In an OSCE the candidate may be asked to perform a 'Focused Examination' on a jaundiced patient. The following article highlights the steps one should follow when carrying out this exam and important findings to look out for.
1) Consent, explain procedure, wash hands, chaperone and specific areas of tenderness
2) General inspection
- From end of bed:
State of patient, breathing rate, perspiration, distress, mental state (Wernicke-Korsakoff syndrome), obvious scars from previous surgery. Any distension throughout body
Grey tinge associated with haemochromatosis
Weight loss obvious, associated with ca pancreas or cholangiocarcinoma
Evidence of pruritis (hyperbilirubinaemia)
Anaemia due to excessive haemolysis
Fever, pain and jaundice associated with cholangitis (Charcot’s triad)
- Hands:
Dupuytren’s contractures
Evidence of anaemia
Finger clubbing
- Face:
Temperature for evidence of viral infection
Fetor hepaticus for alcoholic liver disease
Mouth for evidence of EBV and apthous ulcers associated with IBD (can cause PSC)
Anaemia signs in eye, Kaiser flaischer rings and discolouration of the sclera
- Chest:
Evidence of pruritis from hyperbilirubinaemia
RV heave associated with RHF due to liver disease, may also show as an elevated JVP
Spider naevi
Gynaecomastia
- Abdomen:
Distension, for evidence of ascites in liver disease
Caput medusa
3) Palpation:
- Palpate superficially and then deeply, the abdomen. Always ask for areas of tenderness. Determine if any guarding is present, voluntary or involuntary. Elicit rebound tenderness
- Determine size of liver, and also repeat for spleen, as this can be enlarged in budd-chiari syndrome as well as increased haemolysis
- Deep palpation
- Elicit Murphy’s sign, only positive if negative on left side
4) Percussion:
- Percuss for ascites, shifting dullness and fluid thrill. Also percuss to determine extremity of liver as well as spleen
5) Auscultation:
- Absent bowel sounds in generalised peritonitis due to gallstone pancreatitis
- Finish by checking for sacral and pitting oedema (heart failure and liver disease), then by performing a PR and a urine sample
6) Thanks patient
7) Differential diagnosis:
- Hepatitis
- Liver metastasis
- Gallstones
- EBV, CMV
- PBC
- PSC
- Gilbert’s
- Sickle Cell
- Malaria
- Transfusion reaction
- Budd-Chiari syndrome
- Alcoholic liver disease
8) Investigations:
- Urine and stool samples (determines type of jaundice)
- Biochemistry (liver enzymes)
- Haemotology (WCC, Hb, platelets and PTT, amylase levels)
- Ultrasound
- If ultrasound is negative, MRCP or ERCP
Author:
Mr Adnan Darr MBCHB, BSc, MSc, MRCS | Speciality:
Examination | Date Added:
02/11/2011
|