History
- • Pain — SOCRATES
- • GI: nausea, vomiting, bowel habit, bleeding, jaundice
- • GU: dysuria, haematuria, frequency, menstrual
- • Weight loss, anorexia, fevers, travel, alcohol
Examination sequence
- • WIPE — flat, expose nipples to knees (cover groin)
- • End-of-bed: cachexia, jaundice, drips, drains, stoma
- • Hands: clubbing, leuconychia, koilonychia, palmar erythema, Dupuytren's, asterixis
- • Face: jaundice, anaemia, glossitis, dentition, telangiectasia
- • Neck: Virchow's node, JVP
- • Chest: spider naevi, gynaecomastia
- • Abdomen: inspect (distension, scars, hernias), palpate (light/deep, organomegaly, masses)
- • Percuss liver, spleen, shifting dullness, fluid thrill
- • Auscultate bowel sounds, bruits, hernial orifices, external genitalia, PR (state intention)
Positive findings
- • RUQ tenderness + Murphy's — cholecystitis
- • Generalised distension + shifting dullness — ascites
- • Splenomegaly: notched, descends from LUQ, dull, can't get above
- • Pulsatile expansile mass — AAA
Differentials
- • Hepatomegaly: alcohol, CCF, malignancy, viral hepatitis
- • Splenomegaly: portal HTN, haematological, infection
- • Ascites: cirrhosis (SAAG ≥1.1), malignancy, HF
Viva questions
Q. Causes of hepatosplenomegaly?
A. Myeloproliferative disorders, lymphoma, infections (malaria, kala-azar, EBV), portal HTN, storage disorders.
Q. How to confirm ascites?
A. Shifting dullness, fluid thrill, USS for small volumes.
Common mistakes
- • Forgetting to ask about pain before palpating
- • Not warming hands
- • Skipping hernial orifices / external genitalia / PR
