundice
4. Lymphadenopathy and sternal tenderness
5. Temperature
• Isolated Splenomegaly
• Lymphoproliferative and myeloproliferative
• Hemolytic Anemia
• chronic infection
• Splenomegaly with Anemia
• Hemolytic Anemia
• Myeloproliferative
• Chronic Infections
• Splenomegaly with jaundice
• lymphoproliferative and myeloproliferative
• hemolytic Anemia
• PVT
• Chronic infection
• Splenomegaly with Anemia and Jaundice
• portal htn
• hemolytic
• hematological
• chronic infection
• pernicious anemia
HEPATOSPLENOMEGALY
• Relevant that will help to rule in and rule out
1. CLD stigmata
2. Anemia
3. Jaundice
4. Lymphadenopathy
• Hepatosplenomegaly with Anemia
• CLD with portal hypertension
• lympho proliferative
• Myeloproliferative
• Chronic infection - Malaria, TB, Brucellosis
• Hemolytic Amemia
• Hepatosplenomegaly With Lymphadenopathy
• Hematological - lympho proliferative, lymphoma
• infections - TB, HIV, brucellosis, IMN
• ? Myeloproliferative, Sarcoid, Cystic disease
• hepatosplenomegally with ascites
1. BUT no Peripheral stigmata of CLD
• disseminated TB
• CCF
• Budd chiari
• Lymphoma
• metastatic liver disease
2. With stigmata of CLD*
• NASH
• ASH
• PBC
• HCC
• Hemochromatosis
ASCITES
• – Possible causes
1. Portal hypertension ( cirrhotic or non cirrhotic)
2. Renal ( nephrotic)
3. Cardiac ( Pulmonary Hypertension, corpulmonale, CCF)
4. Hematological malignancies
5. Rheumatological causes/ Connective tissue diseases
6. Peritoneal causes
• – Thought Process
• In abdomen, focus to find spleen, liver, masses, kidneys, paraaortic nodes.
• – Then in relevant examination, look for
1. Hands ( stigmata of CLD, stigmata of connective tissue diseases)
2. Neck ( JVP and Lymph nodes)
3. Face ( Rash, wasting, periorbital puffiness)
4. Auscultate Precordium ( loud p2, Murmur)
5. front of chest ( Gynaecomastia, spider, Sternal tenderness)
• If we find nothing, then cause is in the peritoneum
• Ascites with Splenomegaly
• Portal hypertension ( could be cirrhotic, could be non cirrhotic)
• SLE, RA
• Lymphoma
• Ascites and Lymph nodes
• Disseminated TB
• SLE
• Malignancy with peritoneal mets
• Lymphoma
• HIV
• Ascites with splenomegaly and Lymph Nodes
• Disseminated TB
• Lymphomas
• Portal HTN with cirrhosis and HCC
• SLE
• Ascites + Hepatosplenomegally
1. without cld
• Lymphoma and hematological
• malignancy
• cardiac
• disseminated tb
• CTD
2. stigmata of CLD
• NASH
• ASH
• PBC
• HCC
• Hemochromatosis
• only ascites . no hepatosplenomegally
1. Peritoneal ( TB, Carcinomatosis, Pancreatic Ascites)
2. Portal Hypertension
3. Renal
4. Cardiac/Respiratory
5. CTD
JAUNDICE
• Isolated Jaundice - ( most of these are also causes of Fluctuating/Recurrent
jaundice)
• Hepatitis
• Cholecystitis
• Hemolytic
• CBD stone, Stricture
• Gilbert
• Jaundice + Tender Hepatomegaly
• Acute viral Hepatitis
• Liver abscess
• Alcoholic
• Congestive hepatomegaly
• Bud chiari
• HCC
• Mets
• Jaundice + Anemia ( PRE HEPATIC )
• RBC Membrane Dwfects ( HS, HE )
• Hb-Pathies ( Thalassemia, Sickle)
• Enzymes ( G6PD, Pyruvate kinase Deficiency)
• Autoimmune Hemolysis
• Post infectious
• Lymphoproliferative
• Post transplant
• Drugs
• Prosthetic valves
• Primary autoimmune (no cause)
• – CLUES
1. Young, Frontal bossing, Malar prominence, Jumbling teeth,
2. Rash, Alopecia, Hirsuitism Stigmata of autoimmune like rash etc, Other
Autoimmune condition - Vitiligo, Thyroid,
3. Scar mark ( Splenectomy, organ Transplant)
4. Lymph Node Palpation
5. Spleen Liver
• Colour - ( Usual interpretation, but not a rule)
• Lemon green - Prehepatic
• Yellow Orange - Hepatic
• Dark Olive - Obstructive
