Demonstration of asterixis of hand (Fig. 5D.11): Asterixis is tested by extending the arms,

dorsiflexing the wrists, and spreading the fingers to observe for the “flap” at the wrist. The flap is due

to irregular myoclonic lapses of posture caused by involuntary 50–200 ms silent periods appearing in

tonically active muscles.

Demonstration of asterixis of leg (Fig. 5D.12): Testing asterixis at the hip joint involves keeping the

patient in a supine position with knees bent and feet flat on the table, leaving the legs to fall to the sides.

Negative myoclonus of the lower limbs at the hip joints repetitively occurs and is appreciated by looking

at the knees.

Fig. 5D.11: Demonstration of asterixis in hands.

Fig. 5D.12: Demonstration of flapping tremors in legs—on leaving the legs to fall apart a negative

myoclonus can be noticed by observing the knee.

Causes of asterixis (flapping tremor)

Bilateral asterexis Unilateral asterexis

Metabolic:

Liver failure, azotemia, respiratory failure

Sedatives: Benzodiazepines, barbiturates

Focal brain lesions at:

Thalamus

Corona radiata

Anterior cerebral artery territory

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Anticonvulsants: Phenytoin (phenytoin flap), carbamazepine, valproic acid, gabapentin

Antipsychotics: Lithium

Antibiotics: Ceftazidime

Others: Metoclopramide

Dyselectrolytemia: Hypomagnesemia, hypokalemia

Bilateral structural brain lesions

Primary motor cortex

Parietal lobe

Cerebellum

Midbrain

Pons

Signs Pointing the Etiology of Cirrhosis

Signs Etiology of cirrhosis

Parotid enlargement, dupuytren’s contracture Alcohol

Tattoo marks, jaundice Hepatitis B/C

Metabolic syndrome NASH

Xanthoma, xanthelasma, obstructive jaundice Primary biliary cirrhosis

Skin hyperpigmentation, organomegaly, diabetes Hemochromatosis

Emphysema and cirrhosis Alpha-1 antitrypsin deficiency

Long standing heart failure Cardiac cirrhosis

Tender liver with absent abdominojugular reflux Budd–Chiari syndrome

Arthritis, skin changes, nephritis Autoimmune

Deforming arthritis on treatment Methotrexate induced

Kayser–Fleischer (KF) ring on cornea Wilson’s disease

Signs of Chronic Alcoholism

Parotid swelling

Dupuytren’s contracture.

ORAL CAVITY EXAMINATION

A torch, tongue depressor, and gloves (for palpation) are needed.

Lips

Angular stomatitis, cheilitis—iron deficiency, riboflavin deficiency

Herpes labialis

Circumoral pigmentation

Addison’s disease.

Teeth

Caries

Color/staining—tobacco, tetracycline (yellow), fluorosis (chalk white), red/erythrodontia (porphyria)

Shape of teeth—peg-shaped incisors and moon molars in congenital syphilis, widely spaced teeth in

acromegaly.

Gums

Gingivitis

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Gum bleeding—scurvy, vitamin K deficiency, acute leukemia, thrombocytopenias, coagulopathies,

gingivitis

Gum hypertrophy

Drugs—phenytoin, nifedipine, cyclosporine

Pregnancy

Acute myeloid leukemia (AML)—M4, M5

Chronic gingivitis

Tumors—epulis

Ulcers and pyorrhea.

Tongue

Macroglossia—acromegaly, myxedema, amyloidosis, down syndrome

Coated tongue—typhoid, candidiasis

Color of tongue

Pale—anemia

Red beefy—B12 deficiency

Magenta—B2 deficiency

Bluish—cyanosis

Yellowish—jaundice

Strawberry—scarlet fever

Dry tongue—dehydration, anticholinergics, diabetes

Leukoplakia, hairy leukoplakia

Fissuring

Geographic tongue—desquamated epithelium

Median rhomboid glossitis.

Buccal Mocosa

Ulcers

Pigmentation

Candidiasis

Koplik spots.

Palate/Pharynx

Ulcers

Postnasal drip

White patch of tonsil:

Candidiasis

Diphtheria

Agranulocytosis

Infectious mononucleosis

Follicular tonsillitis

Vincents angina

Malignancy

Tonsilolith.

Causes of oral ulcers

Aphthous ulcer

Infections Gastrointestinal disease

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Herpetic stomatitis

Chickenpox

Hand, foot, and mouth disease

Herpangina

Infectious mononucleosis

Human immunodeficiency virus (HIV)

Acute necrotizing gingivitis

Tuberculosis

Syphilis

Candida

Celiac disease

Crohn’s disease

Ulcerative colitis

Connective tissue disorders

Lupus erythematosus

Behçet’s syndrome

Reiter’s disease

Dermatological disorders

Lichen planus

Pemphigus

Pemphigoid

Erythema multiforme

Dermatitis herpetiformis

Linear immunoglobulin A (IgA) disease

Epidermolysis bullosa

Malignancy

Drugs—cytotoxic agents, antibiotics

Radiation

Trauma

Pigmentation of oral mucosa

Addison’s disease

Peutz–Jeghers syndrome

Hemochromatosis

Heavy metal—lead (Burtonian line)

Acanthosis

Drugs like hormones, oral contraceptives, cyclophosphamide, busulfan, bleomycin, clofazimine, chloroquine

Pregnancy

Laugier–Hunziker syndrome

Nevi

Malignant melanoma

SYSTEMIC EXAMINATION

The order of examination of abdomen is preferably done—Inspection→Auscultation→Palpation and

Percussion.

(As the auscultatory findings might change post-palpation and percussion)

Inspection

Position of patient:

Most of the gastrointestinal tract (GIT) examination (inspection) is done in supine position (standing

position is adapted for examination of dilated veins).

Expose from chest to mid-thigh preferably.

Relax abdominal wall muscles by flexing the thigh with arms by the side of the patient.

Shape of abdomen:

Shape Condition seen

Scaphoid Normal

Generalized abdominal distention

[The 7 F’s]

Fluid

Fat

Flatus

Feces

Fetus

Full bladder

Fatal neoplasm

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Localized abdominal distention Indicates a organomegaly or mass

Fullness of flanks indicates Free fluid

Skin over the abdomen:

Findings Seen in

Discoloration Pancreatitis

Cullen’s sign—discoloration around umbilicus

Grey turner’s sign—discoloration over the flanks

Ecchymosis or purpura Coagulopathy

Striae atrophica or gravidarum (white

or pink wrinkled linear marks)

Recent change in size of the abdomen

Pregnancy

Ascites Wasting diseases

Severe dieting

Purple striae Cushing’s syndrome (pigmented)

Linea nigra Pigmentation of the abdominal wall in the midline below the umbilicus, seen in

pregnancy

Erythema ab igne Brown mottled pigmentation produced by constant application of heat, usually a

hot water bottle or heat pad, on the skin of the abdominal wall.

It is a sign of chronic pain as in chronic pancreatitis.

Paracentesis marks Indicate diagnostic/therapeutic ascitic tapping

Sinuses Tuberculosis

Crohn’s disease

Stretched shiny skin Indicates tense ascites

Scars (Fig. 5D.13):

Few commonly employed incisions over the abdomen as showed in Figure 5D.13.

Quadrants of abdomen (Fig. 5D.14):

Abdomen can be grossly divided into four quadrants as shown in Figure 5D.14 with help of

transumbilical plane and median plane.

Fig. 5D.13: Surgical incisions commonly employed.

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Fig. 5D.14: Four quadrants of the abdomen.

Regions of abdomen (Fig. 5D.15):

Abdomen can also be divided into nine regions with the help of right and left midclavicular line,

transtubercular plane, and subcostal plane as shown in Figure 5D.15.

Umbilicus:

Finding Seen in

Slightly retracted and inverted Normal

Everted Suggestive of tense ascites

Umbilical hernia Indicate lax abdominal wall with gross ascites

Umbilical node Sister Mary Joseph node seen in metastasis from GIT cancers

Normally,

Ratio decreased—umbilicus is displaced up (smiling

umbilicus)

Pelvic mass

Ovarian tumors

Ratio increased—umbilicus displaced down (weeping

umbilicus)

Upper abdominal mass

Ascites

Spinoumbilical distance (distance between ASIS to

umbilicus)

Normally equidistant

Shift of umbilicus to one side indicates tumors/mass originating

from other side

Movement with Respiration

Method of examination: Shine a light, across the patient’s abdomen, and watch for the abdominal wall

movements.

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