Editors: Thomas, James; Monaghan, Tanya Title: Oxford Handbook of Clinical Examination and Practical kills, !

st Edition Co"yright #$%&&' Oxford (ni)ersity Press * Table of Contents * Cha"ter + , The -bdomen Cha"ter + The -bdomen P.%%% -""lied anatomy The abdomen incl/des the "erine/m, external and internal genitalia and the ing/inal regions. Ho0e)er, these com"onents are disc/ssed in Cha"ters !% and !1. 2o/ndaries The abdomen is defined as the region lying bet0een the thorax abo)e and the "el)ic ca)ity belo0. The anterior abdominal 0all is bo/nded by the 'th to !%th costal cartilages and the xi"hoid "rocess of the stern/m s/"eriorly and the ing/inal ligaments and "el)ic bones inferiorly. The abdominal ca)ity is se"arated from the thoracic ca)ity by the dia"hragm. There is no s/ch delineation, ho0e)er, bet0een the abdomen and the "el)is and, as a conse3/ence, definitions )ary. -bdominal contents The abdomen contains str/ct/res 0hich form "art of 4/st abo/t e)ery body system. The digesti)e organs of the oeso"hag/s, stomach, small intestine, large intestine and the associated organs 5li)er, gall bladder and biliary system, exocrine "ancreas6 all lie 0ithin the abdomen. The endocrine "ortion of the "ancreas, the adrenal glands and gonads re"resent the endocrine system. 7rom the cardio)asc/lar system the abdominal aorta 0ith its im"ortant branches to the li)er, s"leen, intestine, kidneys, and lo0er limbs. The imm/nological system is re"resented by the s"leen. The m/lti"le lym"h nodes s/rro/nding the aorta and intestines and the M-8T tiss/e 0ithin the intestine itself. The 0hole of the /rinary system is "resent 5kidneys, /reters, bladder, and /rethra6. 9t is 0orth remembering that, m/ch like the thorax, the abdomen is lined by a rather thin layer of membrano/s tiss/e: the "eritone/m. This is a do/ble lining:;<the :;="arietal:;> "eritone/m co)ers the internal s/rface of the abdominal 0alls 0hilst the :;=)isceral:;> "eritone/m co)ers the organs. 2et0een the t0o layers 5the :;="eritoneal ca)ity:;>6 is a small amo/nt of fl/id 0hich acts a l/bricant allo0ing the abdominal contents to mo)e against each other as the body changes "osition or, for exam"le, as the g/t contorts 0ith "eristalsis. - select fe0 organs lie behind the "eritone/m on the "osterior abdominal 0all. They are the "ancreas, a "ortion of the d/oden/m, the ascending and descending colon and the kidneys. -bdominal regions The anterior abdominal 0all is artificially di)ided into + "ortions for descri"ti)e "/r"oses. ? imaginary lines can be dra0n 5see 7ig. +.!6:;@ ! horiAontal line bet0een the anterior s/"erior iliac s"ines. ! horiAontal line bet0een the lo0er border of the ribs.

% )ertical lines at the mid,cla)ic/lar "oint.

To make life easier, the abdomen can also be sim"ly di)ided into ? 3/adrants by imagining ! horiAontal and ! )ertical line crossing at the /mbilic/s 5see 7ig. +.%6. P.%%1

7ig. +.! The + segments of the anterior abdominal 0all. t/dents sho/ld familiariAe themsel)es 0ith these along 0ith the organs lying in each area.

7ig. +.% The ? 3/adrants of the anterior abdominal 0all. P.%%? Oeso"hageal sym"toms Bys"hagia This is diffic/lty s0allo0ing and is the "rinci"al sym"tom of oeso"hageal disease. 5 ee 2ox +.! for im"ortant ca/ses.6 Chen a "atient com"lains of dys"hagia yo/ sho/ld attem"t to establish:

8e)el of obstr/ction: 0here does the "atient feel the foodDli3/id stickingE Patients can often "oint to a le)el on the chest altho/gh the sensation /s/ally correlates "oorly 0ith the act/al le)el of obstr/ction. Onset: Ho0 3/ickly did the sym"toms emergeE Obstr/ction ca/sed by cancer, for exam"le, may "rogress rather ra"idly o)er a fe0 months 0hereas those 0ith a benign "e"tic strict/re may describe a )ery long history of FOGB and "rogressi)e dys"hagia. Co/rse: intermittentE Present for only the first fe0 s0allo0s 5lo0er oeso"hageal ring, s"asm6E Progressi)e 5cancer, strict/re, achalasia6E olidsDli3/ids: both solids and li3/ids being affected e3/ally s/ggests a motor ca/se 5achalasia, s"asm6. Ho0e)er, if solids are affected more than li3/ids, some "hysical obstr/ction is more likely 5e.g. cancer6. -ssociated sym"toms: heartb/rn 5leads to oeso"hageal strict/res6, 0eight loss, 0asting, fatig/e 5"erha"s s/ggesti)e of cancer6. Co/ghing and choking s/ggest :;="haryngeal dys"hagia:;> d/e to motor dysf/nction 5e.g. motor ne/ron disease ca/sing b/lbar, or "se/dob/lbar "alsy6.

Odyno"hagia This is "ain on s0allo0ing. (s/ally a rather /n"leasant s/bsternal sensation d/ring the s0allo0 and s/ggesti)e of oeso"hageal inflammation 5infecti)e oeso"hagitis:;<candidida, her"es, cytomegalo)ir/s; "e"tic /lceration; ca/stic damage; oeso"hageal "erforation6. Gemember to ask of "otential ca/ses d/ring the BHx. Heartb/rn and acid refl/x -lso kno0n as gastro,oeso"hageal refl/x disease 5FOGB6. 9t is ca/sed by the reg/rgitation of stomach contents into the oeso"hag/s d/e to an incom"etent anti,refl/x mechanism at the gastro, oeso"hageal 4/nction. Ty"ical feat/res ite: mid,line, retrosternal Gadiation: to the throat and occasionally the infra,sca"/lar regions

Hat/re: :;=b/rning:;> -ggra)ating factors: 0orse after meals and 0hen "erforming "ost/res 0hich raise the intra,abdominal "ress/re 5bending, stoo"ing, lying s/"ine6. -lso 0orse d/ring "regnancy. -ssociated sym"toms: Often accom"anied by acid or bitter taste 5acid reg/rgitation6 or s/dden filling of the mo/th 0ith sali)aI 5:;=0aterbrash:;>6

-cid refl/x may be 0orsened by certain foods 5alcohol, caffeine, chocolate, fatty meals6 and some dr/gs 5calci/m channel blockers, anticholinergics6 0hich act to :JK the FOJ s"hincter "ress/re. Hiat/s hernia is another im"ortant ca/se of refl/x sym"toms:;<be s/re to en3/ire abo/t this in the history.

P.%%L Bys"e"sia Commonly kno0n as indigestion. Mery common and "resents as a )ariety of sym"toms incl/ding: (""er abdominal discomfort 2loating

2elching.

No/ sho/ld be on the alert for feat/res s/ggesti)e of a serio/s "athology 5anaemia, 0eight loss, dys"hagia, PG blood loss, melaena, and abdominal masses6. 2ox +.! ome ca/ses of dys"hagia Oral: "ainf/l mo/th /lceration, oral, or throat infections. He/rological: cerebro)asc/lar e)ent, b/lbar and "se/dob/lbar "alsies, myasthenia gra)is.

Bysmotility: achalasia, systemic sclerosis, "resbyoeso"hag/s. Mechanical: "haryngeal "o/ch, oeso"hageal cancer, "e"tic strict/re, other benign strict/res, extrinsic com"ression of the oeso"hag/s 5e.g. large l/ng or thyroid t/mo/r6.

P.%%O Ha/sea, )omiting, and )omit/s Ha/sea and )omiting Ha/seaI: a feeling of sickness:;<the inclination to )omit. 9t /s/ally occ/rs in 0a)es and may be associated 0ith retching or hea)ing. 9t can last from seconds to days de"ending on the ca/se. Momiting 5emesis6: /s/ally follo0s na/sea and a/tonomic sym"toms s/ch as sali)ation. 9t is the forcef/l ex"/lsion of the gastric contents by reflex contractions of the thoracic and abdominal m/scles. The :;=)omiting centre:;> is in the med/lla and is com"osed of many efferent n/clei in serial comm/nication 0ith each other. Chen the entire circ/it is acti)ated by afferent stim/li, the com"lete set of actions re3/ired to ca/se )omiting are triggered. Timing No/ sho/ld be clear on exactly 0hen the )omiting tends to occ/r:;<"artic/larly its relation to meals e.g. )omiting delayed for *! ho/r after meals is s/ggesti)e of gastro,oeso"hageal obstr/ction or gastro"aresis. Early morning )omiting is ty"ical of "regnancy or raised intracranial "ress/re. Hat/re of the )omit/s -ltho/gh /n"leasant, yo/ sho/ld en3/ire abo/t the exact nat/re of any )omited material and attem"t to see a sam"le, if "ossible. 2lood 5haematemesis6

Presence of blood indicates bleeding in the /""er gastrointestinal tract 5oeso"hag/s, stomach, d/oden/m6. - history of bleeding m/st be ex"lored in the context of other abdominal sym"toms. -sk es"ecially abo/t: The amo/nt of blood and exact nat/re of it 5see 2ox +.16. Pre)io/s bleeding e"isodes, treatment and o/tcome 5e.g. "re)io/s s/rgeryE6

Cigarette smoking. (se of dr/gs s/ch as as"irin, H -9Bs and 0arfarin. Gemember to ask abo/t 0eight loss, dys"hagia, abdominal "ain and melaena 5consider the "ossibility of neo"lastic disease6.

2ile -ssess the "resence or absence of bile. Gemember that bile comes largely in % colo/rs:;<the green "igment 5bili)erdin6 often seen to colo/r the )omit/s in the absence of /ndigested food. The yello0 "igment 5bilir/bin6 a""ears as orange, often occ/rring in small l/m"s.II (ndigested food 0itho/t bile s/ggests a lack of connection bet0een the stomach and the small intestine 5e.g. "yloric obstr/ction6. P.%%' 2ox +.% 9m"ortant ca/ses of )omiting -c/te: F9 tract infections 5)iral gastroenteritis e.g. :;=food "oisoning:;> Hor0alk, )iral he"atitis6, systemic bacterial infection, mechanical bo0el obstr/ction, alcohol intoxication, ac/te /""er F9 bleed, /rinary tract infection. Chronic: "regnancy, /raemia, dr/gs 5narcotics, digitalis, amino"hylline, cancer chemothera"y6, gastro"aresis 5diabetes mellit/s, scleroderma, dr/gs6.

Other: "e"tic /lcer disease, motor disorders 5"ost,s/rgery or a/tonomic dysf/nction6, he"atobiliary disease, alcoholism, cancer.

:PQ BonRt forget abo/t central ner)o/s system and )estib/lar "roblems. 2ox +.1 Ca/ses of /""er F9 bleeding Pe"tic /lceration Erosi)e or /lcerati)e oeso"hagitis

Fastritis Marices 5oeso"hagealDgastric6 Fastric and oeso"hageal t/mo/rs Mallory,Ceiss tear Bie/lafoyRs lesion Masc/lar anomalies 5e.g. angiodys"lasia, -M malformation6

Herediatory haemorragic telangectasia Connecti)e tiss/e disorders Masc/litis 2leeding disorders.

2ox +.? Hat/re of haematemesis 8arge )ol/me of fresh, red blood s/ggests acti)e bleeding 5co,incident li)er disease andDor hea)y alcohol intake may s/ggest bleeding oeso"hageal )arices, abdominal "ain and heartb/rn s/ggest a gastric or oeso"hageal so/rce s/ch as a "e"tic /lceration or FOGB6. mall streaks at the end of "rolonged retching may indicate minor oeso"hageal tra/ma at the FOJ 5Mallory,Ceiss tear6.

Coffee,gro/nds: this is the term /sed for blood that has been :;=altered:;> by ex"os/re to stomach acid. 9t a""ears bro0n and in small l/m"s.

P.%%S -bdominal "ain 8ike "ain in any other region, abdominal "ain may "resent in )ery different 0ays and has many different ca/ses. No/ sho/ld establish the site, radiation, se)erity, character, fre3/ency, d/ration, any exacerbating or relie)ing factors, and associated sym"toms. ite 8ike most organs, those in the abdomen cannot be felt directly:;<the "ain is referred to areas of the abdominal 0all according to the organRs embryological origin 5see 7ig. o""osite6. -sk the "atient to "oint to the area affected. They often find this challenging and may indicate a 0ide area. 9n this case, ask them to :;=/se one finger:;> and "oint to the area of maxim/m intensity. :;=(se one finger and "oint to 0here the "ain is 0orst.:;> 2ox +.L ites of abdominal "ain and embryologic origins E"igastric: foreg/t 5stomach, d/oden/m, li)er, "ancreas, gallbladder6 Peri/mbilical: midg/t 5small and large intestines incl/ding a""endix6

/"ra"/bic: hindg/t 5rect/m and /rogenital organs6

- )ery localiAed "ain may originate from the "arietal "eritone/m. E.g. a""endicitis:;<may begin as an /mbilical "ain 5referred from the a""endix6 then :;=mo)e:;> to the right iliac fossa as the inflammation s"reads to the "eritone/m o)erlying the a""endix. Gadiation -sk the "atient if the "ain is felt else0here or if they ha)e any other "ains 5they may not associate the radiated "ain 0ith the abdominal "ain6. ome exam"les incl/de: Gight sca"/la: gallbladder

ho/lder,ti": dia"hragmatic irritation Mid,back: "ancreas.

Character -sk the "atient 0hat sort of "ain it is. Fi)e some exam"les if they ha)e tro/ble b/t be caref/l not to lead the "atient. - co/"le of exam"les incl/de: Colicky: this is "ain that comes and goes in 0a)es and indicates obstr/ction of a hollo0, m/sc/lar,0alled organ 5intestine, gall,bladder, bile d/ct, /reter6. 2/rning: /s/ally indicates an acid ca/se and is related to the stomach, d/oden/m or lo0er end of the oeso"hag/s. -ggra)atingDrelie)ing factors -sk the "atient 0hat a""ears to make the "ain better or 0orse:;<or 0hat they do to get rid of the "ain if they s/ffer from it often. P.%%+

7ig. +.1 Ty"ical sites of "ain according to origin. 7indings ome characteristic "ains: Genal colic: colicky "ain at the renal angles #T loins, 0hich are tender to to/ch, radiating to the groinsDtesticlesDlabia. Ty"ically, the "atient 0rithes aro/nd, /nable to find a "osition that relie)es the "ain. 2ladder "ain: a diff/se se)ere "ain in the s/"ra"/bic region.

Prostatic "ain: a d/ll ache 0hich may be felt in the lo0er abdomen, rect/m, "erine/m or anterior thighs. (rethral "ain: )ariable in "resentation ranging from a :;=tickling:;> discomfort to a se)ere shar" "ain felt at the end of the /rethra 5ti" of the "enis in males6 and exacerbated

by mict/rition. Can be so se)ere that "atients attem"t to :;=hold on:;> to /rine ca/sing yet more "roblemsU

mall bo0el obstr/ction: colicky central "ain associated 0ith )omiting, abdominal distension #T consti"ation. Colonic "ain: as abo)e /nder :;=small bo0el:;> b/t sometimes tem"orarily relie)ed by defaecation or "assing flat/s. 2o0el ischaemia: d/ll, se)ere, constant, right /""er 3/adrantDcentral abdominal "ain exacerbated by eating. 2iliary "ain: se)ere, constant, right /""er 3/adrantDe"igastric "ain that can last ho/rs and is often 0orse after eating fatty foods. Pancreatic "ain: e"igastric, radiating to the back and "artly relie)ed by sitting /" and leaning for0ard. Pe"tic /lcer "ain: d/ll, b/rning "ain in the e"igastri/m. Ty"ically e"isodic at night, 0aking the "atient from slee". Exacerbated by eating and sometimes relie)ed by cons/ming milk or antacids.

P.%1& 2o0el habit Patients sho/ld be asked ho0 often they o"en their bo0els and if this has changed recently. -sk also abo/t the other sym"toms on these "ages. Consti"ation - disorder that can mean different things to different "eo"le. Hormal bo0el habit ranges from 1 timesDday to once e)ery 1 days. :;=Consti"ation:;> is the "assage of stool V1 timesD0eek, or stools that are hard or diffic/lt to "ass. - thoro/gh history sho/ld incl/de: B/ration of consti"ation. tool siAe and consistency.

training, "artic/larly at the end of e)ac/ation. -ssociated sym"toms 5na/sea, )omiting, 0eight loss6. Pain on defaecation. Gectal bleeding. 9nterc/rrent diarrhoeaE 7l/id and fibre intake. Be"ression, lack of exercise.

BHx 5"rescri"tion and o)er,the,co/nter6. Partic/larly codeine, antide"ressants, al/mini/m and calci/m antacids. Metabolic or endocrine diseases 5thyroid disorders, hy"ercalcaemia, diabetes, "haechromocytoma, Hirshs"r/ngRs disease6. He/rological "roblems 5a/tonomic ne/ro"athy, s"inal cord in4/ry, m/lti"le sclerosis6.

Biarrhoea Befined as an increase in stool )ol/me 5*%&&ml daily6 and fre3/ency 51Dday6. -lso a change in consistency to semi,formed or li3/id stool. No/ sho/ld establish the time co/rse since ac/te diarrhoea is s/ggesti)e of infection. -sk es"ecially abo/t: Colo/r, consistency, offensi)e smell, ease of fl/shing. B/ration.

Boes the diarrhoea dist/rb the "atientRs slee"E 9s there any blood, m/c/s, or "/sE -ssociated "ain or colicE 9s there /rgencyE Ha/sea, )omiting, 0eight lossE -ny difference if the "atient fastsE
o o

Ho change in :;=secretory:;> diarrhoea:;<e.g. E. coli, ta"h. a/re/s. Bisa""ears on fasting: :;=osmotic:;> diarrhoea.

7oreign tra)el. Gecent antibiotics.

P.%1! 2ox +.O ome ca/ses of consti"ation 8o0,fibre diet. Physical immobility.

7/nctional bo0el disease. Br/gs 5e.g. o"iates, antide"ressants, al/mini/m, antacids6. Metabolic and endocrine diseases 5e.g. hy"othyroidism, hy"ercalcaemia, hy"okalaemia, diabetes mellit/s, "or"hyria, "haeochromocytoma6.

He/rological disorders 5e.g. a/tonomic ne/ro"athy, s"inal cord in4/ry, m/lti"le sclerosis6. Colonic strict/re. -norectal disease 5e.g. anal fiss/re:;<ca/ses "ain to the extent that the "atient may a)oid defaecating altogether6. Habit/al neglect. Be"ression. Bementia.

2ox +.' ome ca/ses of diarrhoea Malabsor"tion: may ca/se steatorrhoea, a fatty, "ale stool 0hich is extremely odoro/s

and diffic/lt to fl/sh. ee box on ".%11. :JW intestinal motility: hy"erthyroidism, irritable bo0el syndrome 5see belo06. Ex/dati)e: inflammation of the bo0el ca/ses small )ol/me, fre3/ent stools, often 0ith blood or m/c/s. 5e.g. colonic carcinoma, CrohnRs disease, /lcerati)e colitis6. Osmotic: large )ol/me of stool 0hich disa""ears 0ith fasting. Ca/ses incl/de lactose intolerance, gastric s/rgery6. ecretory: high )ol/me of stool 0hich "ersists 0ith fasting. Ho "/s, blood or excessi)e fat. Ca/ses incl/de: gastrointestinal infections, carcinoid syndrome, )illo/s adenoma of the colon, Xollinger,Ellison syndrome, M9PI,secreting t/mo/r.

P.%1% Gectal bleeding and melaena There are many ca/ses of PG blood,loss b/t, as al0ays, a detailed history 0ill hel". Betermine: The amo/nt.
o

mall amo/nts can a""ear dramatic, colo/ring toilet 0ater red.

The nat/re of the blood 5red, bro0n, black6. 9s it mixed 0ith the stool or :;=on:;> the stoolE 9s it s"attered o)er the "an, 0ith the stool or only seen on the "a"erE -ny associated feat/res 5m/c/s may indicate inflammatory bo0el disease or colonic cancer6.

Melaena

This is 4et,black, tar,like and "/ngent,smelling stools re"resenting blood from the /""er F9 tract 5or right side of the large bo0el6 that has been :;=altered:;> by "assage thro/gh the g/t. The "resence of melaena is often 3/eried in hos"ital in,"atients b/t those 0ho ha)e smelt tr/e melaena rarely forget the ex"erienceU -sk abo/t iron s/""lementation or bism/th,containing com"o/nds:;<ca/se blackened stools b/t 0itho/t the melaena smell or consistency. M/c/s Clear, )iscoid secretion of the m/c/s membranes.I Contains m/c/s, e"ithelial cells, le/kocytes and )ario/s salts s/s"ended in 0ater. The "resence of m/c/s in, or on, stools may indicate: 9nflammatory bo0el disease. olitary rectal /lcer.

mall or large bo0el fist/la. Colonic )illo/s adenoma. 9rritable bo0el syndrome.

7lat/s mall amo/nts of gas fre3/ently esca"e from the bo0el )ia the mo/th 5er/ctation6 and an/s and the notable excess of this is a common feat/re of both f/nctional and organic disorders of the gastrointestinal tract. Often associated 0ith abdominal bloating and ca/sed by the fermentation of certain foods by colonic flora. Excessi)e flat/s is a "artic/lar feat/re of: Hiat/s hernia. Pe"tic /lceration.

Chronic gall,bladder disease. -ir,s0allo0ing 5aero"hagy6. High,fibre diet.

P.%11 2ox +.S Ca/ses of lo0er F9 bleeding Haemorrhoids. -nal fiss/re.

Bi)ertic/lar disease. Colonic carcinoma. Colonic "oly". -ngiodys"lasia.

9nflammatory bo0el disease. 9schaemic colitis. MeckelRs di)ertic/l/m. mall bo0el disease 5e.g. t/mo/r, di)ertic/lae, int/ss/sce"tion, CrohnRs6. olitary rectal /lcer. Haemobilia 5bleeding into the biliary tree6.

2ox +.+ 7at malabsor"tion 5steatorrhoea6 - common feat/re of "ancreatic ins/fficiency 5e.g. d/e to chronic "ancreatitis, cystic fibrosis6. -lso ca/sed by diseases s/ch as coeliac disease, inflammatory bo0el disease, blind bo0el loo"s, and short bo0el syndrome. No/ sho/ld be a0are of these feat/res and ex"lore them all f/lly if one is mentioned by the "atient: Pale stool. Offensi)e smelling.

Poorly formed. Biffic/lt to fl/sh 5floats6.

P.%1? Ja/ndice and "r/rit/s Ja/ndice Ja/ndice 5:;=icter/s:;>6 is a yello0 "igmentation of skin, sclera, and m/cosa ca/sed by excess bilir/bin in the body fl/ids. 9t is /s/ally considered a :;=sign:;> as it is seen on examination. ee also ".LS and 2ox +.!&. -sk abo/t: The colo/r of the /rine 5dark in cholestatic 4a/ndice6. The colo/r and consistency of the stools 5"ale in cholestatic 4a/ndice6.

-bdominal "ain 5e.g. ca/sed by gallstones6.

The follo0ing sho/ld be incl/ded in any thoro/gh history b/t yo/ sho/ld make a s"ecial "oint of asking abo/t: Pre)io/s blood transf/sions. Past history of 4a/ndice.

Br/gs 5e.g. antibiotics, H -9Bs, oral contrace"ti)es, "henothiaAines6. 9M dr/g /se.

Tattoos and body "iercing. 7oreign tra)el. ex/al history. 7Hx of li)er disease. -lcohol cons/m"tion. -ny "ersonal contacts 0ho also ha)e 4a/ndice.

Pr/rit/s This is itching of the skin and may be either localiAed or generaliAed. 9t has many ca/ses:;<it is "artic/larly associated 0ith cholestatic li)er disease 5e.g. "rimary biliary cirrhosis, sclerosing cholangitis6. -bdominal s0elling The fi)e classic ca/ses of abdominal s0elling 5:;=the L 7s:;>6 are sho0n o""osite in 2ox +.!!. To these, yo/ sho/ld also add :;=t/mo/r:;>. 9n decom"ensated cirrhosis, a combination of "ortal 5sin/soidal6 hy"ertension and Ha and H%O retention fa)o/rs the trans/dation of fl/id into the "eritoneal ca)ity 5ascites6. The res/ltant s0elling may be /nsightly:;<it can also ca/se shortness of breath by "/tting "ress/re on the dia"hragm from belo0, "artic/larly 0hen s/"ine and may be associated 0ith "le/ral eff/sions. ee ".'1' for the ca/ses and classification of ascites. P.%1L 2ox +.!& Ca/ses of 4a/ndice Prehe"atic Haemolysis. FilbertRs disease.

B/bin,Johnson syndrome. Gotor syndrome. Haemodialysis.

He"atocell/lar

Cirrhosis 5and the ca/ses thereof:;<see OHCMO, ".%1%6. -c/te he"atitis 5)iral, alcoholic, a/toimm/ne, dr/g,ind/ced6. 8i)er t/mo/rs. Cholestasis from dr/gs 5e.g. chlor"romaAine6.

Posthe"atic

Obstr/ction of biliary o/tflo0 d/e to: 8/minal obstr/ction: gallstones. Call "athology: congenital bile d/ct abnormalities, "rimary biliary cirrhosis, tra/ma, t/mo/r.

External com"ression: "ancreatitis, lym"hadeno"athy, "ancreatic t/mo/r, -m"/lla of Mater t/mo/r.

2ox +.!! 7i)e ca/ses of abdominal s0elling:;<:;=the L 7s:;> 7at. 7l/id.

7lat/s. 7aeces. 7et/s.

P.%1O (rinary and "rostate sym"toms (rinary fre3/ency This is the "assing of /rine more often than is normal for the "atient. Y/antify this:;<ho0 many times in a day:;<and also ask abo/t the )ol/me of /rine "assed each time 5yo/ are attem"ting to decide 0hether the "atient is "rod/cing more /rine than normal or sim"ly feeling the /rge to /rinate more than normal6. (rgency This is the s/dden need to /rinate, a feeling that the "atient may not be able to make it to the toilet in time. -sk abo/t the )ol/me ex"elled. Hoct/ria (rination d/ring the night. Boes the "atient 0ake from slee" to /rinateE Ho0 many times a nightE Ho0 m/ch /rine is ex"elled each timeE (rinary incontinence The loss of )ol/ntary control of bladder em"tying. Patients may be hesitant to talk abo/t this so try to a)oid the "hrase :;=0etting yo/rself. No/ co/ld ask abo/t it immediately after asking abo/t /rgency:;@ :;=Bo yo/ e)er feel the des"erate need to em"ty yo/r bladderE:;@ Ha)e yo/ e)er not made it in timeE:;> or by asking abo/t a :;=loss of control:;>. There are L main ty"es of /rinary incontinence: :;=Tr/e:;>: total lack of control of /rinary excretion. /ggesti)e of a fist/la bet0een the /rinary tract and the exterior or a ne/rological condition. Figgle: incontinence d/ring bo/ts of la/ghter. Common in yo/ng girls.

tress: leakage associated 0ith a s/dden :JW in intra,abdominal "ress/re of any ca/se 5e.g. co/ghing, la/ghing, sneeAing6.

(rge: intense /rge to /rinate s/ch that the "atient is /nable to get to the toilet in time. Ca/ses incl/de o)er,acti)ity of the detr/ser m/scle, /rinary infection, bladder stones and bladder cancer. Bribbling or o)erflo0: contin/al loss of /rine from a chronically distended bladder. Ty"ically in elderly males 0ith "rostate disease.

Terminal dribbling - male com"laint and /s/ally indicati)e of "rostate disease. This is a dri""ing of /rine from the /rethra at the end of mict/rition, re3/iring an abnormally "rotracted shake of the "enis and may ca/se embarrassing staining of clothing. Hesitancy Biffic/lty in starting to mict/rate. The "atient describes standing and 0aiting for the /rine to start flo0ing. (s/ally d/e to bladder o/tflo0 obstr/ction d/e to "rostatic disease or strict/res. Bys/ria :;=Pain on mict/rition:;> /s/ally described by the "atient as :;=b/rning:;> or :;=stinging:;> and felt at the /rethral meat/s. -sk 0hether it is thro/gho/t the "assage of /rine or only at the end 5:;=terminal dys/ria:;>6. P.%1' Haemat/ria The "assage of blood in the /rine. -l0ays an abnormal finding. Gemember that :;=microsco"ic haemat/ria:;> 0ill be /ndetectable to the "atient, only sho0ing on di",testing. 9ncom"lete em"tying This is the sensation that there is more /rine left to ex"el at the end of mict/rition. /ggests detr/ser dysf/nction or "rostatic disease. 9ntermittency The disr/"tion of /rine flo0 in a sto",start manner. Ca/ses incl/de "rostatic hy"ertro"hy, bladder stones, and /reterocoeles. Olig/ria and an/ria Olig/ria is scanty or lo0,)ol/me /rination and is defined as the excretion of V1&&ml /rine in %? ho/rs. Ca/ses can be "hysiological 5dehydration6 or "athological 5intrinsic renal disease, shock or obstr/ction6. -n/ria is the absence of /rine formation and yo/ sho/ld attem"t to r/le o/t /rinary tract obstr/ction as a matter or /rgency. Other ca/ses incl/de se)ere intrinsic renal dysf/nction and shock. Poly/ria This is excessi)e excretion of large )ol/mes of /rine and m/st be caref/lly differentiated from /rinary fre3/ency 5the fre3/ent "assage of small amo/nts of /rine6. Ca/ses )ary 0idely b/t incl/de the ingestion of large )ol/mes of 0ater 5incl/ding hysterical "olydi"sia6, diabetes mellit/s 5the osmotic effect of gl/cose in the t/b/les enco/rages more /rine to be made6, fail/re of the action of -BH at the renal t/b/le 5as in diabetes insi"id/s6 and defecti)e renal concentrating ability 5e.g. chronic renal fail/re6.

Gemember also to ask the "atient abo/t the /se of di/retic medicationU P.%1S -""etite and 0eight 8oss of a""etite and changes in 0eight are rather non,s"ecific sym"toms b/t sho/ld raise s/s"icion of a serio/s disease if either is se)ere, "rolonged, or /nex"ected. :PQ Gemember that 0eight loss has many ca/ses o/tside of the abdomen and a thoro/gh systems en3/iry sho/ld be cond/cted. Ceight loss may not be noticed by "atients if they donRt reg/larly 0eigh themsel)es:;<ask abo/t clothes becoming loose. Gemember that the "atient may ha)e been intentionally losing 0eight:;<thro0ing yo/ off the scent. -sk if the loss is :;=ex"ected:;>. :PQ 2e0areU -scites 0eights !kgD8 and some "atients 0ith li)er fail/re may ha)e !&:;<%&8 of ascites, masking any :;=dry 0eight:;> loss. -sk the "atient abo/t their eating habit and a)erage daily diet. Try to determine: Chen the sym"tom 0as first noticed. Y/antify the "roblem. 9n the case of 0eight loss, determine exactly ho0 and o)er 0hat time "eriod.

The ca/se of the anorexia:;<does eating make the "atient feel sickE Boes eating ca/se "ainE 5E.g. gastric /lcer, mesenteric angina, "ancreatitis.6 -ny accom"anying sym"toms 5abdominal "ain, na/sea, )omiting, fe)er6.

-sk also abo/t: The colo/r and consistency of stools 5e.g. steatorrhoeaE6.

(rinary sym"toms 5see

".%1O

Gecent change in tem"erat/re tolerance.

9n e)ery case, yo/ sho/ld calc/late the "atientRs 2M9 as on ".OO. The combination of 0eight loss 0ith :JW a""etite may s/ggest malabsor"tion or a hy"ermetabolic state 5e.g. thyrotoxicosis6. P.%1+ P.%?& The rest of the history Past medical history

-sk es"ecially abo/t: Pre)io/s s/rgical "roced/res incl/ding "eri, and "osto"erati)e com"lications and anaesthetic com"lications. Chronic bo0el diseases 5e.g. 92B incl/ding recent flare,/"s and treatment to date6.

Possible associated conditions 5e.g. diabetes 0ith haemachromatosis6.

Br/g history Think abo/t dr/gs that can "reci"itate abdominal diseases and remember to ask abo/t o)er,the, co/nter dr/gs. 7or exam"le: He"atitis: halothane, "henytoin, chlorothiaAides, "yraAinamide, isoniaAid, methyl do"a, HMF Co- red/ctase inhibitors 5:;=statins:;>6, sodi/m )al"roate, amiodarone, antibiotics, H -9Bs. Cholestasis: chlor"romaAine, s/l"honamides, s/l"honyl/reas, rifam"icin, nitrof/rantoin, anabolic steroids, oral contrace"ti)e "ill.

7atty li)er: tetracycline, sodi/m )al"roate, amiodarone. -c/te li)er necrosis: "aracetamol. -sk also abo/t "re)io/s blood transf/sions.

moking mokers are at :JW risk of "e"tic /lceration, oeso"hageal cancer, colorectal cancer. moking may also ha)e a detrimental o/tcome on the nat/ral history of CrohnRs disease. There is some e)idence that smoking may "rotect against /lcerati)e colitis. -lcohol -s al0ays, a detailed history is re3/ired:;<see ".??. 9f de"endence is s/s"ected, r/n thro/gh the C-FE 3/estionnaire:;<see 2ox +.!%. 7amily history -sk es"ecially abo/t a history of inflammatory bo0el disease, coeliac disease, "e"tic /lcer disease, hereditary li)er diseases 5e.g. CilsonRs, haemochromatosis6 bo0el cancer, 4a/ndice, anaemia, s"lenectomy, and cholecystectomy. ocial history Gisks of ex"os/re to he"atotoxins and he"atitis thro/gh occ/"ation. Tattoos.

9llicit dr/g /se 5es"ecially sharing needles6. ocial contacts 0ith a similar disease 5"artic/larly rele)ant to 4a/ndice6. Gecent foreign tra)el.

Bietary history -mo/nt of fr/it, )egetables and fibre in the diet. E)idence of lactose intolerance.

Change in sym"toms related to eating certain food gro/"s. ensiti)ities to 0heat, fat, caffeine, gl/ten.

P.%?! 2ox +.!% The C-FE 3/estionnaire - "ositi)e res"onse to any of the ? 3/estions may indicate someone at risk of alcohol ab/se. "ositi)e ans0er to % or more 3/estions makes the "resence of alcohol de"endence likely. C Ha)e yo/ e)er felt that yo/ sho/ld C/t do0n yo/r drinkingE A Ha)e yo/ e)er got Angry 0hen someone s/ggested that yo/ sho/ld c/t do0nE GBo yo/ e)er feel G/ilty abo/t yo/r drinkingE E Bo yo/ e)er need an :;=Eye,o"ener:;> in the morning to steady yo/r ner)es or get rid of a hango)erE P.%?% O/tline examination -s al0ays, ens/re ade3/ate "ri)acy. 9deally the "atient sho/ld be lying flat 0ith the head "ro""ed on a single "illo0, arms lying at the sides. The abdomen sho/ld be ex"osed at least from the bottom of the stern/m to the sym"hysis "/bis:;<"referably the 0hole /""er torso sho/ld be /nco)ered. Bo not ex"ose the genitalia /nless needed later. The examination sho/ld follo0 an orderly ro/tine. The a/thorsR s/ggestion is sho0n belo0. 9t is standard "ractice to start 0ith the hands and 0ork "roximally:;<this establishes a :;="hysical ra""ort:;> before yo/ examine more delicate or embarrassing areas. 2ox +.!1 7rame0ork for the abdominal examination Feneral ins"ection. The hands.

The arms. The axillae. The face. The chest. 9ns"ection of the abdomen. Pal"ation of the abdomen.
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8ight. Bee". "ecific organs.

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Examination of the hernial orifices. External genitalia.

Perc/ssion 5#T examination of ascites6. -/sc/ltation. Bigital examination of the an/s, rect/m #T "rostate.

Feneral ins"ection 8ooking at the "atient from the end of the bed to assess their general health and look for any ob)io/s abnormalities described in High or lo0 body mass. The state of hydration.

Cha"ter 1 before mo)ing closer. 8ook es"ecially for:

7e)er. Bistress. Pain. M/scle 0asting. Peri"heral oedema. Ja/ndice. -naemia.

P.%?1 P.%?? Hand and /""er limb Take the "atientRs right hand in yo/rs and examine caref/lly for the follo0ing signs. HailsI 8e/konychia: 0hitening of the nail bed d/e to hy"oalb/minaemia 5e.g. maln/trition, malabsor"tion, he"atic disease, ne"hritic syndrome6. Zoilonychia: :;=s"ooning:;> of the nails making a conca)e sha"e instead of the normal con)exity. Ca/ses incl/de congenital and chronic iron deficiency.

M/ehrckeRs lines: these are trans)erse 0hite lines. een in hy"oalb/minaemic states incl/ding se)ere li)er cirrhosis.

Cl/bbing: described on ".%&S. -bdominal ca/ses are cirrhosis, inflammatory bo0el disease and coeliac disease. 2l/e l/n/lae: a bl/ish discolo/ration of the normal lan/lae seen in CilsonRs disease.

ee also Cha"ter ?. Palms Palmar erythema: :;=li)er "alms:;>. This is a blotchy reddening of the "alms of the hands, es"ecially affecting the thenar and hy"othenar eminences. 9t can also affect the soles of the feet. -ssociated 0ith chronic li)er disease, "regnancy, thyrotoxicosis, rhe/matoid arthritis, "olycythaemia and 5rarely6 chronic le/kaemia. 9t can also be a normal finding. B/"/ytrenRs contract/re: this is thickening and fibro/s contraction of the "almar fascia. 9n early stages, "al"able irreg/lar thickening of the fascia is seen, es"ecially that o)erlying the ?th and Lth metacar"als. This can "rogress to a fixed flexion deformity of the fingers starting at the Lth and 0orking across to the 1rd or %nd. Often bilateral, it may also affect the feet. een es"ecially in alcoholic li)er disease b/t may also be seen in man/al 0orkers 5or may be familial6.

-naemia: "allor in the "almar creases s/ggests significant anaemia.

He"atic fla" 5asterixis6 This is identical to the fla" seen in hy"erca"nic states 5see ".%&S6. -sk the "atient to stretch o/t their hands in front of them 0ith the hands dorsiflexed at the 0rists and fingers o/tstretched and se"arated 5see fig.6. The "atient sho/ld hold that "osition for at least !L seconds. 9f :;=fla":;> is "resent, the "atientRs hands 0ill mo)e in 4erky, irreg/lar flexionDextension at the 0rist and MCP 4oints. The fla" is nearly al0ays bilateral. May be s/btle and intermittent. This is characteristic of ence"halo"athy d/e to li)er fail/re. 9f a sign of he"atic ence"halo"athy in a "atient 0ith "re)io/sly com"ensated li)er disease, it may ha)e been "reci"itated by infection, di/retic medication, electrolyte imbalance, diarrhoea or consti"ation, )omiting, centrally acting dr/gs, /""er F9 bleeding, abdominal "aracentesis, or s/rgery. P.%?L The /""er limb Examine the arms for any signs of: 2r/ising: may be a sign of: o He"atocell/lar damage and the res/lting coag/lation disorder.
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Thrombocyto"enia d/e to hy"ers"lenism. Marro0 s/""ression 0ith alcohol.

Petechiae: "in,"rick bleeds 0hich do not blanche 0ith "ress/re. Possibly a sign of thrombocyto"enia. M/scle 0asting: seen as a :JK in m/scle mass, "ossibly 0ith o)erlying skin hanging loosely. - late manifestation of maln/trition and often seen in "atients 0ith chronic alcoholic li)er disease. cratch marks 5excoriations6: s/ggests itch 5"r/rit/s6 is "resent and may be the only )isible feat/re of early cholestasis.

2e caref/l not to miss -M fist/lae or haemodialysis cathetersU The axillae Examine caref/lly for: 8ym"hadeno"athy -canthosis nigricans 5a thickened, blackening of the skin. Mel)ety in a""earance. May be associated 0ith intra,abdominal malignancy6.

7ig. +.? Testing for he"atic fla". The "atient sho/ld hold their arms o/tstretched 0ith 0rists dorsiflexed and fingers extended and abd/cted for at least !L seconds. P.%?O 7ace and chest Eyes -sk the "atient to look straight ahead 0hilst yo/ look closely at their eyes, orbits and s/rro/nding skin. Then ask the "atient to look /" 0hilst yo/ gently retract the lo0er lid 0ith a finger, looking at the /nderlying sclera and con4/ncti)a. 8ook es"ecially for:

Ja/ndice: a yello0 discolo/ration of the sclera. This is /s/ally the first "lace that 4a/ndice can be seen. Partic/larly /sef/l in "atient 0ith dark skin tones in 0hom 4a/ndice 0o/ld not be other0ise ob)io/s. -naemia: "allor of the con4/ncti)ae. No/Rll need ex"erience to s"ot this easily. Zayser,7leisher rings: best seen 0ith a slit,lam" in an o"hthalmology clinic. - greenish, yello0 "igmented ring 4/st inside the cornea,scleral margin. B/e to co""er de"osition. een in CilsonRs disease. [anthelasma: raised yello0 lesions ca/sed by a b/ild /" of li"ids beneath the skin:;<often seen encircling the eyes, es"ecially at the nasal side of the orbit.

Mo/th -sk the "atient to sho0 yo/ their teeth then :;=o"en 0ide:;> and look caref/lly at the state of the teeth, the tong/e and the inner s/rface of the cheeks. No/ sho/ld also s/btly attem"t to smell the "atientRs breath. -ng/lar stomatitis: a reddening and inflammation at the corners of the mo/th. - sign of thiamine, )itamin 2!%, and iron deficiencies. Circ/moral "igmentation: Hy"er"igmented areas s/rro/nding the mo/th. een in Pe/tA, JegherRs syndrome.

Bentition: note false teeth or if there is e)idence of tooth decay. Telangiectasia: dilatation of the small )essels on the g/ms and b/ccal m/cosa. een in Osler,Ceber,Gend/ syndrome 5 OHCMO, ".'1%6.

F/ms: look es"ecially for /lcers 5ca/ses incl/de coeliac disease, inflammatory bo0el disease, 2eh\]etRs disease and GeiterRs syndrome6 and hy"ertro"hy 5ca/sed by "regnancy, "henytoin /se, le/kaemia, sc/r)y ^)itamin C deficiency_ or inflammation ^gingi)itis_6. 2reath: smell es"ecially for:
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:;=7etor he"atic/s:;> a s0eet,smelling breath. Zetosis: sickly s0eet :;="ear,dro":;> smelling breath (raemia: a fishy smell

Tong/e: look es"ecially for:

o

Flossitis: smooth, erythemato/s s0elling of the tong/e. Ca/ses incl/de deficiencies of iron, )itamin 2!%, and folate deficiencies Macroglossia: enlarged tong/e. Ca/ses incl/de amyloidosis, hy"othroidism, acromegaly, Bo0nRs syndrome, and neo"lasia.

8e/ko"lakia: a 0hite,colo/red thickening of the tong/e and oral m/c/s membranes. - "remalignant condition ca/sed by smoking, "oor dental hygiene, alcohol, se"sis and sy"hilis. Feogra"hical tong/e: "ainless red rings and lines on the s/rface of the tong/e looking rather like a ma". Can be ca/sed by )itamin 2% 5ribofla)in6 deficiency or may be a normal )ariant.

P.%?'

Candidiasis: :;=thr/sh:;>. - f/ngal infection of the oral membranes seen as creamy 0hite c/rd,like "atches 0hich can be scra"ed off re)ealing erythemato/s m/cosa belo0. Ca/ses incl/de imm/nos/""ression, antibiotic /se, "oor oral hygiene, iron deficiency and diabetes.

The neck Examine the cer)ical and s/"racla)ic/lar lym"h nodes as on ".OS. 8ook es"ecially for a s/"racla)ic/lar node on the left,hand side 0hich, 0hen enlarged, is called Mircho0Rs node 5TroisierRs sign,s/ggesti)e of gastric malignancy6. The chest 8ook at the anterior chest and notice es"ecially: "ider nae)i: telangiectatic ca"illary lesions. o - central red area 0ith engorged ca"illaries s"reading o/t from it in a :;=s"idery:;> manner.
o o

Ca/sed by engorgement of ca"illaries from a central :;=feeder:;> )essel. 9f the lesion is tr/ly a s"ider nae)/s, it 0ill be com"letely eliminated by "ress/re at the centre /sing a "en,"oint or similar and 0ill fill o/t0ards 0hen the "ress/re is released. Can range in siAe from those that are only 4/st )isible /" to L or Omm in diameter. 7o/nd in the distrib/tion of the s/"erior )ena ca)a 5see 7ig. +.L6. - normal ad/lt is :;=allo0ed:;> /" to L s"ider nae)i. Ca/ses incl/de chronic li)er disease and oestrogen excess

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Fynaecomastia: the excessi)e de)elo"ment of male mammary glands d/e to d/ctal "roliferation s/ch that they resemble "ost,"/bertal female breasts.
o

This is often embarrassing for the "atient so be sensiti)e.

Ca/sed by alcoholic li)er disease, congenital adrenal hy"er"lasia and se)eral commonly /sed dr/gs incl/ding s"ironolactone, digoxin, and cimetidine. Can also be seen d/ring "/berty in the normal male.

7ig. +.L Bistrib/tion of drainage to the s/"erior )ena ca)e and the area to look for s"ider nae)i. The normal ad/lt may ha)e /" to L s/ch lesions. P.%?S 9ns"ection of the abdomen Cith the abdomen ex"osed, yo/ sho/ld make a caref/l and methodical ins"ection. Hote es"ecially: cars These may be the res/lt of tra/ma or "re)io/s s/rgery. Gecent scars 0ill be "ink and )asc/lar. Old scars are 0hite and may be ind/rated. -bdominal distension Boes the abdomen look s0ollenE Consider the L 7s 5 the /mbilic/s. 5E)ertedE Bee"E6 7ocal s0ellings 2ox +.!! ".1?6 and note the state of

Treat an abdominal s0elling as yo/ 0o/ld do any other l/m" 5 ".+S6 and bear in mind the /nderlying anatomy and "ossible organ in)ol)ement. Bi)arication of the recti Partic/larly in the elderly and in "atients 0ho ha)e had abdominal s/rgery, the t0in rect/s abdominis m/scles may se"arate laterally on contraction, ca/sing the /nderlying organs to b/lge thro/gh the res/ltant mid,line ga". -sk the "atient to lift their head off the bed or to sit /" slightly and 0atch for the a""earance of a longit/dinal midline b/lge. Prominent )asc/lat/re 9f )eins are seen co/rsing o)er the abdomen, note their exact location.

-ttem"t to ma" the direction of blood flo0 0ithin them: o Place % fingers at one end of the )ein and a""ly occl/si)e "ress/re
o

Mo)e ! finger along the )ein, em"tying that section of blood in a :;=milking:;> action. Gelease the "ress/re from one finger and 0atch for flo0 of blood back into the )ein. Ge"eat, em"tying blood in the other direction. B/e to the )eno/s )al)es, yo/ sho/ld be able to determine the direction of blood flo0 in that )ein.

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9nferior flo0 of blood s/ggests s/"erior )ena ca)a obstr/ction. /"erior flo0 of blood s/ggests inferior )ena ca)a obstr/ction. 7lo0 radiating o/t from the /mbilic/s 5:;=ca"/t med/sae:;>6 indicates "ortal )ein hy"ertension 5"orto,systemic sh/nting occ/rs thro/gh the /mbilical )eins 0hich become engorged6.

Ob)io/s "/lsations 8ook across the abdomen for any "/lsations. - "/lsatile, ex"anding mass in the e"igastri/m may be an abdominal aortic ane/rysm. Peristaltic 0a)es (s/ally only seen in thin, fit, yo/ng indi)id/als. - )ery ob)io/s bo0el "eristalsis is seen as ri""ling mo)ements beneath the skin and may indicate intestinal obstr/ction. triae :;= tretch marks:;> are "ink or 0hite streaky lines ca/sed by changes in the tension of the abdominal 0all. These may be normal in ra"idly gro0ing P.%?+ "/bescent teens. -lso seen in obesity, "regnancy 5:;=striae gra)idar/m:;>6, ascites and follo0ing ra"id 0eight loss or abdominal "aracentesis. 2ear in mind that these 0ill t/rn "inkD"/r"le in C/shingRs yndrome like other scars 5see ".!%'6. kin discolo/ration There are % classical "atterns of br/isingDdiscolo/ration indicating the "resence of retro"eritoneal blood 5seen es"ecially in "ancreatitis6: C/llenRs sign: discolo/ration at the /mbilic/s and s/rro/nding skin Frey,T/rnerRs sign: discolo/ration at the flanks tomas 8ook for s/rgical stomas or fist/lae, noting their exact location, nat/re of the stoma and a""earance of the ex"osed m/cosa 5if any6. Gemember that a stoma may be from the large

bo0el, small bo0el, or renal tract. 8ook also at the contents of the stoma bag noting any abnormalities s/ch as diarrhoea, "/s, m/c/s or blood. Colostomy: /s/ally seen in the left iliac fossa and 0ill be fl/sh to the skin. 52ag may contain semi,solid to formed stool.6 9leostomy: /s/ally in the right iliac fossa and formed as a :;=s"o/t:;> of bo0el m/cosa extending from the abdominal 0all to "re)ent the l/minal contents harming the abdominal 0all. 52ag 0ill contain semi,formed and li3/id stool.6

(rostomy: often formed as an ileal cond/it 0ith /reters connected to a "ortion of small bo0el and then to the abdominal 0all. (s/ally in the right iliac fossa. 52ag 0ill contain /rine.6 He"hrostomy: drainage of /rine from the kidney "el)is to the exterior. (s/ally a tem"orary meas/re follo0ing o"erati)e "roced/res to the renal tract or to decom"ress an obstr/cted system. (s/ally at the flank. 52ag 0ill contain /rine.6

7ig. +.O ome common abdominal s/rgical scars. P.%L& Pal"ation Feneral a""roach The "atient sho/ld be "ositioned lying s/"ine 0ith the head s/""orted by a single "illo0 and arms at their sides. 3/at by the side of the bed or co/ch so that the "atientRs abdomen is at yo/r eye le)el. Each of the ? 3/adrants 5see ".%%%6 sho/ld be examined in t/rn 0ith light, and then dee"

"al"ation before foc/sing on s"ecific organs 5 ".%L%6. The order they are examined in doesnRt matter:;<find a ro/tine that s/its yo/. -sk the "atient if there is any area of tenderness and remember to examine this "art last.

2efore yo/ begin, ask the "atient to let yo/ kno0 if yo/ ca/se any discomfort. No/ sho/ld be able to examine the abdomen 0itho/t looking at it closely. 9nstead, yo/ sho/ld 0atch the "atientRs face for signs of "ain. 8ight "al"ation 7or this, yo/ /se the finger,ti"s and "almar as"ects of the fingers. 8ay yo/r right hand on the "atientRs abdomen and gently "ress in by flexing at the metacar"o,"halangeal 4oints. 9f there is "ain on light "al"ation, attem"t to determine 0hether the "ain is 0orse 0hen yo/ "ress do0n or 0hen yo/ release the "ress/re 5:;=rebo/nd tenderness:;>6.

9f the abdominal m/scles seem tense, determine 0hether it is localiAed or generaliAed. Ens/re the "atient is relaxed,it may be hel"f/l for the "atient to bend their knees slightly, relaxing the abdominal m/scles. -n in)ol/ntary tension in the abdominal m/scles:;<a""arently "rotecting the /nderlying organs:;<is called :;=g/arding:;>.

Bee" "al"ation Once all ? 3/adrants are lightly "al"ated, re,examine /sing more "ress/re. This sho/ld enable yo/ to feel for any masses or str/ct/ral abnormalities. 9f a mass is felt, treat it as yo/ 0o/ld any other l/m" describing its exact location, siAe, sha"e, s/rface, consistency, mobility, mo)ement 0ith res"iration, tenderness and 0hether or not it is "/lsatile. 9t is often "ossible to detect the "/tty,like consistency of stool in the sigmoid colon. No/ sho/ld treat this as any other :;=l/m":;> to be s/re of its nat/re. P.%L! 2ox +.!? igns of "eritonitis Pain on light "al"ation. Gebo/nd tenderness.

9n)olo/ntary g/arding. Pain rec/rring 0ith slight mo)ement of the examining hand. -bsent bo0el so/nds 5 ".%O%6.

P.%L% Pal"ating the abdominal organs 8i)er The normal li)er extends from the Lth intercostal s"ace on the right of the midline to the costal margin, hiding /nder the ribs so is often not normally "al"able:;<donRt 0orry if yo/ canRt feel oneU (sing the flat of the right hand, start "al"ation from the right iliac fossa.

No/ sho/ld angle yo/r hand s/ch that the index finger is aligned 0ith the costal margin 5see 7ig. +.'6. Exert gentle "ress/re and ask the "atient to take a dee" breath. Cith each in0ard breath, yo/r fingers sho/ld drift slightly s/"eriorly as the li)er mo)es inferiorly 0ith the dia"hragm. Gelax the "ress/re on yo/r hand slightly at the height of ins"iration. 9f the li)er is 4/st abo)e the "osition of yo/r hand, the lateral s/rface of yo/r index finger 0ill strike the li)er edge and glide o)er it 0ith a "al"able :;=ste":;>. 9f the li)er is not felt, mo)e yo/r hand !,%cm s/"eriorly and feel again. Ge"eat the "rocess, mo)ing to0ards the ribs /ntil the li)er is felt.

9f a li)er edge is felt, yo/ sho/ld note: Ho0 far belo0 the costal margin it extends in finger,breadths or 5"referably6 centimetres and record the n/mber caref/lly. The nat/re of the li)er edge 5is the s/rface smooth or irreg/larE6.

The "resence of tenderness. Chether the li)er is "/lsatile.

7indings 9t is often "ossible to "al"ate the li)er 4/st belo0 the costal margin at the height of ins"iration in normal, healthy, thin "eo"le.

-n enlarged li)er has many ca/ses:;<see

OHCMO, ".L!S.

- normal li)er may be "al"able in "atients 0ith COPB or asthma in 0hom the chest is hy"er,ex"anded or in "atients 0ith a s/bdia"hrag,matic collection. The li)er may also be "al"able in the "resence of :;=GiedelRs lobe:;>:;<a normal )ariant in 0hich a "ro4ection of the li)er arises from the inferior s/rface of the right lobe. More common in females. Commonly mistaken for a right kidney or enlarged gallbladder.

Fallbladder 8ies at the right costal margin at the ti" of the +th rib, at the lateral border of the rect/s abdominis. Hormally only "al"able 0hen enlarged d/e to biliary obstr/ction or ac/te cholecystitis. 7elt as a b/lbo/s, focal, ro/nded mass 0hich mo)es 0ith ins"iration. Position the right hand "er"endic/lar to the costal margin and "al"ate in a medial :J` lateral direction 5see 7ig. +.S6. P.%L1

7ig. +.' Pal"ation of the li)er:;<align the lateral s/rface of the index finger 0ith the costal margin and "al"ate from the right iliac fossa to the ribs in a ste",0ise fashion.

7ig. +.S Pal"ation of the gallbladder:;<the examining hand sho/ld be "er"endic/lar to the costal margin at the ti" of the +th rib 50here the lateral border of the rect/s m/scle meets the costal cartilages6. 2ox +.!L 9m"ortant gallbladder signs M/r"hyRs sign - sign of cholecystitis:;<"ain on "al"ation o)er the gallbladder d/ring dee" ins"iration. Only "ositi)e if there is HO "ain on the left at the same "osition. Co/r)oisierRs la0 9n the "resence of 4a/ndice, a "al"able gallbladder is "robably HOT ca/sed by gallstones. P.%L? "leen

The largest lym"hatic organ 0hich )aries in siAe and sha"e bet0een indi)id/als:;<ro/ghly the siAe of a clenched fist 5!%cm x 'cm6. Hormally hidden beneath the left costal cartilages and im"al"able. Enlargement of the s"leen occ/rs in a do0n0ard direction, extending into the left /""er 3/adrant 5and e)en the left lo0er 3/adrant6 across to0ards the right iliac fossa.

Pal"ated /sing a similar techni3/e to that /sed to examine the li)er 5 ".%L%6. No/r left hand sho/ld be /sed to s/""ort the left of the ribcage "osterolaterally. No/r right hand sho/ld be aligned 0ith the fingerti"s "arallel to the left costal margin 5see 7ig. +.+6. tart "al"ation 4/st belo0 the /mbilic/s in the midline and 0ork to0ards the left costal margin asking the "atient to take a dee" breath in and feeling for the mo)ement of the s"leen /nder yo/r fingers:;<m/ch like "al"ating the li)er. The inferior edge of the s"leen may ha)e a "al"able :;=notch:;> centrally 0hich 0ill hel" yo/ differentiate it from any other abdominal mass. 9f a s"leen is felt, meas/re the distance to the costal border in finger,breadths or 5"referably6 centimetres.

:PQ -n im"al"able s"leen may sometimes become "al"able by re"ositioning the "atient. -sk them to roll onto their right hand side and re"eat the examination as abo)e. P.%LL

7ig. +.+ Pal"ation of the s"leen:;<align the fingerti"s of yo/r right hand 0ith the left costal border and start "al"ating 4/st belo0 the /mbilic/s 0orking to0ards the left /""er 3/adrant. 2ox +.!S ome ca/ses of:;@ He"atomegaly -lcohol. Gight heart fail/re.

Heo"lasia 5"rimary cancer, metastases, myelo"roliferati)e disorders, le/kaemia, lym"homa6. Chronic li)er disease 5H2 cirrhosis ca/ses a small, shr/nken li)er6. 9nfections 5ac/te )iral he"atitis, br/cellosis, t/berc/losis6. -myloidosis. Haemochromatosis. 2iliary obstr/ction.

"lenomegaly Massi)e 5*Scm6: malaria, Zala,aAar, Fa/cherRs disease. Moderate 5?,Scm6: "ortal hy"ertension secondary to cirrhosis, lym"ho"roliferati)e disorders and many others.

Mild: lym"ho"roliferati)e disorders, "ortal hy"ertension secondary to cirrhosis, infectio/s he"atitis, gland/lar fe)er, s/bac/te endocarditis, sarcoidosis, rhe/matoid arthritis, connecti)e tiss/e diseases, haematological disorders 5idio"athic thrombocyto"aenia, hereditary s"herocytosis, "olycythaemia r/bra )era6.

He"atos"lenomegaly Myelo"roliferati)e disorders, lym"ho"roliferati)e disorders, chronic li)er disease 0ith "ortal hy"ertension, infection 5ac/te )iral he"atitis, br/cellosis, CeilRs disease, toxo"lasmosis, CMM6, l/"/s, amyloidosis, sarcoidosis, thyrotoxicosis, acromegaly, "ernicio/s anaemia, sickle,cell anaemia. P.%LO Zidneys The kidneys are retro"eritoneal, lying on the "osterior abdominal 0all either side of the )ertebral col/mn bet0een T!% and 81 )ertebrae. They mo)e slightly inferiorly 0ith ins"iration. The right kidney lies a little lo0er than the left 5dis"laced by the li)er6. Pal"ation is :;=biman/al:;> 5both hands6. No/ may be able to feel the lo0er "ole of the right kidney in normal, thin "eo"le. Place yo/r left hand behind the "atient at the right loin. Place yo/r right hand belo0 the right costal margin at the lateral border of the rect/s abdominis.

Zee"ing the fingers of yo/r right hand together, flex them at the metacar"o,"halangeal 4oints "/shing dee" into the abdomen. -sk the "atient to take a dee" breath:;<yo/ may be able to feel the ro/nded lo0er "ole of the kidney bet0een yo/r hands, sli""ing a0ay 0hen the "atient exhales. This techni3/e of /sing one hand to mo)e the kidney to0ard the other is called :;=renal ballottement:;>.

Ge"eat the "roced/re for the left kidney,leaning o)er and "lacing yo/r left hand behind the "atientRs left loin.

Table 9.1 Differentiating an enlarged spleen and an enlarged left kidney Enlarged spleen Enlarged kidney 9m"ossible to feel abo)e Can feel abo)e the organ Has a central :;=notch:;> on the leading Ho notch:;<b/t yo/ may feel the central hilar notch edge medially Mo)es early on ins"iration Mo)es late on ins"iration Mo)es inferio,medially on ins"iration Mo)es inferiorly on ins"iration Hot ballottable 2allottable B/llness to "erc/ssion Gesonant "erc/ssion note d/e to o)erlying bo0el gas May enlarge to0ard the /mbilic/s Enlarges inferiorly lateral to the midline 7indings (nilateral "al"able kidney: hydrone"hrosis, "olycystic kidney disease, renal cell carcinoma, ac/te renal )ein thrombosis, renal abscess, ac/te "yelone"hritis. 2ilateral "al"able kidneys: bilateral hydrone"hrosis, bilateral renal cell carcinoma, "olycystic kidney disease, ne"hrotic syndrome, amyloidosis, lym"homa, acromegaly. P.%L'

7ig. +.!& Pal"ation of the right kidney.

7ig. +.!! Pal"ation of the left kidney. P.%LS 2ladder The /rinary bladder is "yramid,sha"ed and lies 0ithin the "el)ic ca)ity. 9t is not "al"able 0hen em"ty. -s it fills, it ex"ands s/"eriorly and may e)en reach as high as the /mbilic/s or 4/st beyond if )ery f/ll. 9t may be diffic/lt to differentiate it from an enlarged /ter/s or o)arian cyst. The f/ll bladder 0ill be: - "al"able, ro/nded mass arising from behind the "/bic sym"hysis. B/ll to "erc/ssion.

No/ 0ill be /nable to feel belo0 it. Press/re on the f/ll bladder 0ill make the "atient feel the need to /rinate.

-orta The abdominal aorta may be "al"ated in the midline abo)e the /mbilic/s, felt as a longit/dinal "/lsatile mass. 9t is "artic/larly "al"able in thin "eo"le. 9f felt: Position the fingers of each hand either side of the o/termost "al"able margins. Meas/re the distance bet0een yo/r fingers. Hormal diameter :ab%,1cm.

Becide 0hether the mass yo/ feel is "/lsatileDex"ansile in itself 5in 0hich case yo/r fingers 0ill mo)e o/t0ards6 or 0hether the "/lsation is transmitted thro/gh other tiss/e 5in 0hich case yo/r fingers 0ill mo)e /"0ards6. ee 7ig. +.!%.

9ng/inal lym"h nodes The ing/inal chain of lym"h nodes lies along the ing/inal ligament bet0een the "/bic t/bercle and the anterior s/"erior iliac s"ine and sho/ld not be missed.

7eel along this line for any l/m"s treating each as yo/ 0o/ld any other 5

".+S6.

mall, firm mobile lym"h nodes are common in healthy "eo"le and are often the res/lt of minor se"sis or abrasions of the lo0er limbs. :PQ 2y this stage of the examination, yo/ sho/ld ha)e examined the nodes in the axillae, neck, s/"racla)ic/lar areas, and the ing/inal regions. The hernial orifices Bescribed on ".%OO. The external genitalia Ho thoro/gh abdominal examination is com"lete 0itho/t examining the genitalia:;<altho/gh in clinical "ractice many lea)e this o/t, considering it ina""ro"riate if yo/ are not s/s"icio/s of any genito,/rinary "athology. ee P.%L+ Cha"ter !%.

7ig. +.!% Pal"ating a "/lsatile mass. 9f the mass itself is ex"ansile 5a6, yo/rfingers 0ill mo)e o/t0ards. 9f the "/lsatility is being transmitted thro/gh o)erlying tiss/es 5b6, yo/r fingers 0ill mo)e /"0ards. P.%O& Perc/ssion 9n the examination of the abdomen, "erc/ssion is /sef/l for:;@ Betermining the siAe and nat/re of enlarged organs or masses. Betecting shifting d/llness 5belo06.

Eliciting rebo/nd tenderness 5

".%L&6.

Organs or masses 0ill a""ear as d/llness 0hereas a bo0el f/ll of gas 0ill seem abnormally resonant. Food techni3/e comes 0ith ex"erience. Practice "erc/ssing o/t yo/r o0n li)er. Perc/ssion techni3/e is described on ".%!?. Examining for ascites 9f fl/id is "resent in the "eritoneal ca)ity 5ascites6, gra)ity 0ill ca/se it to collect in the flanks 0hen the "atient is lying flat:;<this 0ill gi)e d/llness to "erc/ssion laterally 0ith central resonance as the bo0el floats. -scites 0ill gi)e a distended abdomen, often 0ith an e)erted /mbilic/s. 9f yo/ s/s"ect the "resence of ascites: Perc/ss centrally :J` laterally 0ith the fingers s"read and "ositioned longit/dinally 5see 7ig. +.!16. 8isten 5and feel6 for a definite change to a d/ll note. There are then % s"ecific tests to "erform:;@ hifting d/llnessI Perc/ss centrally :J` laterally /ntil d/llness is detected. This marks the air,fl/id le)el in the abdomen. Zee" yo/r finger "ressed there as yo/:;@

-sk the "atient to roll onto the o""osite side 5i.e. if d/llness is detected on the right, roll the "atient to their left,hand side6. -sk the "atient to hold the ne0 "osition for chalf a min/te. Ge"eat "erc/ssion mo)ing laterally to central o)er yo/r mark. 9f the d/llness tr/ly 0as an air,fl/id le)el, the fl/id 0ill no0 be mo)ed by gra)ity a0ay from the marked s"ot and the "re)io/sly d/ll area 0ill be resonant.

7l/id thrill 9n this test, yo/ are attem"ting to detect a 0a)e transmitted across the "eritoneal fl/id. This is only really "ossible 0ith massi)e ascites. No/ need an assistant for this test 5yo/ can ask the "atient to hel"6. -sk yo/r assistant to "lace the /lnar edge of one of their hands in the midline of the abdomen 5see 7ig. +.!16. Place yo/r left hand on one side of the abdomen, abo/t le)el 0ith the midcla)ic/lar line.

Cith yo/r right hand, flick the o""osite side of the "atientRs abdomen. 9f a :;=fl/id thrill:;> can be detected, yo/ 0ill feel the ri""le from the flick transmitted as a ta" to yo/r left hand.

The assistantRs hand is im"ortant,it "re)ents transmission of the im"/lse across the s/rface of the abdominal 0all.6 P.%O!

7ig. +.!1 Testing for a fl/id thrill. -sk an assistant to "lace their hand centrally on the abdomen:;<this "re)ents transmission of the im"/lse thro/gh the abdominal 0all. 8i)er Perc/ss to ma" the /""er and lo0er borders of the li)er,note the length, in centimetres, at the midcla)ic/lar line. "leen Perc/ssion from the left costal margin to0ards the midaxillary line and the lo0er left ribs may re)eal d/llness s/ggesti)e of s"lenic enlargement that co/ld not normally be "al"ated. Zidneys (sef/l in differentiating an enlarged kidney from an enlarged s"leen or li)er. The kidneys lie dee" in the abdomen and are s/rro/nded by "erine"hric fat 0hich makes them resonant to "erc/ssion. "lenomegaly or he"atomegaly 0ill a""ear d/ll. 2ladder B/llness to "erc/ssion in the s/"ra"/bic region may be hel"f/l in determining 0hether an ill, defined mass is an enlarged bladder 5d/ll6 or distended bo0el 5resonant6. P.%O% -/sc/ltation -n im"ortant "art of the abdominal examination 0hich is easily missed. 2o0el so/nds These are lo0,"itched g/rgling so/nds "rod/ced by normal g/t "eristalsis. They are intermittent b/t 0ill )ary in timing de"ending on 0hen the last meal 0as eaten. Practise listening to as many abdomens as "ossible to /nderstand the normal range of so/nds. 8isten 0ith the dia"hragm of the stethosco"e 4/st belo0 the /mbilic/s. Hormal: lo0,"itched g/rgling, intermittent. High,"itched: often called :;=tinkling:;>. These so/nds are s/ggesti)e of "artial or total bo0el obstr/ction.

2orborygm/s: this is a lo/d lo0,"itched g/rgling that can e)en be heard 0itho/t a stethosco"e. 5The so/nds are called :;=borborygmi:;>.6 Ty"ical of diarrhoeal states or abnormal "eristalsis. -bsent so/nds: if no so/nds are heard for % min/tes, there may be a com"lete lack of "eristalsis:;<i.e. a "aralytic ile/s or "eritonitis.

2r/its These are so/nds "rod/ced by the t/rb/lent flo0 of blood thro/gh a )essel:;<similar in so/nd to heart m/rm/rs. 8isten 0ith dia"hragm of the stethosco"e. 2r/its may occ/r in normal ad/lts b/t raise the s/s"icion of "athological stenosis 5narro0ing6 0hen heard thro/gho/t both systole and diastole. There are se)eral areas yo/ sho/ld listen at on the abdomen:;@ J/st abo)e the /mbilic/s o)er the aorta 5abdominal aortic ane/rysm6. Either side of the midline 4/st abo)e the /mbilic/s 5renal artery stenosis6.

-t the e"igastri/m 5mesenteric stenosis6. O)er the li)er 5-M malformations, ac/te alcoholic he"atitis, he"atocell/lar carcinoma6.

7riction r/bs These are creaking so/nds like that of a "le/ral r/b 5 ".%!'6 heard 0hen inflamed "eritoneal s/rfaces mo)e against each other 0ith res"iration. 8isten o)er the li)er and the s"leen in the right and left /""er 3/adrants res"ecti)ely. Ca/ses incl/de he"atocell/lar carcinoma, li)er abscesses, recent "erc/taneo/s li)er bio"sy, li)er or s"lenic infarction and TB,associated "erihe"atitis 57itA,H/gh,C/rtis yndrome6. Meno/s h/ms Garely, it is "ossible to hear the h/m of )eno/s blood flo0 in the /""er abdomen o)er a ca"/t med/sa 5 P.%O1 P.%O? :;=Per rect/m:;> examination This is an im"ortant "art of the examination and sho/ld not be a)oided sim"ly beca/se it is considered /n"leasant. 9t is "artic/larly im"ortant in "atients 0ith sym"toms of PG bleeding, tenesm/s, change in bo0el habit and "r/rit/s ani. :PQ Gemember: :;=9f yo/ donRt "/t yo/r finger in it, yo/ may "/t yo/r foot in itU:;> 2efore yo/ begin Ex"lain to the "atient 0hat is in)ol)ed and obtain )erbal consent. Choose yo/r 0ords caref/lly, ad4/sting yo/r 0ording to s/it the "atientU 7a)o/rite "hrases incl/de :;=tail,end:;>, :;=back, "assage:;>, and :;=bottom:;>. ay that yo/ need to examine their back "assage :;=0ith a ".%?S6 %#d to "orto,systemic sh/nting of blood.

finger:;>. Carn that it :;="robably 0onRt h/rt:;> b/t may feel :;=cold:;> and :;=a little /n/s/al:;>. No/ sho/ld ask for another member of staff to cha"erone,g/arding yo/rself against f/t/re claims of ina""ro"riate treatment and reass/ring the "atient.I -s yo/ "roceed, ex"lain each stage to the "atient. I This is still contro)ersial in the (Z at the time of 0riting. Official ad)ice is that all doctors sho/ld ha)e a cha"erone 0hen "erforming an intimate examination. 9n "ractice, male doctors "erforming an examination on a female al0ays ha)e a cha"erone "resent 0hilst the need for a cha"erone in other sit/ations is 4/dged indi)id/ally at the time. E3/i"ment Cha"erone Hon,sterile glo)es

Tiss/es 8/bricating 4elly 5e.g. -3/agel#e6

Techni3/e Cith informed )erbal consent obtained, ens/re ade3/ate "ri)acy. (nco)er the "atient from 0aist to knees.

-sk the "atient to lie in the left lateral "osition 0ith their legs bent s/ch that their knees are dra0n /" to their chest and their b/ttocks facing to0ards yo/:;<"referably "ro4ecting slightly o)er the edge of the bedDco/ch. Ens/re that there is a good light so/rce:;<"referably a mobile lam". P/t on a "air of glo)es. e"arate the b/ttocks caref/lly by lifting the right b/ttock 0ith yo/r left hand. 9ns"ect the "erianal area and an/s
o

8ook for rashes, excoriations, skin tags, anal 0arts, fist/lo/s o"enings, fiss/res, external haemorrhoids, abscesses, faecal soiling, blood, and m/c/s.

-sk the "atient to strain or :;=bear do0n:;> and 0atch for the "ro4ection of "ink m/c/sa of a rectal "rola"se. 8/bricate the ti" of yo/r right index finger 0ith the 4elly. 2egin by "lacing the "/l" of yo/r right index finger against the an/s in the midline and "ress in firmly b/t slo0ly.
o

Most anal s"hincters 0ill reflexly tighten 0hen to/ched b/t 0ill 3/ickly relax 0ith contin/ed "ress/re.

Chen the s"hincter relaxes, gently ad)ance the finger into the anal canal. -ssess anal s"hincter tone by asking the "atient to clench yo/r finger.

P.%OL

Gotate the finger back0ards and for0ards co)ering the f/ll 1O&#d, feeling for any thickening or irreg/larities. P/sh the finger f/rther:;</" to the hilt if "ossible:;<to the rect/m. Examine all 1O&#d by mo)ing the finger in s0ee"ing motions. Hote:
o o o

The "resence of thickening or irreg/larities of the rectal 0all. The "resence of "al"able faeces:;<and its consistency. -ny "oints of tenderness.

Hext, in the male, identify the "rostate gland 0hich can be felt thro/gh the anterior rectal 0all.
o

The normal "rostate is smooth,s/rfaced, firm 0ith a slightly r/bbery text/re meas/ring %,1cm diameter. 9t has % lobes 0ith a "al"able central s/lc/s.

Fently 0ithdra0 yo/r finger and ins"ect the glo)e for faeces, blood, or m/c/s and note the colo/r of the stool, if "resent. Tell the "atient that the examination is o)er and 0i"e any faeces or 4elly from the natal cleft 0ith the tiss/es. ome "atients may "refer to do this themsel)es. Thank the "atient and ask them to redress. No/ may need to hel".

7indings 9f any mass or abnormality is identified on the exterior or interior of the areas examined, its exact location sho/ld be noted. 9t is con)entional to record as the "osition on a clock face 0ith !% oRclock indicating the anterior side of the rect/m at the "erine/m. Other feat/res of the mass sho/ld be recorded as described on ".+S. 2enign "rostatic hy"er"lasia: the "rostate is enlarged b/t the central s/lc/s is "reser)ed, often exaggerated. Prostate cancer: the gland loses its r/bbery consistency and may become hard. The lateral lobes may be irreg/lar and nod/lar. There is often distortion or loss of the central s/lc/s. 9f the t/mo/r is large and has s"read locally, there may be thickening of the rectal m/cosa either side of the gland creating :;=0inging:;> of the "rostate.

Prostatitis: the gland 0ill be enlarged, boggy, and )ery tender.

:PQ Hints

9f the "atient ex"eriences se)ere "ain, 0ith gentle "ress/re on the anal o"ening, consider:;@ anal fiss/re, ischiorectal abscess, anal /lcer, thrombosed haemorrhoid, or "rostatitis. 9n this sit/ation, yo/ may ha)e to a""ly local anaesthetic gel to the anal margin before "roceeding. 9f in do/bt, ask a senior.

P.%OO The hernial orifices - hernia is an abnormal "rotr/sion of a str/ct/re, organ or "art of an organ o/t of the ca)ity in 0hich it belongs. - hernia can /s/ally be :;=red/ced:;> i.e. its contents ret/rned to the original ca)ity either s"ontaneo/sly or by mani"/lation. -bdominal hernias are /s/ally ca/sed by "ortions of bo0el "rotr/ding thro/gh 0eakened areas of the abdominal 0all. 9n the abdomen, hernias /s/ally occ/r at nat/ral o"enings of the abdominal 0all 5e.g. ing/inal canals, femoral canals, /mbilic/s, oeso"hageal hiat/s6 or ac3/ired 0eak s"ots s/ch as s/rgical scars. Most abdominal hernias ha)e an ex"ansile co/gh im"/lse,asking the "atient to co/gh 0ill :JW the intra,abdominal "ress/re ca/sing a )isible or "al"able im"/lse. trang/lation: hernias that cannot be red/ced 5irred/cible6 may become fixed and s0ollen as their blood s/""ly is occl/ded ca/sing ischaemia and necrosis of the herniated organ. The hernias are "ainf/lly s0ollen 0ith o)erlying erythema and may ca/se disr/"tion of normal g/t f/nction 5e.g. intestinal obstr/ction6. -n a""roach to hernias

Betermine the characteristics as yo/ 0o/ld any l/m" 5 ".+S6 incl/ding "osition, tem"erat/re, tenderness, sha"e, siAe, tension, and com"osition. Make note of the characteristics of the o)erlying skin. Pal"ate the hernia and feel for a co/gh im"/lse. -ttem"t red/ction of the hernia. Perc/ss and a/sc/ltate the hernia 5listening for bo0el so/nds or br/its6. -l0ays remember to examine the same site on the o""osite side.

9ng/inal hernias -natomy The ing/inal canal extends from the "/bic t/bercle to the anterior s/"erior iliac s"ine. 9n the male, it carries the s"ermatic cord 5)as deferens, blood )essels and ner)es6. 9n the female, it is m/ch smaller and carries the ro/nd ligament of the /ter/s. -fter testic/lar descent, the canal closes b/t the site is 0eakened. The internal ring is an o"ening in the trans)ersalis fascia lying at the miding/inal "oint, half0ay bet0een the anterior s/"erior iliac s"ine and the "/bic sym"hysis 5abo/t !.Lcm abo)e the femoral "/lse6.

The external ring is an o"ening of the external obli3/e a"one/rosis and is immediately abo)e and medial to the "/bic t/bercle 5see 7ig. +.!?6. Birect ing/inal hernia: this is herniation at the site of the external ring. 9ndirect ing/inal hernia: this is the most common site 5SLf of all hernias6. Herniation is thro/gh the internal ring 0ith bo0el or oment/m tra)elling do0n the ing/inal canal and may "rotr/de thro/gh the external ring into the scrot/m. More likely to strang/late than direct ing/inal hernias. P.%O' Examination The "atient sho/ld be examined standing,/" and /ndressed from the 0aist do0n 5some hernias may s"ontaneo/sly red/ce 0hen s/"ine6. Pal"ate es"ecially for tenderness and consistency of the l/m".
o o

Herniated oment/m 0ill a""ear r/bbery, non,fl/ct/ant, and d/ll to "erc/ssion. Herniated g/t 0ill be fl/ct/ant, resonant. No/ may be able to hear bo0el so/nds 0ithin the hernia.

Cith % fingers on the mass, ask the "atient to co/gh and feel for an ex"ansile co/gh im"/lse. -ttem"t to red/ce the hernia by massaging it back to0ards it s/s"ected site of origin.
o

7or indirect hernias, yo/ sho/ld /se the flat of yo/r hand, directing the hernia form belo0 and g/ide it thro/gh the external ring, /" the ing/inal canal laterally to0ards the internal ring.

Once red/ced, the hernia sho/ld not rea""ear /ntil yo/ release the "ress/re. Cith the hernia red/ced, try "ressing o)er the site of the internal ring and asking the "atient to co/gh. -n indirect hernia 0ill remain red/ced 0hereas a direct hernia 0ill "rotr/de once more.

7ig. +.!? ites of the internal and external ing/inal rings. P.%OS Table 9.2 Differentiation of inguinal hernias Indirect inguinal hernia Direct inguinal hernia Can descend into the scrot/m Mery rarely descends to the scrot/m Ged/ces /"0ards, laterally, back0ards Ged/ces /"0ards and back0ards Gemains red/ced 0ith "ress/re at the internal Hot controlled by "ress/re o)er the internal ring ring The ca/sati)e defect is not "al"able Befect in the abdominal 0all is "al"able Gea""ears at the internal ring and flo0s Gea""ears in the same "osition as before medially red/ction 7emoral hernias -natomy The femoral canal is the small com"onent of the femoral sheath medial to the femoral )essels and contains loose connecti)e tiss/e, lym"hatic )essels and lym"h nodes. 9t is bordered anteriorly by the ing/inal ligament, the "ectineal ligament "osteriorly, the femoral )ein laterally, and the lac/nar ligament medially. 7emoral hernias are "rotr/sions of bo0el or oment/m thro/gh this s"ace. They are more common in middle,aged and elderly 0omen and can easily strang/late d/e to the small, rigid o"ening they "ass thro/gh. Examination Examine 0ith the "atient standing /" and /ndressed from the 0aist do0n. Examine as yo/ 0o/ld any other hernia and attem"t red/ction.

9f "resent, a femoral hernia 0ill a""ear as a l/m" 4/st lateral and inferior to the "/bic t/bercle, abo/t %cm medial to the femoral "/lse.

P.%O+

2ox +.!+ Bifferential diagnosis of a femoral hernia 9ng/inal hernia. Mery large lym"h node.

Ecto"ic testicle. Psoas b/rsa or abscess. 8i"oma.

Other abdominal 0all hernias (mbilicalD"ara/mbilical: herniation thro/gh a defect near the /mbilic/s 5considered congenital if identified in children6. E"igastric: herniation thro/gh the linea alba abo)e the /mbilic/s.

"igalean: herniation thro/gh the linea semil/naris 5lateral to the rect/s sheath6, /s/ally belo0 and lateral to the /mbilic/s. Gare. Obt/rator: herniation thro/gh the obt/rator canal, associated 0ith increasing age and m/lti"arity. Perineal: herniation thro/gh the "el)ic floor dia"hragm. Gare. 9ncisional: Herniation thro/gh the site of "re)io/s s/rgery. The b/lge is /s/ally seen /nderlying a s/rface s/rgical scar. 9ncreasing incidence 0ith ad)anced age b/t can be ca/sed by 0o/nd infection and associated fasciitis or m/scle necrosis.

P.%'& 9m"ortant "resenting "atterns Chronic li)er disease -ny of the follo0ing feat/res may be seen. Cith se)ere disease and :;=decom"ensation:;>, more 0ill become a""arent:;@ :;g Ja/ndice. :;g P/r"/ra. :;g Palmar erythema. :;g Easy br/ising. :;g 8e/conychia. :;g E"istaxis. :;g Cl/bbing. :;g Menorrhagia. :;g "ider nae)i. :;g 8oss of libido. :;g Telangiectasia. :;g Hair loss. :;g He"atomegaly. :;g 2ilateral "arotid s0elling. :;g -scites. :;g Ence"halo"athy. :;g Mariceal bleeding,manifesting as haematemesis andDor melaena. :>h :>; :;g Fynaecomastia. :;g 2reast atro"hy. :;g Testic/lar atro"hy. :;g 9rreg/lar menses.

:;g 9m"otence. :;g -menorrhoea. Portal hy"ertension Gaised "ress/re in the he"atic "ortal )ein often secondary to li)er disease or non,cirrhotic ca/ses s/ch as "ortal )ein thrombosis. Ca/ses "orto,systemic sh/nting and oeso"hageal )arices. igns: 7etor he"atic/s "lenomegaly

Gisk of gastrointestinal blood loss from )arices 5anaemia, haematemesis, melaena6 -scites Ca"/t med/sae.

-lcoholic li)er disease May ca/se all the feat/res of chronic li)er disease as described abo)e. 9n addition, alcohol de"endency or addiction is associated 0ith: Tolerance. Cithdra0al sym"toms.

-lcohol taken in larger amo/nts and for longer than intended. Persistent desire to :;=c/t do0n:;>. Excessi)e time s"ent in acti)ities related to alcohol intake. -bandoning social, occ/"ational or recreational acti)ities. Contin/ed /se des"ite an a0areness of the ad)erse "hysiological and "sychological effects of contin/ed /se.

7atty li)er :;=He"atic steatosis:;> and has many other ca/ses incl/ding dr/gs, "regnancy and diabetes mellit/s. Be"osition of fat as a res/lt of "referential alcohol oxidation. Ge)ersible 0ith abstinence b/t may "roceed to cirrhosis 0ith contin/ed /se. Ho s"ecific clinical feat/res. P.%'! -lcoholic he"atitis He"atocell/lar inflammation 0ith lym"hocyte infiltration, steatosis, cholestasis, fibrosis and necrosis. Clinical feat/res incl/de: 7e)er. Ja/ndice.

Tender he"atomegaly. May hear a br/it o)er the li)er.

Cirrhosis

e)ere he"atic fibrosis 0ith :;=micronod/les:;>. 8oss of he"atocytes, im"aired synthetic f/nction and "ortal hy"ertension. Other ca/ses of cirrhosis incl/de chronic )iral he"atitis 52 or C6, sclerosing cholangitis, CilsonRs disease, haemachromotosis, iT!,antitry"sin deficiency, "rimary biliary cirrhosis, 2/dd,chiari syndrome and se)eral dr/gs 5e.g. amiodarone, methyldo"a and methotrexate6. Clinical feat/res can be any of those listed /nder :;=chronic li)er disease:;> abo)e. Extra,he"atic manifestations of alcoholic li)er diseaseDalcoholism Obesity or maln/trition. Biarrhoea.

Fastric erosions. Pe"tic /lcer disease. Pancreatitis. Marices. -scites. "lenomegaly. Hy"ertension. 8oss of %#d sex/al characteristics. Osteomalacia. Osteo"orosis. 7alls. eiA/res. Cogniti)e im"airment 5 Metabolic ence"halo"athy. Peri"heral ne/ro"athy. -taxic gait 5 ".1L&6. ".L&%6.

CernickeRs ence"halo"athy. ZorsakoffRs syndrome. Cardiomyo"athy. -rrythmias 5es". atrial fibrillation6.

He"atic ence"halo"athy h/nting of blood a0ay from the "ortal circ/lation, seen in chronic li)er disease, allo0s "otentially ne/rotoxic s/bstances absorbed in the g/t to by"ass the li)er 0here they 0o/ld normally be remo)ed. ee OHCMO, ".%1& for management. He"atic ence"halo"athy is graded as follo0s :;@ Frade & Hormal mental state Frade 9 -ltered mood or beha)io/r 5:JK attention s"an, diffic/lty 0ith n/mbers and lack or a0areness6 Frade 99 :JW dro0siness, sl/rred s"eech, mildDmod conf/sion Frade t/"or b/t res"onsi)e to stim/li, significant conf/sion, restlessness 999 Frade Coma 9M P.%'% Malabsor"tion H/mero/s disorders can ca/se malabsor"tion states. They can be gro/"ed as "ancreatic ins/fficiency, bile salt malabsor"tion, small bo0el m/cosa defects 5coeliac disease, tro"ical s"r/e, giardiasis, disaccharidase deficiency, Chi""leRs disease, short bo0el syndrome6, bacterial o)ergro0th, and s"ecific deli)ery defects. Feneral sym"toms and signs of malabsor"tion incl/de: M/scle 0asting. Ceight loss.

Pallor. Biarrhoea 50atery6. teatorrhoea: "ale, fatty stools; offensi)e smelling and diffic/lt to fl/sh. Flossitis. -ng/lar stomatitis 5)itamin 2%, 2!% and folic acid deficiencies6. 9ntra,oral "/r"/ra and easy br/ising 5)itamin Z deficiency6. 7ollic/lar keratitis: hy"erkeratotic 0hite "atches 5)itamin - deficiency6.

-c/te "ancreatitis 5see also OCHMO, ".?'S6 ym"toms Pain:;<central abdominal or e"igastric, radiating thro/gh to the back. ometimes relie)ed slightly by sitting for0ards. Momiting. igns

Tachycardia. 7e)er. Ja/ndice 5rarely6. Peritonitis 5bo0el ile/s, )ery tender abdomen, g/arding6. Getro"eritoneal bleed: C/llenRs or Frey,T/rnerRs signs 5 ".%?+6.

Chronic "ancreatitis 9n de)elo"ed co/ntries, the commonest ca/se is chronic hea)y alcohol intake. ee OHCMO, ".%L% for more information. - small gro/" of "atients can inherit chronic "ancreatitis thro/gh an a/tosomal dominant gene 0ith incom"lete "enetrance. Clinical feat/res are /s/ally d/e to "ancreatic enAyme deficiencies and malabsor"tion and chronic "ain. There may be ac/te exacerbations, "resenting as ac/te "ancreatitis. 8oss of "ancreatic endocrine f/nction may ca/se diabetes. Cholangitis 2iliary se"sis. /ggested by :;=CharcotRs triad:;>: Gight /""er 3/adrant "ain. 7e)er.

Ja/ndice. ".%L16.

No/ may also be able to elicit M/r"hyRs sign 5 P.%'1

Coeliac disease - common ca/se of malabsor"tion. -ffects ! in %&&& in the (Z 5! in 1&& in 9reland6. T,cell mediated a/toimm/ne disease of the small bo0el m/cosa characteriAed by )illo/s atro"hy and :JW intra,e"ithelial lym"hocytosis in res"onse to ingestion of gl/ten. 7or treatment and "rognosis, see OHCMO, ".%L%. Fl/ten is a high,molec/lar 0eight com"o/nd containing gliadins and "e"tides. 7o/nd in a h/ge n/mber of fo/nds containing 0heat, barley and rye. Contro)ersy exists o)er eating oats. Clinical feat/res: ym"toms Tiredness. Malaise.

Biarrhoea or steatorrhoea. -bdominal discomfort and bloating. Ceight loss.

-nxiety. Be"ression. Peri"heral "araesthesia. M/scle 0asting. Mo/th /lceration. -ng/lar stomatitis. -nkle oedema 5lo0 ser/m alb/min6. Polyne/ro"athy. M/scle 0eakness. Tetany.

igns

-ssociated 0ith -/toimm/ne thyroid disorders, chronic li)er disease, fibrosing al)eolitis, /lcerati)e colitis, ins/lin,de"endent diabetes mellit/s. Possible com"lications to be a0are of mall bo0el lym"homa 5rare6. mall bo0el adenocarcinoma 5rarer6.

(lcerati)e 4e4/nitis. "lenic atro"hy. -naemia. Osteomalacia. Osteo"orosis. econdary lactose intolerance.

P.%'? 9nflammatory bo0el disease: /lcerati)e colitis 5(C6 - chronic rela"sing disease of /nkno0n aetiology in)ol)ing s/"erficial inflammation of the colonic m/cosa, starting from the rect/m and 0orking "roximally 0itho/t any breaks. The terminal ile/m may be affected by :;=back0ash ileitis:;>. ee also Periods of remission may gi)e no sym"toms at all. ym"toms Biarrhoea 5often 0ith blood or m/c/s6. OHCMO, ".%??.

Ceight loss. 7e)er. -bdominal "ain. Procitis may ca/se rectal bleeding, m/c/s, tenesm/s, and consti"ation.

Com"lications to be a0are of: Toxic megacolon. 9ron deficiency anaemia.

:JW risk of colorectal carcinoma. 7ist/la,formation 5rare6.

9nflammatory bo0el disease: CrohnRs disease 8ike /lcerati)e colitis 5abo)e6, this is a chronic inflammatory disease of the gastrointestinal tract b/t differs from (C in that lesions occ/r any0here from mo/th to an/s b/t es"ecially at the terminal ile/m and ano,rect/m. Pathology in)ol)es dee" /lceration, :;=cobblestoning:;> of the m/cosa, fiss/ring and abscess formation 0ith :;=ski" lesions:;> and non,caseating gran/lomas. ee also OHCMO, ".%?O. ym"toms 9f disease is limited to the colon, sym"toms may be identical to (C. 8oose stools or diarrhoea 5/s/ally not bloody6. -norexia.

Malaise. Ceight loss. -bdominal "ain 5insidio/s, often in the right lo0er 3/adrant6. Perianal "ain. Joint "ains.

Hote on examination:;@ 5these can occ/r in (C also6 -"htho/s mo/th /lcers. ()eitis.

-naemia. -rthro"athy.

-cti)e CrohnRs disease Colicky "ain often in the right iliac fossa. May ha)e diarrhoea 0ith blood and m/c/s.

Ceight loss. 2orborygm/s 5 ".%O%6.

May be a "al"able inflammatory mass in the right iliac fossa. -bdominal distension. #T 2o0el obstr/ction.

P.%'L -cti)e CrohnRs colitis imilar "resentation to /lcerati)e colitis. Perianal disease more likely to "rod/ce fiss/ring and fist/la formation. Com"lications to be a0are of 7ist/la formation 5from the bo0el to any other abdominal organ or the exterior6. mall :JW risk of colorectal carcinoma 5es"ecially in long,standing disease limited to the colon6.

Mitamin 2!% deficiency. 9ron deficiency. -bscess formation. trict/re formation. ystemic infection.

Extra,intestinal feat/res of inflammatory bo0el disease ero,negati)e arthro"athy of large or small 4oints 5"eri"heral, non,deforming, "artic/larly at the knees, ankles, and 0rists6. acroiliitis.

-nterior /)etitis. Erythema nodos/m. Pyoderma gangrenos/m. (reteric calc/li. Fallstones. clerosing cholangitis.

Cholangiocarcinoma. H/tritional deficiencies 5Osteo"orosisE OsteomalaciaE6 2ile salt malabsor"tion Osteo"orosis secondary to long,term steroid /se or malabsor"tion. ystemic amyloidosis.

9rritable bo0el syndrome,Gome 99 diagnostic criteria -t least !% 0eeks, 0hich need not be consec/ti)e, in the "receding !% months of abdominal discomfort or "ain that has % o/t of 1 feat/res: Gelief 0ith defaecation. Onset associated 0ith a change in fre3/ency of stool.

Onset associated 0ith a change in form of stool.

Other sym"toms 0hich s/""ort the diagnosis of 92 : -bnormal stool fre3/ency 5*1Dday or V1D0eek6. -bnormal stool form 5l/m"yDhard, looseD0atery6.

-bnormal stool "assage 5straining, /rgency, feeling of incom"lete e)ac/ation6. Passage of m/c/s. 2loating or feeling of abdominal distension.

P.%'O The elderly "atient Fastrointestinal disease "resents as a h/ge s"ectr/m in elders, encom"assing n/trition, oral care, and continence in addition to the range of "resentations described in this cha"ter. Chilst many older "eo"le s/ffer gastrointestinal sym"toms, often d/e to /nderlying illnesses or the effect of medication, they may be embarrassed abo/t disc/ssing them. Tho/ghtf/l and holistic assessment is "aramo/nt, and sim"le inter)entions can "ay di)idends. History Oral care: is often o)erlooked, b/t a key "art of any assessment. Bent/res may be ill fitting or lost, and dietary intake can s/ffer as a conse3/ence, and hos"ital in"atients are "artic/larly "rone to losing their dent/res. Clarify sym"toms and diagnoses: Boes the "atient really ha)e an irritable bo0elE 5 ee belo0.6 Many "atients may describe themsel)es as ha)ing s/ch diagnoses, b/t take the time to clarify 0hat this means. Gecent changes of bo0el habit, e)en in later life m/st al0ays be )ie0ed 0ith a degree of alarm and ca/ses considered.

Consti"ation: can often lead to serio/s decline in "atients 0ith consti"ation. This is often easily remediable.

Ceight and n/trition: ask yo/rself 0hy has the "atient lost 0eight. The range of diagnoses is broad, b/t contem"late mood, dietary habits, and f/nctional abilities in yo/r assessments,it may be a matter of dislike of deli)ered froAen mealsU Br/g history: al0ays consider the side effects of medication,analgesics and consti"ation, recent antibiotics, and diarrhoea. -sk abo/t o)er,the,co/nter dr/gs incl/ding H -9Bs 5to"ical dr/gs tooU6 and a"erients. Continence: another key "art of the assessment; try to disc/ss sensiti)ely and determine if there factors additional to any F9 dist/rbance, incl/ding mobility, cognition and )is/al "roblems. This do)etails 0ith the e)er im"ortant f/nctional history.

Examination Feneral: look o/t for signs of 0eight loss:;<0asting, "oorly fitting clothes etc. 7or in"atients, a com"leted 0eight chart and caref/l consideration may alle)iate some of the "roblems of "oor n/trition and ac/te illness. 8ook in the mo/th: as a range of diagnoses is often a""arent. Bent/re care sho/ld be assessed 5"oor cleaning associated 0ith rec/rrent stomatitis6, and other "roblems s/ch as oral candida are ob)io/s.

Obser)e: for other signs of systemic disease that might "oint to the ca/se of the gastrointestinal sym"toms 5e.g. m/lti"le telangiectasia, )al)/lar heart disease in F9 bleeding6. Examine: thoro/ghly for lym"hadeno"athy. Gemember to examine hernial orifices:;<the ca/se of abdominal "ain may be instantly ob)io/s:;<and correctable. Gectal examination: )ital,changes in bo0el habit, continence, iron deficiency anaemia, bladder sym"tomatology all indicate this.

P.%'' Biagnoses not to be missed 7/nctional bo0el disorders: tend to be less common in older "eo"le, so al0ays consider /nderlying organic "roblems. Endosco"ic examinations are often 0ell tolerated and ha)e a good diagnostic yield. 2iliary se"sis: is the 1rd most common so/rce of infection in older "eo"le 5after chest and /rine se"sis6, and may lack many of the salient "resenting feat/res described "re)io/sly in this cha"ter. 2e alert to this "ossibility 0hen considering differential diagnoses and choosing antibiotics. Ce thank Br Gichard 7/ller for "ro)iding this "age.

Editor: Thomas, James, Monaghan, Tanya J/d/l: 2/k/ Pegangan Oxford Pemeriksaan Zlinis dan Zeteram"ilan Praktis, Edisi ! Co"yright $ %&&' Oxford (ni)ersity Press * Baftar 9si* 2ab + , -bdomen 2ab + The -bdomen P.%%% Tera"an anatomi "er/t ini meli"/ti "erine/m, genitalia eksternal dan internal dan daerah ing/inal. Ham/n, kom"onen ini dibahas dalam 2ab !% dan !1. 2atas "er/t ini didefinisikan sebagai 0ilayah yang terletak di antara dada atas dan rongga "angg/l di ba0ah ini. Binding anterior abdomen berbatasan dengan kartilago kosta ' sam"ai !% dan "roses xi"hoid dari stern/m s/"erior dan ligamen ing/inal dan t/lang "angg/l inferior. Gongga "er/t di"isahkan dari rongga dada oleh diafragma. Tidak ada delineasi terseb/t, nam/n, antara "er/t dan "angg/l dan, sebagai akibatnya, definisi ber)ariasi. 9si "er/t "er/t ini berisi str/kt/r yang mer/"akan bagian dari ham"ir setia" sistem t/b/h. Organ "encernaan dari eso"hag/s, "er/t, /s/s kecil, /s/s besar dan organ,organ yang terkait 5hati, kand/ng em"ed/ dan sistem em"ed/, "ankreas eksokrin6 sem/a terletak di dalam "er/t. 2agian endokrin dari "ankreas, kelen4ar adrenal dan gonad mer/"akan sistem endokrin. Bari sistem kardio)ask/lar aorta abdominalis dengan cabang,cabang "enting /nt/k hati, lim"a, /s/s, gin4al, dan t/ngkai ba0ah. istem im/nologi di0akili oleh lim"a. Zelen4ar getah bening sekitarnya bebera"a aorta dan /s/s dan 4aringan M-8T dalam /s/s it/ sendiri. el/r/h sistem /rin hadir 5gin4al, /reter, kand/ng kemih, dan /retra6. Perl/ diingat bah0a, sama se"erti dada, "er/t dibatasi oleh la"isan yang agak ti"is 4aringan bermembran: "eritone/m. 9ni adalah ; lining: ganda j: ; c "arietal: ; > "eritone/m meli"/ti "erm/kaan internal dari dinding "er/t sedangkan ; c : ; > )isceral: "eritone/m meli"/ti organ. -ntara d/a la"isan 5: ; c "eritoneal ca)ity: ; >6 adalah se4/mlah kecil cairan yang berf/ngsi sebagai "el/mas yang mem/ngkinkan isi "er/t /nt/k bergerak terhada" sat/ sama lain sebagai "er/bahan ata/ "osisi t/b/h, misalnya, sebagai contorts /s/s dengan gerak "eristaltik. eb/ah organ bebera"a "ilih terletak di belakang "eritone/m "ada dinding "osterior abdomen.

Mereka adalah "ankreas, sebagian dari d/oden/m, kolon naik dan t/r/n dan gin4al. Baerah "er/t Binding anterior abdomen secara artifisial terbagi men4adi + bagian /nt/k t/4/an deskri"tif. ? baris khayalan da"at ditarik 5lihat Fambar +.!.6 # ; k l ! garis horiAontal antara d/ri iliaka anterior s/"erior. l ! garis horiAontal antara batas ba0ah t/lang r/s/k. l % garis )ertikal "ada titik "ertengahan kla)ik/laris. (nt/k memb/at hid/" lebih m/dah, "er/t 4/ga bisa dengan sederhana dibagi men4adi ? k/adran dengan membayangkan ! horisontal dan ! garis )ertikal "ersim"angan di /mbilik/s 5lihat Fambar. +.%6. P.%%1

Fambar. +.! + segmen dinding anterior abdomen. is0a har/s membiasakan diri dengan ini bersama dengan organ,organ berbaring di daerah masing,masing. Fambar. +.% ? k/adran dari dinding anterior abdomen. P.%%? Oeso"hageal ge4ala Bisfagia 9ni adalah kes/litan menelan dan mer/"akan ge4ala /tama dari "enyakit esofag/s. 5. 8ihat Zotak +.! /nt/k "enyebab "enting6 Zetika seorang "asien mengel/h disfagia -nda har/s ber/saha /nt/k meneta"kan: l Tingkat obstr/ksi: mana "asien merasa makanan D menem"el cairE Pasien seringkali da"at men/n4/kkan tingkat di dada meski"/n sensasi biasanya berkorelasi b/r/k dengan tingkat yang sebenarnya dari halangan. l Onset: ce"at 2agaimana ge4ala m/nc/lE Obstr/ksi yang disebabkan oleh kanker, misalnya, m/ngkin kema4/an agak ce"at selama bebera"a b/lan sedangkan dengan strikt/r "e"tik/m 4inak m/ngkin menggambarkan se4arah yang sangat "an4ang FEGB dan disfagia "rogresif. l Z/rs/s: intermittentE Hadiah /nt/k hanya menelan "ertama 5cincin esofag/s bagian ba0ah, ke4ang6E Progresif 5kanker, "enyem"itan, achalasia6E l olids D cairan: baik "adatan dan cairan yang ter"engar/h sama men/n4/kkan "enyebab motor 5achalasia, ke4ang6. Ham/n, 4ika "adatan di"engar/hi lebih dari cairan, bebera"a rintangan fisik lebih m/ngkin 5kanker misalnya6. l -ssociated ge4ala: sakit maag 5menyebabkan strikt/r esofag/s6, "en/r/nan berat badan, 0asting, kelelahan 5m/ngkin s/gestif dari kanker6. 2at/k dan tersedak menyarankan ; c : ; > dys"hagia: faring akibat disf/ngsi motor 5misalnya "enyakit motor ne/ron menyebabkan kel/m"/han b/lbar,ata/ "se/dob/lbar6. Odyno"hagia 9ni adalah nyeri saat menelan. 2iasanya sensasi s/bsternal agak tidak menyenangkan selama menelan dan s/gestif dari "eradangan esofag/s 5oeso"hagitis: ; infektif jcandidida, her"es,

cytomegalo)ir/s, /lserasi "e"tik/m, ker/sakan a"i, "erforasi esofag/s6. 9ngatlah /nt/k meminta "enyebab "otensial selama BHx. M/las dan asam s/r/tnya J/ga dikenal sebagai "enyakit refl/ks gastro,esofageal 5FEGB6. Hal ini disebabkan oleh reg/rgitasi isi lamb/ng ke dalam kerongkongan karena adanya mekanisme anti,refl/ks tidak kom"eten di "ersim"angan gastro,esofag/s. 7it/r khas l it/s: "ertengahan,line, retrosternal l Gadiasi: /nt/k tenggorokan dan kadang,kadang daerah infra,ska"/lae l ifat: : ; c b/rning: ; > l mem"er"arah faktor: b/r/k setelah makan dan ketika "ost/r "erforming yang meningkatkan tekanan intra,abdomen 5memb/ngk/k, memb/ngk/k, berbaring terlentang6. J/ga lebih b/r/k selama kehamilan. l -ssociated Fe4ala: eringkali disertai dengan rasa asam ata/ "ahit 5reg/rgitasi asam6 ata/ tiba, tiba "engisian m/l/t dengan l/dah I 5: ; c 0aterbrash: ; >6 -cid refl/x m/ngkin di"erb/r/k oleh makanan tertent/ 5alkohol, kafein, coklat, makanan berlemak6 dan bebera"a obat 5calci/m channel blockers, antikolinergik6 yang bertindak /nt/k : J jtekanan sfingter Pemerintah Je"ang. Hiat/s hernia mer/"akan "enyebab "enting refl/x sym"toms: ; j"astikan /nt/k menanyakan tentang hal ini dalam se4arah. P.%%L Pencernaan yg tergangg/ (m/mnya dikenal sebagai gangg/an "encernaan. angat /m/m dan m/nc/l sebagai berbagai ge4ala termas/k: l -tas ketidaknyamanan "er/t l Zemb/ng l bersenda0a. -nda har/s 0as"ada /nt/k fit/r s/gestif dari "atologi yang seri/s 5anemia, berat badan, disfagia, kehilangan PG darah, melaena, dan massa "er/t6. Zotak +.! 2ebera"a "enyebab disfagia l Oral: menyakitkan /lserasi m/l/t, lisan, ata/ infeksi tenggorokan. l He/rologis: "eristi0a serebro)ask/lar, b/lbar dan "se/dob/lbar "alsies, myasthenia gra)is. l Bysmotility: achalasia, sclerosis sistemik, "resbyoeso"hag/s. l Teknik: kantong faring, kanker oeso"hageal, strikt/r "e"tik/m, strikt/r 4inak lainnya, kom"resi ekstrinsik dari kerongkongan 5misalnya "ar/,"ar/ besar ata/ t/mor tiroid6. P.%%O M/al, m/ntah, dan m/ntahan M/al dan m/ntah l M/al I: "erasaan sickness: ; jkecender/ngan /nt/k m/ntah. 9ni biasanya ter4adi "ada gelombang dan m/ngkin terkait dengan m/ntah ata/ sesak. Hal ini da"at berlangs/ng dari detik /nt/k hari tergant/ng "ada "enyebabnya. l M/ntah 5emesis6: biasanya mengik/ti ge4ala m/al dan otonom se"erti air li/r. 9ni adalah

"eng/siran k/at dari isi lamb/ng oleh kontraksi refleks dari otot,otot dada dan "er/t. # ; c m/ntah centre: ; > ada di med/la dan terdiri dari banyak inti eferen dalam kom/nikasi serial dengan sat/ sama lain. Zetika sel/r/h rangkaian diaktifkan oleh rangsangan aferen, set lengka" tindakan yang dib/t/hkan /nt/k menyebabkan m/ntah yang di"ic/. Pemilihan 0akt/ -nda har/s 4elas tentang ka"an te"atnya m/ntah cender/ng occ/r: ; jter/tama kaitannya dengan makan misalnya m/ntah tert/nda selama* ! 4am setelah makan adalah s/gestif dari obstr/ksi gastro,esofageal ata/ gastro"aresis. m/ntah "agi dini khas kehamilan ata/ "eningkatan tekanan intrakranial. ifat m/ntahan Cala/"/n tidak menyenangkan, -nda har/s bertanya tentang sifat yang te"at dari berbagai bahan m/ntah dan ber/saha /nt/k melihat sam"el, 4ika m/ngkin. Barah 5hematemesis6 Zehadiran darah men/n4/kkan "endarahan "ada sal/ran "encernaan bagian atas 5kerongkongan, lamb/ng, d/oden/m6. e4arah "erdarahan har/s dieks"lorasi dalam konteks ge4ala "er/t lainnya. Tanyakan ter/tama tentang: l J/mlah darah dan sifat yang te"at dari it/ 5lihat Zotak +.16. l "erdarahan ebel/mnya e"isode, "engobatan dan hasil 5misalnya o"erasi sebel/mnyaE6 l Gokok merokok. l Pengg/naan obat,obatan se"erti as"irin, H -9Bs dan 0arfarin. l 9ngatlah /nt/k bertanya tentang berat badan, disfagia, sakit "er/t dan melaena 5mem"ertimbangkan kem/ngkinan "enyakit neo"lastik6. Em"ed/ Menilai ada ata/ tidak adanya em"ed/. 9ngat bah0a em"ed/ sebagian besar berasal dalam % colo/rs: ; "igmen jhi4a/ 5bili)erdin6 sering terlihat 0arna m/ntahan dalam ketiadaan makanan tercerna. Pigmen k/ning 5bilir/bin6 m/nc/l sebagai 4er/k, sering ter4adi "ada ben4olan kecil .II makanan tercerna tan"a em"ed/ men/n4/kkan k/rangnya h/b/ngan antara "er/t dan /s/s kecil 5misalnya obstr/ksi "ilor/s6. P.%%' Zotak +.% Penting "enyebab m/ntah l -k/t: infeksi sal/ran F9 5Fastroenteritis )ir/s misalnya : ; c makanan "oisoning: ; > Hor0alk, he"atitis )ir/s6, infeksi bakteri sistemik, obstr/ksi /s/s mekanik, intoksikasi alkohol, F9 bagian atas ak/t berdarah, infeksi sal/ran kemih. l kronis: kehamilan, /raemia, obat,obatan 5narkotika, digitalis, aminofilin, kemotera"i kanker6, gastro"aresis 5diabetes melit/s, skleroderma, obat,obatan6. l 8ainnya: "enyakit /lk/s "e"tik/m, gangg/an motor 5"asca,o"erasi ata/ disf/ngsi otonom6, "enyakit he"atobiliary, alkoholisme, kanker. :,Q Jangan l/"a sistem saraf tentang "/sat dan masalah )estib/lar. Zotak +.1 Penyebab "erdarahan F9 atas l (lk/s "e"tik/m l Erosi)e ata/ esofagitis /lseratif l Fastritis l )arises 5esofag/s D lamb/ng6 l lamb/ng dan t/mor esofag/s

l Mallory,Ceiss air mata l Bie/lafoyRs lesi l Masc/lar anomali 5angiodys"lasia misalnya, malformasi -M6 l Herediatory telangectasia "endarahan l gangg/an 4aringan ikat l Mask/litis l Perdarahan gangg/an. Zotak +.? ifat hematemesis l )ol/me besar segar, darah merah men/n4/kkan "erdarahan aktif 5co,insiden "enyakit hati dan D ata/ kons/msi alkohol berat m/ngkin menyarankan "erdarahan )arises esofag/s, sakit "er/t dan m/las menyarankan s/mber lamb/ng ata/ esofag/s se"erti /lserasi "e"tik/m ata/ FEGB6. l goresan kecil "ada akhir m/ntah yang berke"an4angan da"at men/n4/kkan tra/ma esofag/s kecil di Pemerintah Je"ang 5Mallory,Ceiss air mata6. l Zo"i,dasar: ini adalah istilah yang dig/nakan /nt/k darah yang telah : ; c altered: > ; oleh "a"aran asam lamb/ng. Tam"aknya coklat dan di ben4olan kecil. P.%%S akit "er/t e"erti rasa sakit di 0ilayah lain, sakit "er/t yang sangat m/ngkin hadir dalam cara yang berbeda dan memiliki banyak "enyebab yang berbeda. -nda har/s meneta"kan lokasi, radiasi, beratnya, karakter, frek/ensi, d/rasi, faktor,faktor mem"erb/r/k ata/ menghilangkan, dan ge4ala terkait. it/s e"erti sebagian besar organ, yang berada di "er/t tidak bisa dirasakan directly: ; jrasa sakit diseb/t daerah dinding "er/t men/r/t asal embriologis organ 5lihat Fambar. 2erla0anan6. l Minta "asien /nt/k men/n4/k ke daerah yang terkena. Mereka sering menem/kan hal ini menantang dan da"at men/n4/kkan bidang yang l/as. Balam hal ini, minta mereka /nt/k mengg/nakan c : ; ! finger: ; > dan titik ke daerah intensitas maksim/m. : ; c F/nakan sat/ 4ari dan men/n4/k ke tem"at rasa sakit 0orst.: ; > Zotak +.L it/s sakit "er/t dan asal embryologic l e"igastri/m: foreg/t 5lamb/ng, d/oden/m, hati, "ankreas, kand/ng em"ed/6 l Peri/mbilical: midg/t 5/s/s kecil dan besar termas/k lam"iran6 l s/"ra"/bik: hindg/t 5d/b/r dan organ /rogenital6 Gasa sakit yang sangat lokal m/ngkin berasal dari "eritone/m "arietalis. Misalnya a""endicitis: ; jm/ngkin m/lai sebagai nyeri "/sar 5dir/4/k dari lam"iran6 kem/dian : ; c mo)e: ; > ke fosa iliaka kanan sebagai "eradangan menyebar ke "eritone/m a"endiks atasnya. Gadiasi Minta "asien 4ika rasa sakit dirasakan di tem"at lain ata/ 4ika mereka memiliki sakit lain 5mereka tidak da"at mengaitkan rasa sakit ter"ancar dengan rasa sakit "er/t6. 2ebera"a contoh termas/k: l Hak t/lang belikat: kand/ng em"ed/ l 2ah/,ti": iritasi diafragma l Mid,kembali: "ankreas. Zarakter Tanyakan "ada "asien a"a 4enis rasa sakit it/. 2erikan bebera"a contoh 4ika mereka mengalami kes/litan ta"i hati,hati tidak /nt/k memim"in "asien. 2ebera"a contoh termas/k:

l Zolik: ini adalah rasa sakit yang datang dan "ergi dalam gelombang dan men/n4/kkan obstr/ksi dari organ, berongga berdinding otot 5/s/s, kand/ng em"ed/, sal/ran em"ed/, /reter6. 2/rning l: biasanya men/n4/kkan "enyebab asam dan berh/b/ngan dengan d/oden/m, "er/t ata/ /4/ng ba0ah kerongkongan. Mem"erb/r/k D menghilangkan faktor Tanyakan "ada "asien a"a yang m/nc/l /nt/k memb/at rasa sakit it/ lebih baik ata/ 0orse: ; jata/ a"a yang mereka lak/kan /nt/k kel/ar dari rasa sakit 4ika mereka menderita dari it/ sering. P.%%+

Fambar. +.1 sit/s Zhas sakit men/r/t asal. Tem/an 2ebera"a karakteristik nyeri: l gin4al kolik: nyeri kolik "ada gin4al s/d/t # T "inggang, yang lemb/t menyent/h, men4alar ke groin D testis D labia. 2iasanya, "asien 0rithes sekitar, tidak da"at menem/kan "osisi yang meng/rangi rasa sakit. l Zand/ng kemih Hyeri: sakit "arah menyebar di daerah s/"ra"/bik. l "rostat nyeri: sakit t/m"/l yang da"at dirasakan di "er/t bagian ba0ah, rekt/m, "erine/m ata/ "aha anterior. l nyeri /retra: )ariabel dalam "resentasi m/lai dari : ; c ketidaknyamanan tickling: ; > /nt/k sakit ta4am "arah dirasakan "ada akhir /retra 5/4/ng "enis "ada "ria6 dan di"erb/r/k oleh berkemih. 2isa begit/ "arah sehingga "asien ber/saha /nt/k : ; c tahan Ona > ; /nt/k /rin menyebabkan masalah lebih banyak lagiU l Obstr/ksi /s/s hal/s: kolik sakit "/sat yang berh/b/ngan dengan m/ntah, distensi "er/t # T sembelit. l kolon nyeri: se"erti di atas di ba0ah : ; c bo0el: kecil ; > ta"i kadang,kadang sementara lega oleh defaecation ata/ kent/t yang le0at. l iskemia /s/s: k/sam, berat, konstan, k/adran kanan atas D nyeri "er/t "/sat di"erb/r/k dengan makan. l bilier nyeri: "arah, konstan, k/adran kanan atas D nyeri e"igastri/m yang da"at 4am terakhir dan sering lebih b/r/k setelah makan makanan berlemak. l "ankreas nyeri: e"igastri/m, men4alar ke belakang dan sebagian lega dengan d/d/k dan bersandar ke de"an. l "e"tik/m /lk/s nyeri: t/m"/l, nyeri terbakar di e"igastri/m. 2iasanya e"isodik "ada malam hari, membang/nkan "asien dari tid/r. Bi"erb/r/k dengan makan dan kadang,kadang lega dengan mengkons/msi s/s/ ata/ antasida. P.%1& (s/s kebiasaan Pasien har/s diminta sebera"a sering mereka memb/ka "er/t mereka dan 4ika ini telah ber/bah bar/,bar/ ini. Tanyakan 4/ga tentang ge4ala lain "ada halaman ini. embelit eb/ah gangg/an yang da"at berarti hal yang berbeda bagi orang yang berbeda. Hormal berkisar

kebiasaan b/ang air besar dari 1 D hari kali /nt/k setia" 1 hari. : ; c Consti"ation: ; > adalah bagian dari Vkotoran 1 kali D mingg/, ata/ kotoran yang s/lit ata/ s/lit /nt/k l/l/s. e4arah menyel/r/h har/s mencak/": l B/rasi konsti"asi. l /k/ran dan konsistensi tin4a. l saring, ter/tama "ada akhir e)ak/asi. l -sosiasi ge4ala 5m/al, m/ntah, "en/r/nan berat badan6. l Hyeri "ada defaecation. l "erdarahan rektal. l diare 9nterc/rrentE l 7l/ida dan as/"an serat. l Be"resi, k/rang olahraga. l BHx 5rese" dan o)er,the,co/nter6. Ter/tama kodein, antide"resan, al/mini/m dan kalsi/m antasida. l metabolik ata/ "enyakit endokrin 5gangg/an tiroid, hi"erkalsemia, diabetes, "haechromocytoma, "enyakit Hirshs"r/ngRs6. l He/rologis masalah 5ne/ro"ati otonom, cedera t/lang belakang, m/lti"le sclerosis6. Biare Bidefinisikan sebagai "eningkatan )ol/me tin4a 5* %&&ml setia" hari6 dan frek/ensi 51Dhari6. J/ga "er/bahan konsistensi tin4a semi,formed ata/ cair. -nda har/s meneta"kan "rogram 0akt/ se4ak diare ak/t adalah infeksi s/gestif. Tanyakan ter/tama tentang: l Carna, konsistensi, ba/ ofensif, kem/dahan memerah. l B/rasi. l -"akah diare menggangg/ tid/r "asienE l -"akah ada ada darah, lendir, ata/ nanahE l -sosiasi nyeri ata/ kolikE l -"akah ada /rgensiE l M/al, m/ntah, "en/r/nan berat badanE l Perbedaan 4ika "/asa "asienE o Tidak ada "er/bahan dalam : ; c ; > secretory: diarrhoea: ; jmisalnya E. coli, ta"h. ta"hylococc/s. o menghilang "ada "/asa: : ; c osmotic: ; > diare. l -sing "er4alanan. l Terbar/ antibiotik. P.%1! Zotak +.O 2ebera"a "enyebab sembelit l Biet rendah serat. l imobilitas fisik. l Penyakit /s/s 7/ngsional. l Obat,obatan 5o"iat misalnya, antide"resan, al/mini/m, antasida6. l metabolik dan "enyakit endokrin 5misalnya hi"otiroidisme, hi"erkalsemia hi"okalemia, diabetes mellit/s, "orfiria, 7eokromositoma6.

l gangg/an ne/rologis 5misalnya ne/ro"ati otonom, cedera t/lang belakang, m/lti"le sclerosis6. l strikt/r kolon. l Penyakit anorectal 5misalnya ; anal fiss/re: jmenyebabkan rasa sakit a"abila "asien m/ngkin menghindari defaecating sama sekali6. l Zebiasaan mengabaikan. l Be"resi. l Bemensia. Zotak +.' 2ebera"a "enyebab diare l Malabsor"si: da"at menyebabkan steatorrhoea, seb/ah lemak, tin4a "/cat yang sangat har/m dan s/lit /nt/k fl/sh. 8ihat kotak "ada ".%11. l : J R/s/s motilitas: hi"ertiroid, sindrom iritasi /s/s besar 5lihat di ba0ah6. l Ex/dati)e: "eradangan /s/s menyebabkan )ol/me kecil, bangk/ sering, sering dengan darah ata/ lendir. 5Misalnya karsinoma kolon, "enyakit Crohn, kolitis /lserati)a6. l Osmotik: )ol/me besar tin4a yang menghilang dengan "/asa. Penyebabnya antara lain intoleransi laktosa, o"erasi lamb/ng6. l ekretori: )ol/me tinggi bangk/ yang berlangs/ng dengan "/asa. Tidak ada nanah, darah ata/ lemak yang berlebihan. Penyebabnya antara lain: infeksi gastrointestinal, sindrom karsinoid, adenoma )ili /s/s besar, sindrom Xollinger,Ellison, t/mor M9P I, mengel/arkan. P.%1% B/b/r "erdarahan dan melaena -da banyak "enyebab PG,kehilangan darah ta"i, se"erti biasa, se4arah rinci akan membant/. Tent/kan: l J/mlah. J/mlah kecil o da"at m/nc/l dramatis, "e0arna merah toilet air. l ifat darah 5merah, coklat, hitam6. l -"akah dicam"/r dengan kotoran ata/ ; c : ; > Ona tin4aE l -"akah ter"ercik di atas "anci, dengan tin4a ata/ hanya terlihat di atas kertasE l etia" fit/r yang terkait 5lendir da"at men/n4/kkan "enyakit "eradangan /s/s besar ata/ kanker kolon6. Melaena 9ni 4et,hitam, tar,s/ka dan kotoran berba/ ta4am,me0akili darah dari sal/ran cerna atas 5ata/ sisi kanan dari /s/s besar6 yang telah : ; c altered: ; > oleh lintas melal/i /s/s. Zehadiran melaena sering ditanyakan di r/mah sakit di,"asien teta"i mereka yang telah berba/ melaena benar 4arang mel/"akan "engalamanU Tanyakan s/"lemen tentang besi ata/ bism/th mengand/ng com"o/nds: ; jmenyebabkan tin4a menghitam ta"i tan"a ba/ melaena ata/ konsistensi. 8endir Jelas, sekresi )iscoid dari sela"/t lendir .I Mengand/ng lendir, sel e"itel, le/kosit dan berbagai garam ters/s"ensi dalam air. -danya lendir, ata/ "ada, bangk/ da"at men/n4/kkan: l Gadang /s/s. l olitary /lk/s d/b/r. l Zecil ata/ fist/la /s/s besar. l adenoma kolon )ili.

l 9rritable bo0el syndrome. Zent/t e4/mlah kecil gas sering melarikan diri dari /s/s melal/i m/l/t 5let/san6 dan an/s dan kelebihan terkenal ini adalah fit/r /m/m dari ked/a gangg/an f/ngsional dan organik dari sal/ran "encernaan. ering dikaitkan dengan "er/t kemb/ng dan disebabkan oleh fermentasi makanan tertent/ oleh flora kolon. kent/t yang berlebihan adalah fit/r kh/s/s dari: l Hiat/s hernia. l /lserasi "e"tik/m. l kronis kand/ng em"ed/ "enyakit. l -ir,menelan 5aero"hagy6. l diet tinggi serat. P.%11 Zotak +.S Penyebab "erdarahan F9 rendah l -mbein. l -nal fiss/re. l di)ertik/lar "enyakit. l karsinoma kolon. l "oli" kolon. l -ngiodys"lasia. l Gadang /s/s. l kolitis iskemik. l Meckel di)ertik/l/m. l Penyakit /s/s kecil 5t/mor misalnya, di)ertic/lae, int/ss/sce"tion, CrohnRs6. l olitary /lk/s d/b/r. l Haemobilia 5"erdarahan ke dalam "ohon em"ed/6. Zotak +.+ 7at malabsor"si 5steatorrhoea6 eb/ah fit/r /m/m dari ins/fisiensi "ankreas 5misalnya akibat "ankreatitis kronis, fibrosis kistik6. J/ga disebabkan oleh "enyakit se"erti "enyakit celiac, "enyakit /s/s inflamasi, loo" /s/s b/ta, dan sindrom /s/s "endek. -nda har/s menyadari fit/r ini dan men4ela4ahi mereka sem/a "en/h 4ika ada yang diseb/tkan oleh "asien: l Pale tin4a. l erangan berba/. l b/r/k terbent/k. l /lit /nt/k fl/sh 5menga"/ng6. P.%1? Penyakit k/ning dan "r/rit/s Penyakit k/ning Penyakit k/ning 5: ; c icter/s: ; >6 adalah "igmentasi k/ning k/lit, sklera, dan m/kosa yang disebabkan oleh kelebihan bilir/bin dalam cairan t/b/h. Hal ini biasanya diangga" sebagai : ; c

sign: ; > se"erti yang terlihat "ada "emeriksaan. 8ihat 4/ga hal.LS dan Zotak +.!&. Tanyakan tentang: l Carna /rin 5gela" kolestasis, 4a/ndice6. l Carna dan konsistensi dari tin4a 5"/cat dalam kolestasis, 4a/ndice6. l Hyeri abdomen 5misalnya yang disebabkan oleh bat/ em"ed/6. 2erik/t ini har/s dimas/kkan dalam se4arah menyel/r/h teta"i -nda har/s memb/at titik kh/s/s bertanya tentang: l transf/si darah sebel/mnya. l lal/ se4arah "enyakit k/ning. l Obat,obatan 5antibiotik misalnya, H -9Bs, kontrase"si oral, fenotiaAin6. l 9M "engg/naan narkoba. l Tato dan tindik t/b/h. l -sing "er4alanan. l eks/al se4arah. l 7Hx "enyakit hati. l -lkohol kons/msi. l etia" kontak "ribadi yang 4/ga memiliki "enyakit k/ning. Pr/rit/s 9ni adalah gatal,gatal "ada k/lit dan m/ngkin baik lokal ata/ /m/m. 9ni memiliki banyak ca/ses: ; jit/ ter/tama terkait dengan "enyakit hati kolestasis 5misalnya sirosis bilier "rimer, sclerosing kolangitis6. Per/t bengkak Zelima "enyebab klasik "embengkakan "er/t 5: ; c L 7 - ; >6 dit/n4/kkan berla0anan dalam Zotak +.!!. (nt/k ini, -nda 4/ga har/s menambahkan : ; c t/mo/r: ; >. Pada sirosis dekom"ensasi, kombinasi dari "ortal 5sin/soidal6 hi"ertensi dan retensi Ha dan H%O ber"ihak "ada trans/dasi cairan ke dalam rongga "eritoneal 5ascites6. Ges/ltan "embengkakan m/ngkin /nsightly: ; jit/ 4/ga bisa menyebabkan sesak na"as dengan meletakkan tekanan "ada diafragma dari ba0ah, ter/tama ketika terlentang dan m/ngkin terkait dengan ef/si "le/ra. 8ihat ".'1' /nt/k "enyebab dan klasifikasi ascites. Hal.%1L Zotak +.!& Penyebab "enyakit k/ning Prehe"atic l hemolisis. l Filbert "enyakit. l sindrom B/bin,Johnson. l Gotor syndrome. l Hemodialisa. He"atocell/lar l irosis 5dan "enyebab thereof: ; jlihat OHCMO, ".%1%6. l he"atitis ak/t 5)ir/s, alkohol, a/toim/n, obat,ind/ksi6. l Hati t/mor. l kolestasis dari obat 5misalnya klor"romaAin6. Posthe"atic /mbatan aliran em"ed/ karena:

l obstr/ksi l/minal: bat/ em"ed/. l Call "atologi: t/mor kelainan kongenital sal/ran em"ed/, sirosis bilier "rimer, tra/ma,. l Eksternal kom"resi: "ankreatitis, limfadeno"ati, t/mor "ankreas, am"/la dari Mater t/mor. Zotak +.!! 8ima "enyebab "er/t s0elling: ; j: ; c L 7 - ; > l 7at. l 7l/ida. l flat/s. l 7eses. l Janin. Hal.%1O Zemih dan "rostat ge4ala 7rek/ensi /rin 9ni adalah le0at air seni lebih sering dari"ada adalah normal bagi "asien. Menghit/ng ka0asan ini ; jbera"a kali dalam daya ;j dan 4/ga bertanya tentang )ol/me /rin mele0ati setia" kali 5-nda sedang ber/saha /nt/k mem/t/skan a"akah "asien mem"rod/ksi /rin lebih dari normal ata/ hanya merasakan dorongan /nt/k b/ang air kecil lebih dari biasanya6. (rgensi 9ni adalah keb/t/han tiba,tiba /nt/k b/ang air kecil, "erasaan bah0a "asien m/ngkin tidak mam"/ memb/at ke toilet "ada 0akt/nya. Tanyakan tentang )ol/me di/sir. Hokt/ria 2/ang air kecil "ada malam hari. -"akah "asien bang/n dari tid/r /nt/k b/ang air kecilE 2era"a kali malamE 2era"a banyak /rin dikel/arkan setia" kaliE 9nkontinensia /rin Hilangnya "engendalian s/karela dari "engosongan kand/ng kemih. Pasien m/ngkin akan rag/, rag/ /nt/k membicarakan hal ini 4adi coba /nt/k menghindari kalimat : ; c "embasahan sendiri. -nda bisa menanyakan tentang hal it/ segera setelah bertanya tentang /rgency: ; k : ; c -"akah -nda "ernah merasa "erl/ "/t/s asa /nt/k mengosongkan kand/ng kemih -nda : ; kE -"akah -nda "ernah tidak berhasil dalam 0akt/ : ; > ata/ dengan bertanya tentang : ; cE hilangnya control: ; >. -da L 4enis /tama dari inkontinensia /rin: l : ; c Tr/e: ; >: tidak adanya kontrol ekskresi kemih. /gestif dari fist/la antara sal/ran kemih dan eksterior ata/ kondisi ne/rologis. l cekikikan: inkontinensia selama b/ti ta0a. (m/m "ada gadis,gadis m/da. l tress: kebocoran yang terkait dengan tiba,tiba : J Rtekanan intra,abdomen dari setia" "enyebab 5misalnya bat/k, terta0a, bersin6. l Mendesak: dorongan yang k/at /nt/k b/ang air kecil sehingga "asien tidak da"at "ergi ke toilet "ada 0akt/nya. Penyebab mencak/" lebih,akti)itas dari otot detr/ser, infeksi sal/ran kencing, bat/ kand/ng kemih dan kanker kand/ng kemih. l Menggiring ata/ o)erflo0: ker/gian yang ter/s,mener/s /rin dari kand/ng kemih kronis b/ncit. 2iasanya "ada "ria lan4/t /sia dengan "enyakit "rostat. Terminal menggiring bola Zel/han laki,laki dan biasanya indikasi "enyakit "rostat. 9ni adalah air seni menetes dari /retra "ada akhir berkemih, yang memerl/kan kocok abnormal berke"an4angan "ada "enis dan da"at menyebabkan noda memal/kan "akaian.

Zerag/an Zes/litan dalam m/lai mict/rate. Pasien menggambarkan berdiri dan men/ngg/ /rin /nt/k m/lai mengalir. 2iasanya karena obstr/ksi kand/ng kemih kel/ar karena "enyakit "rostat ata/ strikt/r. Bis/ria : ; c Hyeri "ada mict/rition: ; > biasanya digambarkan oleh "asien sebagai : ; c b/rning: ; > ata/ : ; c stinging: ; > dan merasa di meat/s /retra. Tanyakan a"akah sel/r/h bagian air seni ata/ hanya "ada akhir 5: ; c terminal dys/ria: ; >6. P.%1' Hemat/ria 2agian darah dalam /rin. elal/ tem/an yang abnormal. 9ngat bah0a : ; c mikrosko"is haemat/ria: ; > akan terdeteksi ke"ada "asien, hanya m/nc/l di di","eng/4ian. Pengosongan lengka" 9ni adalah sensasi bah0a ada /rin yang tersisa /nt/k meng/sir "ada akhir berkemih. Betr/ser men/n4/kkan disf/ngsi ata/ "enyakit "rostat. 9ntermittency Fangg/an aliran /rin secara sto",start. Penyebab termas/k hi"ertrofi "rostat, bat/ kand/ng kemih, dan /reterocoeles. Olig/ria dan an/ria Olig/ria adalah hanya sedikit ata/ b/ang air kecil rendah )ol/me dan didefinisikan sebagai ekskresi V1&& ml /rin dalam %? 4am. Penyebab bisa fisiologis 5dehidrasi6 ata/ "atologis 5"enyakit intrinsik shock, gin4al ata/ obstr/ksi6. -n/ria adalah tidak adanya "embent/kan /rin dan -nda har/s ber/saha /nt/k menyingkirkan obstr/ksi sal/ran kemih sebagai s/at/ "ermasalahan ata/ mendesak. Penyebab lainnya termas/k disf/ngsi gin4al berat intrinsik dan shock. Poli/ria 9ni adalah ekskresi berlebihan )ol/me besar air seni dan har/s hati,hati dibedakan dari frek/ensi kencing 5sering "er4alanan se4/mlah kecil /rin6. Penyebab ber)ariasi teta"i meli"/ti kons/msi )ol/me besar air 5termas/k "olidi"sia histeris6, diabetes mellit/s 5"engar/h osmotik dari gl/kosa dalam t/b/l/s mendorong /rin lagi yang bisa dib/at6, kegagalan tindakan -BH di t/b/l/s gin4al 5se"erti "ada diabetes insi"id/s6 dan kemam"/an berkonsentrasi cacat gin4al 5misalnya gagal gin4al kronis6. 9ngatlah 4/ga /nt/k menanyakan "asien tentang "engg/naan obat di/retikU Hal.%1S Hafs/ makan dan berat Zehilangan nafs/ makan dan "er/bahan berat adalah ge4ala agak tidak s"esifik teta"i sehar/snya menimb/lkan kec/rigaan "enyakit seri/s 4ika salah sat/ "arah, berke"an4angan, ata/ tidak terd/ga. :,Q 9ngatlah bah0a "en/r/nan berat badan memiliki banyak "enyebab di l/ar "er/t dan sistem "enyelidikan menyel/r/h har/s dilak/kan. 2erat badan m/ngkin tidak di"erhatikan oleh "asien 4ika mereka tidak secara terat/r berat badan

; themsel)es: jbertanya tentang "akaian men4adi longgar. 9ngat bah0a "asien m/ngkin telah senga4a kehilangan ; 0eight: jmelem"ar -nda kel/ar aroma. Tanyakan a"akah ker/gian yang : ; c ex"ected: ; >. :,Q Cas"adalahU -scites bobot !kg D 8 dan bebera"a "asien dengan gagal hati m/ngkin memiliki ; !&- j%&8 dari asites, masking setia" ; : ; c 0eight: kering > r/gi. Tanyakan "ada "asien tentang kebiasaan mereka makan dan makanan sehari,hari rata,rata. Cobalah /nt/k menent/kan: l Zetika ge4ala "ertama kali melihat. l Menghit/ng masalah. Balam hal "en/r/nan berat badan, menent/kan dengan te"at bagaimana dan selama 4angka 0akt/ bera"a lama. l Penyebab ; anorexia: jtidak makan memb/at "asien merasa sakitE l -"akah makan menimb/lkan rasa sakitE 5Misalnya t/kak lamb/ng, angina mesenterika, "ankreatitis.6 l etia" ge4ala yang menyertai 5sakit, "er/t m/al, m/ntah, demam6. Tanyakan 4/ga tentang: l Carna dan konsistensi dari kotoran 5misalnya steatorrhoeaE6. l Fe4ala /rin 5lihat hal.%1O l bar/,bar/ ini toleransi "er/bahan s/h/. Balam setia" kas/s, -nda har/s menghit/ng 2M9 sebagai "asien di ".OO. Zombinasi "en/r/nan berat badan dengan nafs/ makan : J Rm/ngkin menyarankan malabsor"si ata/ keadaan hy"ermetabolic 5thyrotoxicosis misalnya6. Hal.%1+ P.%?& isa se4arah 8al/ ri0ayat medis Tanyakan ter/tama tentang: l "rosed/r bedah ebel/mnya termas/k kom"likasi "eri,dan "asca o"erasi dan kom"likasi anestesi. l "enyakit /s/s kronis 5misalnya 92B termas/k bar/,bar/ ini s/ar,/" dan "engobatan sam"ai saat ini6. l terkait kondisi Zem/ngkinan 5misalnya diabetes dengan haemachromatosis6. Obat se4arah Pikirkan tentang obat,obatan yang da"at memic/ "enyakit "er/t dan 4angan l/"a /nt/k menanyakan obat tentang o)er,the,co/nter. ebagai contoh: l He"atitis: halotan, fenitoin, chlorothiaAides, "iraAinamid, isoniaAid, metil do"a, inhibitor HMF Co- red/ktase 5: ; c statins: ; >6, )al"roate natri/m, amiodarone, antibiotik, H -9B. l kolestasis: klor"romaAin, s/l"honamides, s/l"honyl/reas, rifam"isin, nitrof/rantoin, steroid anabolik, "il kontrase"si oral. l 8emak hati: tetrasiklin, natri/m )al"roate, amiodarone. l nekrosis hati ak/t: "arasetamol. l Tanyakan 4/ga tentang transf/si darah sebel/mnya. Merokok

Perokok beresiko : J Rdari /lk/s "e"tik/m, kanker oeso"hageal, kanker kolorektal. Merokok 4/ga m/ngkin memiliki hasil yang mer/gikan "ada ri0ayat alami "enyakit Crohn. -da bebera"a b/kti bah0a merokok da"at melind/ngi terhada" radang borok /s/s besar. -lkohol e"erti biasa, se4arah rinci re3/ired: ; jlihat ".??. Jika ketergant/ngan dic/rigai, 4alankan melal/i 3/estionnaire: -HFZ-G ; jlihat Zotak +.!%. e4arah kel/arga Tanyakan kh/s/snya tentang ri0ayat "enyakit radang /s/s, "enyakit celiac, "enyakit /lk/s "e"tik/m, "enyakit hati ket/r/nan 5misalnya Cilson, hemokromatosis6 kanker /s/s, sakit k/ning, anemia, s"lenektomi, dan kolesistektomi. e4arah sosial l Gisiko "a"aran he"atotoxins dan he"atitis melal/i "eker4aan. l Tato. l "engg/naan obat terlarang 54ar/m ter/tama berbagi6. l osial kontak dengan "enyakit yang sama 5ter/tama yang rele)an dengan "enyakit k/ning6. l be"ergian ke l/ar negeri terbar/. Biet se4arah l J/mlah b/ah, say/r dan serat dalam makanan. l 2/kti intoleransi laktosa. l Per/bahan ge4ala yang berh/b/ngan dengan makan kelom"ok makanan tertent/. l ensiti)itas terhada" gand/m, lemak, kafein, gl/ten. P.%?! Zotak +.!% Z/esioner -HFZ-G eb/ah res"on "ositif terhada" salah sat/ dari ? "ertanyaan yang da"at men/n4/kkan seseorang "ada risiko "enyalahg/naan alkohol. Ja0aban "ositif atas "ertanyaan % ata/ lebih memb/at adanya ketergant/ngan alkohol m/ngkin. C -"akah -nda "ernah merasa bah0a -nda har/s Z/rangi min/m -ndaE eb/ah -"akah -nda "ernah menda"at marah ketika seseorang menyarankan bah0a -nda har/s ditebangE F -"akah -nda "ernah merasa bersalah tentang min/m -ndaE E -"akah -nda "ernah memerl/kan : ; c Mata,o"ener: > ; di "agi hari /nt/k saraf stabil ata/ menyingkirkan mab/kE P.%?% Faris 2esar "emeriksaan e"erti biasa, memastikan "ri)asi yang memadai. 9dealnya "asien har/s berbaring datar dengan ke"ala bersandar "ada bantal t/nggal, lengan berbaring di sam"ing. Per/t boleh terkena setidaknya dari bagian ba0ah stern/m ke simfisis "/bis: ; jlebih dis/kai sel/r/h t/b/h bagian atas har/s ditem/kan. Jangan biarkan alat kelamin kec/ali di"erl/kan nanti. "emeriksaan har/s mengik/ti r/tinitas terat/r. aran "en/lis ditam"ilkan di ba0ah. 9ni adalah "raktik standar /nt/k mem/lai dengan tangan dan "roximally: "eker4aan ; jini membent/k : ; c ra""ort: > ; fisik sebel/m -nda memeriksa daerah lebih lemb/t ata/ memal/kan. Zotak +.!1 Zerangka "emeriksaan "er/t

l (m/m ins"eksi. l Tangan. l 8engan. l aksila it/. l Ca4ah. l dada. l Pemeriksaan "er/t. l Pal"asi "er/t. o 8ight. o Bee". o "esifik organ. o Pemeriksaan l/bang hernial. o Eksternal alat kelamin. l Perc/ssion 5# T "emeriksaan ascites6. l -/sk/ltasi. l Bigital "emeriksaan an/s, rekt/m # T "rostat. (m/m "emeriksaan Melihat "asien dari /4/ng tem"at tid/r /nt/k menilai kesehatan /m/m dan mencari setia" kelainan yang 4elas di/raikan dalam 2ab 1 sebel/m "indah lebih dekat. Cari kh/s/snya /nt/k: l Tinggi ata/ massa t/b/h rendah. l Zeadaan hidrasi. l Bemam. l Bistress. l Pain. l Otot 0asting. l Peri"heral edema. l Penyakit k/ning. l -nemia. P.%?1 P.%?? Tangan dan ekstremitas atas -mbil tangan kanan "asien dalam -nda dan memeriksa dengan hati,hati /nt/k tanda,tanda berik/t. Z/k/ I l 8e/konychia: 0hitening dari k/k/ karena hy"oalb/minaemia 5misalnya giAi b/r/k, malabsor"si, "enyakit hati, sindrom ne"hritic6. l Zoilonychia: : ; c s"ooning: ; > dari k/k/ memb/at bent/k cek/ng b/kan kon)eksitas normal. Penyebabnya antara lain kek/rangan Aat besi ba0aan dan kronis. garis l M/ehrckeRs: ini adalah garis,garis "/tih melintang. Terlihat di negara,negara hy"oalb/minaemic termas/k sirosis hati berat. l Cl/bbing: di4elaskan "ada ".%&S. menyebabkan "er/t adalah sirosis, "enyakit /s/s inflamasi dan "enyakit celiac.

l 2l/e l/n/lae: seb/ah "er/bahan 0arna kebir/an dari lan/lae normal terlihat "ada "enyakit Cilson. I 8ihat 4/ga 2ab ?. Palms l "almar eritema: : ; c hati "alms: ; >. 9ni adalah kemerahan 4era0at dari tela"ak tangan, ter/tama yang mem"engar/hi tenar dan eminences hi"otenar. Hal ini 4/ga da"at mem"engar/hi tela"ak kaki. Terkait dengan "enyakit hati kronis, kehamilan, tirotoksikosis, rhe/matoid arthritis, "olisitemia dan 54arang6 le/kemia kronis. Hal ini 4/ga da"at men4adi tem/an yang normal. contract/re l B/"/ytrenRs: ini menebal dan kontraksi fibrosa fasia "almaris. Pada taha" a0al, tidak terat/r "enebalan fasia gamblang terlihat, ter/tama yang atasnya it/ metakar"al ? dan L. Hal ini da"at berkembang men4adi deformitas fleksi teta" dari 4ari m/lai dari L dan beker4a di ke 1 ata/ %. ering bilateral, 4/ga da"at mem"engar/hi kaki. Terlihat ter/tama "ada "enyakit hati alkoholik, teta"i 4/ga da"at dilihat "ada "eker4a man/al 5ata/ m/ngkin kel/arga6. l -nemia: "/cat di li"atan "almaris men/n4/kkan anemia signifikan. Hati fla" 5asterixis6 Hal ini identik dengan fla" terlihat di negara,negara hi"erka"nia 5lihat ".%&S6. Minta "asien /nt/k meng/l/rkan tangan mereka di de"an mereka dengan tangan dorsiflexed di "ergelangan tangan dan 4ari ter/l/r dan di"isahkan 5lihat gambar.6. Pasien har/s memegang "osisi it/ setidaknya selama !L detik. Jika : ; c fla": ; > hadir, tangan "asien akan bergerak di dendeng, tidak terat/r fleksi D ekstensi "ada "ergelangan tangan dan sendi MCP. fla" ini ham"ir selal/ bilateral. M/ngkin hal/s dan intermiten. 9ni adalah karakteristik dari ensefalo"ati akibat kegagalan hati. Jika tanda ensefalo"ati he"atik "ada "asien dengan "enyakit hati sebel/mnya kom"ensasi, hal it/ m/ngkin telah di"ic/ oleh infeksi, obat di/retik, ketidakseimbangan elektrolit, diare ata/ sembelit, m/ntah, sentral bertindak obat,obatan, atas "erdarahan F9, "aracentesis "er/t, ata/ o"erasi. P.%?L Ekstremitas atas Periksa sen4ata /nt/k tanda,tanda: l Memar: m/ngkin tanda dari: o He"atocell/lar ker/sakan dan gangg/an koag/lasi dihasilkan. o Trombosito"enia akibat hi"ers"lenisme. /ms/m o "enindasan dengan alkohol. l "etechiae: "in,t/s/kan berdarah yang tidak blanche dengan tekanan. M/ngkin tanda trombosito"enia. l Otot memb/ang,b/ang: dilihat sebagai J : jmassa otot, m/ngkin dengan k/lit atasnya menggant/ng longgar. eb/ah manifestasi akhir dari kek/rangan giAi dan sering terlihat "ada "asien dengan "enyakit hati kronis alkohol. l cratch tanda 5excoriations6: men/n4/kkan gatal 5"r/rit/s6 hadir dan m/ngkin fit/r hanya terlihat dari kolestasis a0al. 2erhati,hatilah /nt/k tidak mele0atkan kateter -M fist/la ata/ hemodialisisU aksila The Periksa dengan hati,hati /nt/k: l 8imfadeno"ati

nigricans acanthosis l 5a menebal, menghitam k/lit bel/dr/ dalam "enam"ilan.. May dikaitkan dengan keganasan intra,abdomen6. Fambar. +.? Peng/4ian /nt/k fla" hati. Pasien har/s memegang tangan mereka terentang dengan "ergelangan tangan dan 4ari dorsiflexed di"er"an4ang dan dic/lik selama minimal !L detik. P.%?O Ca4ah dan dada Mata Minta "asien /nt/k melihat l/r/s ke de"an sementara -nda melihat lebih dekat di mata mereka, orbit dan k/lit di sekitarnya. Zem/dian meminta "asien /nt/k mencari sementara -nda lemb/t menarik kembali t/t/" lebih rendah dengan 4ari, melihat sclera yang mendasari dan kon4/ngti)a. Cari kh/s/snya /nt/k: l Penyakit k/ning: seb/ah "er/bahan 0arna k/ning sclera. 9ni biasanya tem"at "ertama yang k/ning da"at dilihat. Ter/tama berg/na "ada "asien dengan 0arna k/lit gela" dalam "enyakit k/ning yang tidak akan dinyatakan 4elas. l -nemia: "/cat kon4/ngti)a terseb/t. -nda har/s "engalaman ke tem"at ini dengan m/dah. l Zayser,7leisher cincin: terbaik dilihat dengan lam"/,celah di klinik o"talmologi. eb/ah cincin ber"igmen k/ning kehi4a/an hanya di dalam margin kornea,scleral. Zarena "engenda"an tembaga. Terlihat "ada "enyakit Cilson. l [anthelasma: mengangkat lesi k/ning disebabkan oleh membang/n li"id ba0ah skin: ; jsering terlihat melingkari mata, ter/tama "ada sisi nasal orbit. M/l/t Minta "asien /nt/k men/n4/kkan gigi mereka kem/dian : ; c terb/ka 0ide: ; > dan melihat dengan hati,hati "ada keadaan gigi, lidah dan "erm/kaan bagian dalam "i"i. -nda 4/ga har/s secara hal/s ber/saha /nt/k ba/ na"as "asien. l ang/lar stomatitis: a kemerahan dan radang "ada s/d/t m/l/t. eb/ah tanda tiamin, )itamin 2!%, dan defisiensi besi. l Circ/moral "igmentasi: hi"er"igmentasi daerah sekitar m/l/t. Bilihat "ada sindrom Pe/tA, JegherRs. l gigi: catatan gigi "als/ ata/ 4ika ada b/kti dari ker/sakan gigi. l telangiectasia: dilatasi dari "emb/l/h kecil "ada g/si dan m/kosa b/kal. Bilihat "ada sindrom Osler,Ceber,Gend/ 5OHCMO, ".'1%6. l F/si: cari ter/tama /nt/k borok 5"enyebab termas/k "enyakit celiac, "enyakit /s/s inflamasi, "enyakit 2eha ] et dan sindrom Geiter6 dan hi"ertrofi 5disebabkan oleh kehamilan, mengg/nakan fenitoin, le/kemia, "enyakit k/dis ^)itamin C defisiensi_ ata/ "eradangan ^gingi)itis_6. l Hafas: ba/ ter/tama bagi: o ; c : ; > keba/b/s/kan he"atic/s: na"as berba/ manis. o Zetosis: : ; c sakit,sakitan manis "ear,Bro"a ; > nafas berba/ o (raemia: ba/ amis l 8idah: mencari ter/tama bagi: o glossitis: hal/s, erythemato/s "embengkakan lidah. Penyebabnya antara lain kek/rangan Aat besi, )itamin 2!%, dan kek/rangan folat

o Macroglossia: lidah di"erbesar. Penyebab termas/k amyloidosis, hy"othroidism, acromegaly, sindrom Bo0n, dan neo"lasia. o 8e/ko"lakia: "enebalan ber0arna "/tih lidah dan sela"/t lendir m/l/t. Zondisi "remaligna disebabkan oleh merokok, miskin kebersihan, gigi alkohol, se"sis dan sifilis. o Feografis lidah: cincin merah tan"a rasa sakit dan garis "ada "erm/kaan lidah tam"ak agak se"erti "eta. Ba"at disebabkan oleh )itamin 2% 5ribofla)in6 kek/rangan ata/ m/ngkin )arian normal. P.%?' l Zandidiasis: : ; c thr/sh: ; >. 9nfeksi 4am/r "ada sela"/t m/l/t di"andang sebagai krim "atch dadih se"erti "/tih yang da"at dikerok dari m/kosa erythemato/s meng/ngka"kan di ba0ah ini. Penyebab termas/k im/nos/"resi, "engg/naan antibiotik, kebersihan m/l/t yang b/r/k, kek/rangan Aat besi dan diabetes. 8eher Memeriksa kelen4ar getah bening leher dan s/"rakla)ik/la se"erti "ada hal.OS. Cari ter/tama /nt/k node s/"rakla)ik/la di sisi kiri yang ketika di"erbesar, diseb/t node Mircho0Rs 5tanda Troisier Teman,s/gestif keganasan lamb/ng6. dada 8ihatlah dada anterior dan "erhatikan kh/s/snya: l "ider nae)i: lesi ka"iler telangiectatic. o eb/ah area merah "/sat dengan ka"iler membesar menyebar kel/ar dari it/ dalam : ; c ; > s"idery: cara. o Bisebabkan oleh kend/rnya ka"iler dari : ; c ka"al "/sat feeder: ; >. o Jika lesi benar,benar nae)/s laba,laba, it/ akan benar,benar diha"/skan oleh tekanan di "/sat dengan mengg/nakan "ena,titik ata/ ser/"a dan akan mengisi kel/ar ketika tekanan dile"askan. o Ba"atkah berbagai /k/ran dari mereka yang hanya terlihat sam"ai L ata/ Omm diameter. O Bitem/kan dalam distrib/si )ena ca)a s/"erior 5lihat Fambar +.L.6. o de0asa normal adalah : ; c allo0ed: ; > sam"ai dengan L nae)i laba,laba. Penyebab o termas/k "enyakit hati kronis dan kelebihan estrogen l ginekomastia: "erkembangan berlebihan kelen4ar "ay/dara laki,laki karena "roliferasi d/kt/s sehingga mereka menyer/"ai "ay/dara 0anita "asca,"/bertas. o Hal ini sering memal/kan bagi "asien 4adi sensitif. o Bisebabkan oleh "enyakit hati alkoholik, hi"er"lasia adrenal kongenital dan obat yang biasa dig/nakan antara lain s"ironolactone, digoksin, dan simetidin. o 2isa 4/ga dilihat selama masa "/bertas "ada laki,laki normal. Fambar. +.L Bistrib/si drainase ke g/a ka)a s/"erior dan daerah /nt/k mencari nae)i laba,laba. Orang de0asa normal da"at memiliki hingga L lesi terseb/t. Hal.%?S 9ns"eksi "er/t Bengan "er/t terb/ka, -nda har/s melak/kan "emeriksaan hati,hati dan metodis. Catatan kh/s/s:

cars 9ni m/ngkin hasil dari tra/ma ata/ o"erasi sebel/mnya. Gecent bekas l/ka akan merah m/da dan "emb/l/h darah. 8ama l/ka ber0arna "/tih dan m/ngkin ind/rated. Bistensi abdomen -"akah "er/t terlihat bengkakE Pertimbangkan L 7s 5Zotak +.!! hal. 1?6 dan catatan keadaan /mbilik/s. 5E)erted Bee"EE6 7ocal bengkak Mengobati "er/t bengkak se"erti yang -nda akan melak/kan a"a"/n ben4olan lain 5".+S6 dan ber/ang dalam "ikiran anatomi yang mendasari dan keterlibatan organ m/ngkin. Percabangan dari recti Ter/tama "ada orang t/a dan "asien yang telah men4alani o"erasi "er/t, yang rekt/s abdominis kembar m/ngkin otot,otot ter"isah lateral "ada kontraksi, menyebabkan organ yang mendasari /nt/k ton4olan melal/i celah "ertengahan,line yang dihasilkan. Minta "asien mengangkat ke"ala mereka dari tem"at tid/r ata/ /nt/k d/d/k dan menonton sedikit /nt/k m/nc/lnya ton4olan longit/dinal garis tengah. Tokoh "emb/l/h darah Jika "emb/l/h darah terlihat mengalir diatas "er/t, "erhatikan lokasi yang te"at mereka. l Mencoba /nt/k memetakan arah aliran darah dalam diri mereka: o Tem"atkan % 4ari di salah sat/ /4/ng /rat dan menera"kan tekanan okl/si o Ferakkan ! 4ari di se"an4ang )ena, "engosongan bah0a bagian dari darah dalam : ; c milking: ; > tindakan. o 8e"askan tekanan dari sat/ 4ari dan menonton /nt/k aliran darah kembali ke "emb/l/h darah. o (langi, mengosongkan darah di arah lain. o Zarena kat/" )ena, -nda har/s da"at menent/kan arah aliran darah dalam "emb/l/h darah yang. l aliran darah inferior )ena ca)a men/n4/kkan obstr/ksi s/"erior. l /"erior aliran darah men/n4/kkan obstr/ksi )ena ca)a inferior. l -r/s memancar kel/ar dari /mbilik/s 5: ; c ca"/t med/sae: ; >6 men/n4/kkan hi"ertensi )ena "ortal 5sh/nting "orto,sistemik ter4adi melal/i "emb/l/h darah "/sat yang men4adi membesar6. Jelas "/lsations 8ihatlah di "er/t /nt/k setia" "/lsations. berdeny/t -, mem"erl/as massa di e"igastri/m m/ngkin mer/"akan ane/risma aorta "er/t. Felombang "eristaltik 2iasanya hanya terlihat di ti"is, cocok, orang m/da. eb/ah gerak "eristaltik /s/s yang sangat 4elas di"andang sebagai gerakan beriak di ba0ah k/lit dan da"at men/n4/kkan obstr/ksi /s/s. triae : ; c tretch marks: ; > adalah garis bergaris,garis merah m/da ata/ "/tih disebabkan oleh "er/bahan ketegangan dinding "er/t. 9ni m/ngkin normal berkembang "esat P.%?+ "/bescent rema4a. J/ga terlihat "ada obesitas, kehamilan 5: ; c gra)idar/m: striae ; >6, ascites dan mengik/ti berat badan yang ce"at ata/ "aracentesis "er/t. 9ngatlah bah0a ini akan men4adi merah m/da D /ng/ di C/shing indrom se"erti bekas l/ka lain 5lihat hal.!%'6. Per/bahan 0arna k/lit

-da % "ola klasik memar D "er/bahan 0arna yang men/n4/kkan adanya darah retro"eritoneal 5terlihat ter/tama di "ankreatitis6: l C/llen tanda: "er/bahan 0arna "ada /mbilik/s dan k/lit sekitarnya l Frey,T/rner tanda: "er/bahan 0arna "ada "angg/l toma Carilah stoma "embedahan ata/ fist/la, mencatat lokasi yang te"at mereka, sifat stoma dan tam"ilan m/kosa ter"a"ar 54ika ada6. 9ngatlah bah0a stoma m/ngkin dari /s/s besar, /s/s kecil, ata/ sal/ran gin4al. 8ihat 4/ga "ada isi kantong stoma mencatat setia" kelainan se"erti diare, nanah, lendir ata/ darah. l Zolostomi: biasanya terlihat "ada fosa iliaka kiri dan akan fl/sh "ada k/lit. 52ag m/ngkin berisi semi,solid /nt/k tin4a terbent/k.6 l ileostomy: biasanya dalam fosa iliaka kanan dan dibent/k sebagai : ; c s"o/t: ; > m/kosa /s/s membentang dari dinding "er/t /nt/k mencegah isi l/men mer/gikan dinding "er/t. 52ag akan berisi bangk/ semi,dibent/k dan cair.6 l (rostomy: sering dibent/k sebagai sal/ran ile/m dengan /reter terh/b/ng ke sebagian /s/s kecil dan kem/dian ke dinding "er/t. 2iasanya dalam fosa iliaka kanan. 52ag akan berisi /rin.6 l nefrostomi: drainase /rin dari "el)is gin4al /nt/k eksterior. 2iasanya tindakan sementara mengik/ti "rosed/r o"erasi "ada sal/ran gin4al ata/ dekom"resi sistem terhambat. 2iasanya di "angg/l. 52ag akan berisi /rin.6 Fambar. +.O 2ebera"a /m/m bekas l/ka bedah "er/t. P.%L& Gabaan Pendekatan (m/m Pasien har/s di"osisikan berbaring telentang dengan ke"ala did/k/ng oleh bantal t/nggal dan lengan di sisi mereka. Jongkok di sam"ing tem"at tid/r ata/ sofa sehingga "er/t "asien adalah di tingkat mata -nda. Masing,masing dari ? k/adran 5lihat ".%%%6 har/s di"eriksa "ada gilirannya dengan cahaya, dan kem/dian "al"asi mendalam sebel/m fok/s "ada organ tertent/ 5".%L%6. (r/tan mereka tidak di"eriksa dalam matter: ; jmenem/kan r/tin yang cocok /nt/k anda. Minta "asien 4ika ada daerah kelemb/tan dan 4angan l/"a /nt/k memeriksa bagian terakhir ini. ebel/m -nda m/lai, mintalah "asien /nt/k memberitah/ -nda 4ika -nda menyebabkan ketidaknyamanan a"a"/n. -nda har/s mam"/ memeriksa "er/t tan"a melihat dari dekat. ebaliknya, -nda har/s mem"erhatikan 0a4ah "asien /nt/k tanda,tanda sakit. Cahaya "al"asi (nt/k ini, -nda mengg/nakan 4ari,ti"s dan as"ek "almar 4ari,4ari. l 8ay tangan kanan -nda di "er/t "asien dan lemb/t tekan oleh meregangkan "ada sendi metacar"o,"halangeal. l Jika ada rasa sakit "ada "al"asi ringan, /"aya /nt/k menent/kan a"akah rasa sakit ini lebih b/r/k bila -nda menekan ke ba0ah ata/ ketika -nda mele"askan tekanan 5: ; c tenderness: rebo/nd ; >6. l Jika otot "er/t tam"ak tegang, menent/kan a"akah lokal ata/ /m/m. Pastikan "asien santai, m/ngkin akan membant/ bagi "asien /nt/k menek/k l/t/t mereka sedikit, melemaskan otot,otot

"er/t. eb/ah ketegangan "aksa di "er/t m/scles: ; jtam"aknya melind/ngi organs: ; mendasarij diseb/t : ; c g/arding: ; >. Bee" "al"asi etelah sem/a ? k/adran yang ringan teraba, memeriksa kembali mengg/nakan lebih banyak tekanan. Hal ini sehar/snya mem/ngkinkan -nda /nt/k merasa /nt/k setia" massa ata/ kelainan str/kt/ral. l Jika massa terasa, mem"erlak/kannya se"erti yang akan -nda ada ben4olan lain yang men4elaskan lokasi yang te"at, /k/ran, bent/k, "erm/kaan, konsistensi, mobilitas, gerakan dengan "erna"asan, kelemb/tan dan a"akah ata/ tidak it/ adalah berdeny/t. l Hal ini sering m/ngkin /nt/k mendeteksi konsistensi dem"/l,se"erti tin4a di kolon sigmoid. -nda har/s mem"erlak/kan ini sebagai setia" : ; c lain l/m": > ; /nt/k memastikan dari alam. P.%L! Zotak +.!? Tanda,tanda "eritonitis l Hyeri "ada "al"asi cahaya. l Gebo/nd kelemb/tan. l 9n)olo/ntary men4aga. l Hyeri ber/lang dengan sedikit gerakan tangan memeriksa. l s/ara /s/s -bsen 5".%O%6. P.%L% Meraba organ,organ "er/t Hati Hati normal meman4ang dari r/ang interkostal L di sebelah kanan garis tengah /nt/k batas kosta, bersemb/nyi di ba0ah t/lang iga sehingga sering tidak biasanya ; "al"able: j4angan kha0atir 4ika anda tidak bisa merasakan sat/U l Mengg/nakan tela"ak tangan kanan, m/lai "al"asi dari fosa iliaka kanan. l -nda har/s s/d/t tangan -nda sedemikian r/"a sehingga 4ari tel/n4/k se4a4ar dengan batas kosta 5lihat Fambar +.'.6. l Tekanan mengerahkan lemb/t dan meminta "asien /nt/k mengambil na"as dalam,dalam. l Bengan setia" na"as ke dalam, 4ari,4ari -nda har/s drift sedikit s/"erior sebagai hati bergerak inferior dengan diafragma. 2ersantai tekanan "ada tangan -nda sedikit "ada ketinggian ins"irasi. l Jika hati adalah te"at di atas "osisi tangan -nda, "erm/kaan lateral 4ari tel/n4/k -nda akan menyerang te"i hati dan mel/nc/r di atas dengan gamblang : ; c ste": ; >. l Jika hati tidak terasa, menggerakkan tangan -nda s/"erior !,%cm dan merasa lagi. l (langi "roses, bergerak ke arah t/lang r/s/k sam"ai hati dirasakan. Jika te"i hati terasa, -nda har/s "erhatikan: l 2era"a 4a/h di ba0ah batas kosta it/ mel/as di 4ari,breadths ata/ 5lebih dis/kai6 sentimeter dan mencatat nomor dengan hati,hati. l ifat dari te"i hati 5adalah "erm/kaan hal/s ata/ tidak terat/rE6. l -danya kelemb/tan. l -"akah hati berdeny/t. Tem/an l Hal ini sering m/ngkin /nt/k meraba hati te"at di ba0ah batas kosta di "/ncak ins"irasi dalam

normal, sehat, orang yang k/r/s. l eb/ah hati membesar memiliki banyak ca/ses: ; jlihat OHCMO, ".L!S. l eb/ah hati normal da"at teraba "ada "asien dengan PPOZ ata/ asma dalam sia"a dada adalah hi"er,di"erl/as ata/ "ada "asien dengan koleksi s/bdia"hrag,matic. l Hati m/ngkin 4/ga teraba di hada"an : ; c ; GiedelRs lobe: )arian > : ; jnormal di mana "royeksi dari hati timb/l dari "erm/kaan inferior lob/s kanan. 8ebih /m/m "ada 0anita. (m/mnya salah /nt/k gin4al kanan ata/ kand/ng em"ed/ di"erbesar. Zand/ng em"ed/ Terletak di margin kosta te"at di /4/ng t/lang r/s/k +, di "erbatasan lateral rekt/s abdominis. 2iasanya hanya teraba saat di"erbesar karena obstr/ksi bilier ata/ kolesistitis ak/t. l Merasa sebagai massa, fok/s b/lat, b/lat yang bergerak dengan ins"irasi. l Posisi tangan kanan tegak l/r/s terhada" batas kosta dan meraba ke arah medial : J Rlateral 5lihat Fambar +.S.6. P.%L1

Fambar. +.' Pal"asi dari ; li)er: jalign "erm/kaan lateral 4ari tel/n4/k dengan batas kosta dan meraba dari fosa iliaka kanan ke t/lang r/s/k secara langkah,bi4aksana. Fambar. +,S Pal"asi dari ; gallbladder: jtangan memeriksa har/s tegak l/r/s terhada" batas kosta di /4/ng t/lang r/s/k + 5di mana batas lateral otot rekt/s memen/hi kartilago kosta6. Zotak tanda,tanda Penting kand/ng em"ed/ +,!L M/r"hy tanda eb/ah tanda cholecystitis: j; nyeri "ada "al"asi selama kand/ng em"ed/ selama ins"irasi dalam. Hanya "ositif 4ika ada HO nyeri di kiri di "osisi yang sama. Co/r)oisierRs h/k/m Bengan keberadaan "enyakit k/ning, kand/ng em"ed/ 4elas T9B-Z m/ngkin disebabkan oleh bat/ em"ed/. P.%L? 8im"a Organ limfatik yang terbesar yang ber)ariasi dalam /k/ran dan bent/k antara indi)id/als: ; jkira,kira se/k/ran ke"alan tin4/ 5!%cm x 'cm6. 2iasanya tersemb/nyi di ba0ah kartilago kosta kiri dan m/dah di"ahami. Pembesaran lim"a ter4adi dalam arah ke ba0ah, mel/as ke dalam k/adran kiri atas 5dan bahkan k/adran kiri ba0ah6 di sel/r/h terhada" fosa iliaka kanan. l teraba mengg/nakan teknik yang sama dengan yang dig/nakan /nt/k meng/4i hati 5".%L%6. l tangan kiri -nda har/s dig/nakan /nt/k mend/k/ng t/lang r/s/k kiri yang "osterolateral. tangan kanan -nda har/s se4a4ar dengan /4/ng 4ari se4a4ar ke margin kosta kiri 5lihat Fambar. +,+6. l M/lai "al"asi te"at di ba0ah /mbilik/s di garis tengah dan beker4a ke arah margin kiri kosta meminta "asien /nt/k mengambil na"as dalam,dalam dalam dan "erasaan /nt/k "ergerakan

lim"a di ba0ah ; fingers: -nda jse"erti meraba hati. l Te"i inferior dari lim"a m/ngkin memiliki : ; c gamblang notch: ; > "/sat yang akan membant/ -nda membedakannya dari massa "er/t lainnya. l Jika lim"a yang dirasakan, meng/k/r 4arak ke "erbatasan "esisir di 4ari,breadths ata/ 5lebih dis/kai6 sentimeter. :,Q eb/ah lim"a teraba kadang,kadang bisa men4adi teraba oleh re"osisi "asien. Minta mereka /nt/k berg/ling ke sisi kanan dan /langi "emeriksaan se"erti di atas. P.%LL

Fambar. +,+ Pal"asi dari ; s"leen: jalign /4/ng 4ari tangan kanan -nda dengan "erbatasan "esisir kiri dan m/lai meraba te"at di ba0ah /mbilik/s beker4a men/4/ k/adran kiri atas. Zotak +.!S 2ebera"a "enyebab O7- ; k He"atomegali l -lkohol. l Hak gagal 4ant/ng. l Heo"lasia 5kanker "rimer, metastasis, gangg/an myelo"roliferati)e, le/kemia, limfoma6. l Penyakit hati kronis 5sirosis H2 menyebabkan hati, kecil meny/s/t6. l 9nfeksi 5he"atitis ak/t, )ir/s br/cellosis, T2C6. l amyloidosis. l hemokromatosis. l obstr/ksi bilier. "lenomegali l Massi)e 5* Scm6: malaria, Zala,aAar, "enyakit Fa/cherRs. l edang 5?,Scm6: hi"ertensi "ortal sek/nder /nt/k sirosis, gangg/an lym"ho"roliferati)e dan banyak lainnya. l ringan: gangg/an lym"ho"roliferati)e, hi"ertensi "ortal sek/nder /nt/k sirosis, he"atitis men/lar, demam kelen4ar, endokarditis s/bak/t, sarkoidosis, rhe/matoid arthritis, "enyakit 4aringan ikat, gangg/an hematologi 5thrombocyto"aenia idio"atik, s"herocytosis t/r/n tem/r/n, "olisitemia r/bra )era6. He"atos"lenomegali gangg/an Myelo"roliferati)e, gangg/an lym"ho"roliferati)e, "enyakit hati kronis dengan hi"ertensi "ortal, infeksi 5ak/t he"atitis )ir/s, br/cellosis, "enyakit Ceil, tokso"lasmosis, CMM6, l/"/s, amyloidosis, sarkoidosis, tirotoksikosis, acromegaly, anemia "ernisiosa, anemia sel sabit. P.%LO Fin4al Fin4al bersifat retro"eritoneal, berbaring di dinding abdomen "osterior ked/a sisi t/lang "/ngg/ng antara )ertebra T!% dan 81. Mereka bergerak sedikit inferior dengan ins"irasi. The gin4al kanan terletak sedikit lebih rendah dari sebelah kiri 5"eng/ngsi oleh hati6. Pal"asi adalah : ; c biman/al: ; > 5ked/a tangan6. -nda m/ngkin da"at merasakan tiang lebih rendah dari gin4al kanan di normal, orang yang k/r/s. l Tem"atkan tangan kiri -nda di belakang "asien di "inggang kanan.

l Tem"atkan tangan kanan -nda di ba0ah margin kosta te"at di "erbatasan lateral rekt/s abdominis. l Men4aga 4ari,4ari tangan kanan -nda bersama,sama, flex mereka di sendi metacar"o,"halangeal mendorong 4a/h ke dalam "er/t. l Mintalah "asien /nt/k mengambil ; breath: dalam j-nda m/ngkin da"at merasakan tiang b/lat lebih rendah dari gin4al antara tangan -nda, men4a/h saat mengemb/skan na"as "asien. l Teknik mengg/nakan sat/ tangan /nt/k memindahkan gin4al terhada" lainnya diseb/t : ; c gin4al ballottement: ; >. l (langi "rosed/r bagi ka/m kiri gin4al,memb/ngk/k dan meletakkan tangan kiri -nda di belakang "inggang kiri "asien. Tabel +.! Membedakan "embesaran lim"a dan gin4al kiri di"erbesar Pembesaran gin4al Pembesaran lim"a M/stahil /nt/k merasa di atas bisa merasa di atas organ Memiliki : ; c "/sat notch: ; > di te"i terkem/ka Ho ; notch: jteta"i -nda m/ngkin merasa takik hilar "/sat medial akhir "ada ins"irasi a0al "ada Mo)es ins"irasi Mo)es 2ergerak inferio,medial "ada Mo)es ins"irasi inferior "ada ins"irasi Tidak ballottable 2allottable Perk/si "erk/si t/m"/l Gesonant di"erhatikan karena di atasnya gas /s/s Mei mem"erbesar men/4/ Mem"erbesar /mbilic/s inferior lateral garis tengah Tem/an l e"ihak gin4al teraba: hidronefrosis, "enyakit gin4al "olikistik, karsinoma sel gin4al, trombosis )ena gin4al ak/t, abses gin4al, "ielonefritis ak/t. l 2ilateral teraba gin4al: hidronefrosis bilateral, bilateral karsinoma sel gin4al, "enyakit gin4al "olikistik, sindrom nefrotik, amyloidosis, limfoma, acromegaly. P.%L'

Fambar. +,!& Pal"asi dari gin4al kanan. Fambar. +.!! Pal"asi gin4al kiri. Hal.%LS Zand/ng kemih Zand/ng kemih adalah berbent/k "iramida dan terletak dalam rongga "angg/l. Hal ini tidak teraba ketika kosong. e"erti mengisi, mengembang s/"erior dan bahkan da"at menca"ai setinggi /mbilik/s ata/ hanya di l/ar 4ika sangat "en/h. M/ngkin s/lit /nt/k membedakannya dari rahim membesar ata/ kista o)ari/m. Zand/ng kemih "en/h akan: l Massa, teraba b/lat timb/l dari belakang simfisis "/bis.

l Membosankan /nt/k "erk/si. l -nda tidak akan da"at merasakan di ba0ahnya. l Tekanan "ada kand/ng kemih "en/h akan memb/at "asien merasa "erl/ /nt/k b/ang air kecil. 2atang nadi -orta "er/t bisa teraba di garis tengah di atas /mbilik/s, merasa sebagai massa berdeny/t longit/dinal. Hal ini ter/tama 4elas "ada orang k/r/s. Jika merasa: l Posisi 4ari,4ari masing,masing tangan ked/a sisi margin teraba terl/ar. l (k/r 4arak antara 4ari,4ari -nda. Hormal diameter : a %,1cm. l P/t/skan a"akah massa yang anda rasa berdeny/t D mel/as dalam dirinya sendiri 5dalam hal ini 4ari,4ari anda akan bergerak kel/ar6 deny/t ata/ a"akah telah dikirim melal/i 4aringan lain 5dalam hal ini 4ari,4ari anda akan bergerak ke atas6. 8ihat Fambar. +.!%. Zelen4ar getah bening ing/inal Gantai kelen4ar getah bening ing/inal terletak di se"an4ang ligament/m ing/inal antara t/berk/l/m "/bis dan s"ina iliaka anterior s/"erior dan tidak boleh dile0atkan. Gasakan l se"an4ang baris ini /nt/k setia" ben4olan mem"erlak/kan masing,masing se"erti yang akan -nda lainnya 5".+S6. Zecil, "er/sahaan mobile kelen4ar getah bening /m/m "ada orang yang sehat dan sering hasil dari se"sis kecil ata/ lecet "ada t/ngkai ba0ah. :,Q Pada taha" "emeriksaan, -nda har/s memeriksa node dalam aksila, leher, area s/"rakla)ik/la, dan daerah ing/inal. hernial yang l/bang Bi4elaskan di ".%OO. Eksternal alat kelamin Tidak ada "emeriksaan "er/t menyel/r/h yang lengka" tan"a memeriksa ; genitalia: j0ala/"/n dalam "raktek klinis banyak meninggalkan hal ini, mengingat tidak te"at 4ika -nda tidak c/riga dari setia" "atologi Fenital,kencing. 8ihat 2ab !%. Hal.%L+

Fambar. +.!% meraba massa berdeny/t. Jika massa it/ sendiri adalah mel/as 5a6, yo/rfingers akan bergerak ke arah l/ar. Jika "/lsatility sedang ditransmisikan melal/i 4aringan diatasnya 5b6, 4ari,4ari anda akan bergerak ke atas. P.%O& Zet/k Balam "emeriksaan abdomen, "erk/si berg/na for/m ; k l Menent/kan /k/ran dan sifat organ di"erbesar ata/ massa. l "ergeseran kebodohan Mendeteksi 5di ba0ah6. l menda"atkan rebo/nd nyeri 5".%L&6. Organ ata/ massa akan m/nc/l sebagai k/sam sedangkan gas /s/s "en/h akan tam"ak normal resonan. teknik baik datang dengan "engalaman. Praktek "erc/ssing kel/ar hati -nda sendiri. Teknik "erk/si di4elaskan "ada ".%!?.

Pemeriksa /nt/k asites Jika ada cairan dalam rongga "eritoneal 5ascites6, gra)itasi akan menyebabkan ia meng/m"/lkan dalam "angg/l ketika "asien berbaring flat: ; jini akan memberikan "erk/si t/m"/l lateral dengan resonansi sentral sebagai /s/s menga"/ng. -scites akan memberikan "er/t b/ncit, sering dengan /mbilic/s membalik kel/ar. Jika -nda menc/rigai adanya asites: l mengetok "/sat : J Rlateral dengan 4ari,4ari menyebar dan "osisi longit/dinal 5lihat Fambar. +.!16. l Bengarkan 5dan rasa6 /nt/k "er/bahan yang "asti ke catatan k/sam. -da kem/dian % tes kh/s/s /nt/k "erforma ; k Pergeseran kebodohan I l mengetok "/sat : J Rlateral sam"ai ket/m"/lan terdeteksi. 9ni menandai tingkat /dara,cairan di dalam "er/t. l Ja/hkan 4ari -nda ditekan sana sebagai yo/: ; k l Mintalah "asien /nt/k mengg/l/ng ke sisi yang berla0anan 5yait/ 4ika k/sam terdeteksi di kanan, roll "asien ke sisi kiri,tangan mereka6. l Mintalah "asien /nt/k memegang "osisi bar/ /nt/k c setengah menit. l (langi "erk/si bergerak lateral ke "/sat terhada" tanda -nda. l Jika kebodohan yang benar,benar adalah tingkat /dara,cairan, cairan sekarang akan di"indahkan oleh gra)itasi 4a/h dari tem"at ditandai dan daerah yang sebel/mnya k/sam akan resonan. 7l/ida getaran Pada tes ini, -nda sedang ber/saha /nt/k mendeteksi gelombang yang di"ancarkan di cairan "eritoneal. 9ni hanya benar,benar m/ngkin dengan ascites masif. -nda "erl/ asisten /nt/k tes ini 5-nda da"at meminta "asien /nt/k membant/6. l Mintalah asisten anda /nt/k menem"atkan te"i /lnaris dari salah sat/ tangan mereka di garis tengah "er/t 5lihat Fambar. +.!16. l Tem"atkan tangan kiri -nda di salah sat/ sisi "er/t, tentang tingkat dengan linea. l Bengan tangan kanan -nda, film sisi berla0anan dari "er/t "asien. l Jika ; c : ; > thrill: cairan da"at dideteksi, -nda akan merasakan riak dari film ditransmisikan sebagai sent/h /nt/k tangan kiri -nda. Tangan asisten adalah "enting,ini mencegah transmisi im"/ls di sel/r/h "erm/kaan dinding "er/t.6 P.%O!

Fambar. +,!1 Peng/4ian /nt/k getaran cairan. Mintalah asisten /nt/k menem"atkan tangan mereka ter"/sat "ada abdomen: ; jini mencegah transmisi im"/ls melal/i dinding "er/t. Hati Mengetok /nt/k memetakan batas atas dan ba0ah dari catatan,hati "an4ang, dalam sentimeter, di linea. 8im"a Perk/si dari margin kosta kiri ke arah garis midaxillary dan t/lang r/s/k kiri ba0ah m/ngkin meng/ngka"kan k/sam s/gestif "embesaran lim"a yang tidak bisa biasanya teraba.

Fin4al 2erg/na dalam membedakan seb/ah gin4al di"erbesar dari "embesaran lim"a ata/ hati. Fin4al terletak 4a/h di dalam "er/t dan dikelilingi oleh lemak "erine"hric yang memb/at mereka resonan "ada "erk/si. "lenomegali ata/ he"atomegali akan m/nc/l k/sam. Zand/ng kemih Perk/si t/m"/l di daerah s/"ra"/bik m/ngkin da"at membant/ dalam menent/kan a"akah s/at/ massa yang tidak 4elas adalah kand/ng kemih membesar 5k/sam6 ata/ /s/s b/ncit 5resonansi6. P.%O% -/sk/ltasi 2agian "enting dari "emeriksaan "er/t yang m/dah ter4a0ab. /ara /s/s 9ni adalah gemericik s/ara bernada rendah yang di"rod/ksi oleh "eristaltik /s/s normal. Mereka adalah intermiten teta"i akan ber)ariasi dalam 0akt/ tergant/ng "ada saat makan terakhir dimakan. 2erlatih mendengarkan sebagai "er/t sebanyak m/ngkin /nt/k memahami berbagai s/ara normal. Bengarkan dengan diafragma dari stetosko" te"at di ba0ah "/sar. l Hormal: gemericik bernada rendah, berselang. l Tinggi bernada: sering diseb/t : ; c tinkling: ; >. 9ni s/ara yang s/gestif dari obstr/ksi /s/s "arsial ata/ total. l 2orborygm/s: ini adalah gemericik bernada rendah keras yang bahkan bisa terdengar tan"a stetosko". 5 /ara diseb/t : ; c borborygmi: ; >.6 Zhas dari negara diare ata/ "eristaltik yang abnormal. l Tidak ada s/ara: 4ika tidak ada s/ara yang terdengar selama % menit, m/ngkin ada k/rang lengka" "eristalsis: jyait/ ; seorang l/m"/h ile/s ata/ "eritonitis. 2r/its 9ni adalah s/ara yang dihasilkan oleh aliran t/rb/len darah melal/i )essel: ; jser/"a s/ara m/rm/r 4ant/ng. Mendengarkan dengan diafragma of stetosko". 2r/its m/ngkin ter4adi "ada orang de0asa normal, teta"i meningkatkan kec/rigaan "atologis stenosis 5"enyem"itan6 saat terdengar di sel/r/h baik sistole dan diastole. -da bebera"a hal -nda har/s mendengarkan "ada "ada abdomen: ; k l Te"at di atas /mbilik/s selama aorta 5ane/risma aorta "er/t6. l alah sat/ sisi dari garis tengah te"at di atas 5stenosis arteri gin4al6 /mbilic/s. l Pada e"igastri/m 5stenosis mesenterika6. l 8ebih dari hati 5-M kelainan, he"atitis alkohol ak/t, karsinoma he"atosel/ler6. Fesekan menggosok 9ni adalah berderit terdengar se"erti yang dari menggosok "le/ra 5hal.%!'6 terdengar ketika meradang "eritoneal "erm/kaan bergerak mela0an sat/ sama lain dengan res"irasi. Bengarkan atas hati dan lim"a di kanan dan k/adran kiri atas masing,masing. Penyebab termas/k karsinoma he"atosel/ler, abses hati, bio"si hati "erk/tan bar/,bar/ ini, hati ata/ infark lim"a dan "erihe"atitis TB terkait 57itA,H/gh,C/rtis yndrome6. Mena h/ms Jarang, dim/ngkinkan /nt/k mendengar deng/ng aliran darah )ena di "er/t bagian atas atas ca"/t med/sa 5hal.%?S6 %a d "orto,sistemik sh/nting darah. P.%O1

P.%O? : ; c rect/m: ; > Per "emeriksaan 9ni adalah bagian "enting dari "emeriksaan dan tidak boleh dihindari hanya karena diangga" tidak menyenangkan. Hal ini ter/tama "enting "ada "asien dengan ge4ala "erdarahan PG, tenesm/s, "er/bahan kebiasaan b/ang air besar dan "r/rit/s ani. :,Q 9ngat: : ; c Jika anda tidak meletakkan 4ari -nda di dalamnya, -nda da"at meletakkan kaki -nda di dalamnya : ; >U ebel/m -nda m/lai Jelaskan ke"ada "asien a"a yang terlibat dan menda"atkan "erset/4/an lisan. Memilih kata,kata -nda dengan hati,hati, menyes/aikan kata,kata -nda ses/ai "asienU frase 7a)orit termas/k : ; c ekor,Enda ; >, : ; c back,"assage: ; >, dan : ; c bottom: ; >. Mengatakan bah0a -nda "erl/ /nt/k memeriksa bagian belakang mereka : ; c dengan > ; finger:. Mem"eringatkan bah0a : ; c m/ngkin tidak akan h/rt: > ; teta"i m/ngkin merasa : ; c cold: ; > dan : ; c sedikit /n/s/al: ; >. -nda har/s meminta seorang anggota staf /nt/k "endam"ing,men4aga diri terhada" klaim masa de"an "engobatan yang tidak te"at dan meyakinkan "asien .I Zetika -nda melan4/tkan, men4elaskan setia" taha" ke"ada "asien. I 9ni masih kontro)ersial di 9nggris "ada saat men/lis. saran resmi adalah bah0a sem/a dokter har/s memiliki "endam"ing saat melak/kan "emeriksaan intim. Balam "rakteknya, dokter "ria melak/kan "emeriksaan terhada" "erem"/an selal/ memiliki "endam"ing hadir sementara keb/t/han /nt/k "endam"ing dalam sit/asi lain dinilai secara indi)id/al "ada saat it/. Peralatan l Penga0al l Hon,steril sar/ng tangan l Jaringan l "el/mas 4elly 5mis. -3/agel# e6 Teknik l Bengan "erset/4/an lisan informasi yang di"eroleh, memastikan "ri)asi yang memadai. l Menem/kan "asien dari "inggang ke l/t/t. l Mintalah "asien /nt/k berbaring di "osisi lateral kiri dengan kaki ditek/k l/t/t mereka se"erti yang mereka ditarik sam"ai dada dan "antat mereka menghada" ke yo/: ; jdis/kai mem"royeksikan sedikit di atas te"i tem"at tid/r D sofa. l Memastikan bah0a ada cahaya yang baik so/rce: ; jlebih dis/kai lam"/ mobile. l Pasang se"asang sar/ng tangan. l Pisahkan bokong hati,hati dengan mengangkat "antat kanan dengan tangan kiri -nda. l Periksa daerah "erianal dan an/s o Carilah r/am, excoriations, tag k/lit, k/til d/b/r, b/kaan fist/lo/s, celah, 0asir eksternal, abses, mengotori feses, darah, dan lendir. l Mintalah "asien /nt/k strain ata/ : ; c menangg/ng do0n: ; > dan menonton /nt/k "royeksi m/c/sa "ink dari "rola"s rekt/m. l 8/masi /4/ng 4ari tel/n4/k kanan -nda dengan 4eli. l M/lailah dengan menem"atkan "/l" dari 4ari tel/n4/k kanan -nda terhada" an/s di garis

tengah dan "ers di tegas nam/n "erlahan. Zebanyakan o anal s"hincters reflexly akan mem"erketat bila disent/h ta"i dengan ce"at akan bersantai dengan tekanan lan4/tan. l 2ila rileks s"hincter, lemb/ t m/ka 4ari ke dalam kanal anal. l Menilai nada anal s"hincter dengan meminta "asien /nt/k menge"alkan 4ari -nda. P.%OL l P/tar 4ari ke belakang dan ke de"an meli"/ti 1O&# d "en/h, "erasaan /nt/k setia" "enebalan ata/ "enyim"angan. l P/sh ; 4ari f/rther: yang jsam"ai gagang 4ika ; "ossible:j ke rekt/m. l Periksa sem/a d 1O&# dengan menggerakkan 4ari dengan gerakan menya"/. Catatan: o -danya "enebalan ata/ "enyim"angan dari dinding d/b/r. o Zehadiran ; faeces: teraba jdan konsistensi. o etia" "oin kelemb/tan. l elan4/tnya, "ada "ria, mengidentifikasi kelen4ar "rostat yang bisa dirasakan melal/i dinding rekt/m anterior. o "rostat normal adalah hal/s,m/nc/l, "er/sahaan dengan tekst/r sedikit karet ber/k/ran diameter %,1cm. 9a memiliki % lob/s dengan s/lc/s sentral gamblang. l lemb/t menarik 4ari -nda dan memeriksa sar/ng tangan /nt/k kotoran, darah, ata/ lendir dan "erhatikan 0arna bangk/, 4ika ada. l 2eritah/ "asien bah0a "emeriksaan telah berakhir dan seka kotoran ata/ 4elly dari s/mbing natal dengan 4aringan. 2ebera"a "asien m/ngkin lebih s/ka /nt/k melak/kan hal ini sendiri. l Terima "asien dan meminta mereka /nt/k ganti r/gi. -nda m/ngkin "erl/ membant/. Tem/an Jika ada massa ata/ kelainan diidentifikasi "ada eksterior ata/ interior daerah di"eriksa, lokasi yang te"at yang har/s di"erhatikan. Hal ini kon)ensional /nt/k merekam sebagai "osisi "ada 0a4ah 4am dengan &&:&& men/n4/kkan sisi anterior rekt/m di "erine/m. 7it/r lain dari massa har/s dicatat se"erti yang di4elaskan "ada ".+S. l 4inak benign "rostatic: "rostat di"erbesar ta"i s/lk/s sentral yang dia0etkan, sering dibesar, besarkan. l Zanker "rostat: kelen4ar kehilangan konsistensi karet dan da"at men4adi keras. 8ob/s lateral m/ngkin tidak terat/r dan nod/lar. -da sering distorsi ata/ kehilangan s/lk/s "/sat. Jika t/mor besar dan telah menyebar secara lokal, m/ngkin ada "enebalan m/kosa d/b/r ked/a sisi kelen4ar menci"takan : ; c 0inging: ; > "rostat. l Prostatitis: kelen4ar akan membesar, bera0a, dan sangat lemb/t. :,Q Pet/n4/k l Jika "asien mengalami sakit "arah, dengan tekanan lemb/t "ada "emb/kaan d/b/r, "ertimbangan ; k fis/ra an/s, abses ischiorectal, maag d/b/r, thrombosed ambeien, ata/ "rostatitis. l Balam sit/asi ini, -nda m/ngkin har/s menera"kan gel anestesi lokal ke margin d/b/r sebel/m melan4/tkan. Jika rag/,rag/, mintalah seorang senior. P.%OO

hernial yang l/bang Hernia adalah "enon4olan abnormal organ, str/kt/r ata/ bagian s/at/ organ dari rongga di mana ia berada. Hernia biasanya da"at : ; c red/ced: ; > yait/ isinya kembali ke rongga asli baik secara s"ontan ata/ dengan mani"/lasi. Hernia "er/t biasanya disebabkan oleh bagian,bagian dari /s/s menon4ol melal/i daerah melemahnya dinding "er/t. Balam "er/t, hernia biasanya ter4adi "ada b/kaan alami dari dinding abdomen 5misalnya kanal ing/inal, kanal femoral, /mbilik/s, tem"at kosong esofag/s6 ata/ titik, titik lemah yang di"eroleh se"erti bekas l/ka bedah. Hernia "er/t Zebanyakan memiliki im"/ls bat/k mel/as,meminta "asien /nt/k bat/k akan : tekanan J Rintra,abdominal menyebabkan im"/ls terlihat ata/ teraba. Pencekikan: hernia yang tidak da"at dik/rangi 5tered/ksi6 da"at men4adi teta" dan bengkak sebagai s/"lai darah mereka ters/mbat menyebabkan iskemia dan nekrosis organ hernia. Para hernia yang menyakitkan bengkak dengan atasnya eritema dan da"at menyebabkan gangg/an f/ngsi /s/s normal 5misalnya gangg/an /s/s6. eb/ah "endekatan /nt/k hernia l Tent/kan karakteristik se"erti yang akan -nda setia" ben4olan 5".+S6 termas/k "osisi, tem"erat/r, kelemb/tan, bent/k, /k/ran, ketegangan, dan kom"osisi. l Memb/at catatan dari karakteristik k/lit di atasnya. l Pal"asi hernia dan merasakan dorongan bat/k. l ("aya "eng/rangan hernia. l mengetok dan a/sc/ltate hernia 5dengarkan s/ara /s/s ata/ br/its6. l elal/ ingat /nt/k memeriksa sit/s yang sama di sisi yang berla0anan. Hernia ing/inal -natomi Zanalis ing/inalis mel/as dari t/berk/l/m "/bik/m ke s"ina iliaka anterior s/"erior. Pada "ria, ia memba0a kabel s"ermatika 5)as deferens, "emb/l/h darah dan saraf6. Pada 0anita, 4a/h lebih kecil dan memba0a ligamen "/taran rahim. etelah ket/r/nan testis, sal/ran dit/t/" ta"i sit/s terseb/t melemah. Cincin internal b/kaan "ada fasia trans)ersalis berbaring "ada titik miding/inal, "ertengahan antara s"ina iliaka anterior s/"erior dan simfisis "/bis 5sekitar !,L cm di atas deny/t nadi femoralis6. Cincin eksternal adalah "emb/kaan a"one/rosis oblik eksternal dan segera atas dan medial t/berk/l/m kemal/an 5lihat Fambar. +.!?6. l Hernia ing/inalis langs/ng: ini adalah herniasi di lokasi dari cincin eksternal. l Hernia ing/inalis tidak langs/ng: ini adalah sit/s yang "aling /m/m 5SLf dari sem/a hernia6. Herniasi adalah melal/i cincin internal dengan /s/s ata/ oment/m "er4alanan meny/s/ri kanalis ing/inalis dan da"at menon4ol melal/i cincin eksternal ke dalam skrot/m. 8ebih m/ngkin /nt/k mencekik dari hernia ing/inal langs/ng. Hal.%O' Pemeriksaan l Pasien har/s di"eriksa berdiri,/" dan memb/ka "akaian dari "inggang ke ba0ah 5bebera"a hernia s"ontan da"at meng/rangi saat telentang6. l Pal"asi ter/tama /nt/k kelemb/tan dan konsistensi ben4olan. o oment/m hernia akan m/nc/l kenyal, tidak berfl/kt/asi, dan k/sam /nt/k "erk/si.

o /s/s hernia akan berfl/kt/asi, resonan. -nda m/ngkin da"at mendengar s/ara /s/s dalam hernia. l Bengan % 4ari "ada massa, mintalah "asien /nt/k bat/k dan merasakan dorongan bat/k mel/as. l Mencoba /nt/k meng/rangi hernia dengan memi4at kembali ke arah it/ did/ga tem"at asal. o (nt/k hernia langs/ng, -nda har/s mengg/nakan tela"ak tanganm/, mengarahkan form/lir di ba0ah ini dan membimbing hernia melal/i cincin eksternal, sam"ai kanalis ing/inalis lateral terhada" cincin internal. l etelah dik/rangi, hernia tidak boleh m/nc/l lagi sam"ai -nda mele"as tekanan. l Bengan hernia berk/rang, coba tekan atas sit/s dari cincin internal dan meminta "asien /nt/k bat/k. eb/ah hernia tidak langs/ng akan teta" berk/rang sedangkan hernia langs/ng akan menon4ol sekali lagi. Fambar. +.!? ites, dari cincin ing/inal internal dan eksternal. P.%OS Tabel +.% Biferensiasi hernia ing/inal 8angs/ng hernia ing/inal hernia ing/inal 8angs/ng Ba"at t/r/n ke dalam skrot/m angat 4arang t/r/n ke skrot/m Meng/rangi ke atas, lateral, Meng/rangi m/nd/r ke atas dan ke belakang Teta" dik/rangi dengan tekanan "ada cincin internal Tidak dikendalikan oleh tekanan atas ring internal Cacat "enyebab tidak Cacat diraba "ada dinding "er/t teraba M/nc/l kembali di cincin internal dan ar/s medial m/nc/l kembali di "osisi yang sama se"erti sebel/mnya "eng/rangan Hernia femoralis -natomi al/ran femoralis adalah kom"onen kecil dari medial sel/b/ng femoralis dengan ka"al femoralis dan berisi 4aringan ikat longgar, "emb/l/h getah bening dan kelen4ar getah bening. Hal ini berbatasan anterior oleh ligament/m ing/inalis, ligament/m "ectineal "osterior, lateral )ena femoralis, dan lac/nar ligamen medial. 7emoral Hernia adalah ton4olan dari /s/s ata/ oment/m melal/i r/ang ini. Mereka lebih sering ter4adi "ada 0anita "ar/h baya dan orang t/a dan da"at dengan m/dah mencekik karena "emb/kaan, kecil kak/ mereka mele0ati. Pemeriksaan l Periksa dengan "asien berdiri dan memb/ka "akaian dari "inggang ke ba0ah. l Periksa se"erti yang -nda lak/kan setia" hernia lain dan "eng/rangan "ercobaan. l Jika ada, hernia femoralis akan m/nc/l sebagai ben4olan hanya lateral dan inferior ke t/berk/l/m kemal/an, sekitar % cm medial deny/t nadi femoralis. Hal.%O+ Zotak +.!+ diagnosis banding dari hernia femoralis l hernia ing/inalis.

l angat kelen4ar getah bening yang besar. l ekto"ik testis. l "soas b/rsa ata/ abses. l 8i"oma. 8ain hernia dinding "er/t l /mbilical D "ara/mbilical: herniasi melal/i cacat dekat /mbilik/s 5diangga" ba0aan a"abila dikenali "ada anak,anak6. l e"igastri/m: herniasi melal/i linea alba di atas /mbilik/s. l "igalean: herniasi melal/i semil/naris linea 5lateral rekt/s sel/b/ng6, biasanya di ba0ah dan lateral ke /mbilic/s. 8angka. l obt/ratori/m: herniasi melal/i kanal obt/ratori/s, terkait dengan meningkatnya /sia dan m/lti"aritas. l Perineal: herniasi melal/i diafragma "angg/l. 8angka. l insisional: herniasi melal/i sit/s o"erasi sebel/mnya. ton4olan ini biasanya terlihat mendasari "erm/kaan bekas l/ka bedah. Meningkatkan ke4adian dengan /sia lan4/t, teta"i bisa disebabkan oleh infeksi l/ka dan fasciitis berh/b/ngan ata/ nekrosis otot. P.%'& Penting menya4ikan "ola Penyakit hati kronis alah sat/ fit/r berik/t m/ngkin terlihat. Bengan "enyakit "arah dan : ; c decom"ensation: ; >, lebih akan men4adi a""arent: ; k : ; g Penyakit k/ning. : ; g P/r"/ra. : ; g "almar eritema. : ; g M/dah memar. : ; g 8e/conychia. : ; g e"istaksis. : ; g Cl/bbing. : ; g menorrhagia. : ; g "ider nae)i. : ; g Zehilangan libido. : ; g telangiectasia. : ; g Gamb/t rontok. : ; g He"atomegali. : ; g 2ilateral "arotid bengkak. : ; g -scites. : ; g ensefalo"ati. : ; g Mariceal "erdarahan,me0/4/dkan sebagai hematemesis dan D ata/ melaena. : >, : > ; : ; g ginekomastia. : ; g Pay/dara atrofi. : ; g atrofi testis. : ; g 9rreg/lar mens. : ; g 9m"otensi. : ; g amenorea. Portal hi"ertensi Bibesarkan tekanan dalam )ena "ortal hati sering sek/nder /nt/k "enyakit hati ata/ "enyebab non,sirosis se"erti trombosis )ena "ortal. Penyebab "orto,sistemik sh/nting dan )arises esofag/s. Tanda,tanda: l keba/b/s/kan he"atic/s l "lenomegali l Gisiko kehilangan darah "encernaan dari )arises 5anemia, hematemesis, melaena6 l -scites l ca"/t med/sa. 2eralkohol "enyakit hati

Ba"at menyebabkan sem/a fit/r dari "enyakit hati kronis se"erti di4elaskan di atas. elain it/, ketergant/ngan ata/ kecand/an alkohol dikaitkan dengan: l Toleransi. l Penarikan ge4ala. l -lkohol yang diambil dalam 4/mlah yang lebih besar dan lebih lama dari"ada yang dimaks/dkan. l Persistent keinginan /nt/k memotong : ; c do0n: > ;. l berlebihan 0akt/ yang dihabiskan di kegiatan yang berkaitan dengan kons/msi alkohol. l Meninggalkan kegiatan sosial, "eker4aan ata/ rekreasi. l 8an4/tan mengg/nakan meski"/n kesadaran efek fisiologis dan "sikologis yang mer/gikan "engg/naan lan4/tan. 7atty hati : ; c hati steatosis: ; > dan memiliki banyak "enyebab lainnya termas/k obat, kehamilan dan diabetes mellit/s. Be"osisi lemak sebagai akibat oksidasi alkohol "referensial. Ge)ersibel dengan "antang teta"i m/ngkin melan4/tkan ke sirosis dengan mengg/nakan lan4/tan. Tidak klinis fit/r s"esifik. P.%'! 2eralkohol he"atitis He"atocell/lar radang dengan infiltrasi limfosit, steatosis, kolestasis, fibrosis dan nekrosis. Fambaran klinis termas/k: l Bemam. l Penyakit k/ning. l Tender he"atomegali. l Mei mendengar kabar angin di atas hati. irosis Parah fibrosis hati dengan : ; c micronod/les: ; >. Zehilangan he"atosit, gangg/an f/ngsi sintetis dan hi"ertensi "ortal. "enyebab lain dari sirosis termas/k he"atitis )ir/s kronis 52 ata/ C6, "rimary sclerosing, "enyakit Cilson, haemachromotosis, i T defisiensi !,antitry"sin, sirosis bilier "rimer, sindrom 2/dd,Chiari dan berbagai obat 5misalnya amiodarone, methyldo"a dan methotrexate6. Fambaran klinis da"at salah sat/ dari yang tercant/m di ba0ah c : ; > disease: hati kronis ; di atas. Extra,hati manifestasi dari "enyakit hati alkoholik D alkoholisme l Obesitas ata/ kek/rangan giAi. l Biare. l 8amb/ng erosi. l /lk/s "e"tik/m "enyakit. l Pankreatitis. l )arises. l -scites. l "lenomegali. l Hi"ertensi. l Hilangnya karakteristik %- d seks/al. l osteomalacia. l Osteo"orosis.

l 7alls. l Ze4ang. l Zognitif "en/r/nan 5hal.L&%6. l Metabolik ensefalo"ati. l Peri"heral ne/ro"ati. l -taxic ki"rah 5".1L&6. l Cernicke ence"halo"athy. l ZorsakoffRs syndrome. l Cardiomyo"athy. l arrythmias 5es". atrial fibrilasi6. He"atik ensefalo"ati h/nting darah dari sirk/lasi "ortal, terlihat "ada "enyakit hati kronis, mem/ngkinkan ber"otensi ne/rotoksik Aat disera" dalam /s/s /nt/k memotong hati di mana mereka biasanya akan diha"/s. 8ihat OHCMO, ".%1& /nt/k mana4emen. Ensefalo"ati hati dinilai sebagai berik/t : ; k Frade & Hormal keadaan mental Frade 9 Bi/bah mood ata/ "erilak/ 5: J jrentang "erhatian, kes/litan dengan angka dan k/rangnya ata/ kesadaran6 mengant/k Zelas 99 : J R, cadel berbicara, ringan D kebing/ngan mod Frade 999 "ingsan teta"i res"onsif terhada" rangsangan, kebing/ngan signifikan, kegelisahan Frade 9M Coma P.%'% Malabsor"si 2erbagai gangg/an bisa menyebabkan negara malabsor"si. Mereka da"at dikelom"okkan sebagai ins/fisiensi "ankreas, malabsor"si garam em"ed/, ker/sakan m/kosa /s/s kecil 5"enyakit celiac, s"r/e tro"is, giardiasis, kek/rangan disaccharidase, "enyakit Chi""le, sindrom /s/s "endek6, "ert/mb/han bakteri yang berlebihan, dan cacat "engiriman yang s"esifik. (m/m ge4ala dan tanda,tanda dari malabsor"si meli"/ti: l Otot 0asting. l 2erat badan. l P/cat. l Biare 5berair6. l teatorrhoea: "/cat, kotoran lemak, ofensif berba/ dan s/lit /nt/k fl/sh. l glossitis. l /d/t stomatitis 5)itamin 2%, 2!% dan kek/rangan asam folat6. l 9ntra,oral "/r"/ra dan m/dah memar 5kek/rangan )itamin Z6. l 7olik/lar keratitis: bercak "/tih hi"erkeratotik 5kek/rangan )itamin -6. Pankreatitis ak/t 5lihat 4/ga OCHMO, ".?'S6 Fe4ala l Pain: ; j"/sat "er/t ata/ e"igastri/m, memancarkan melal/i ke belakang. Zadang,kadang sedikit lega dengan d/d/k de"an. l M/ntah. Tanda,tanda l Takikardia.

l Bemam. l Penyakit k/ning 54arang6. l Peritonitis 5/s/s ile/s, "er/t sangat lemb/t, men4aga6. l retro"eritoneal berdarah: C/llenRs ata/ tanda,tanda Frey,T/rner 5".%?+6. Pankreatitis Zronis Bi negara ma4/, "enyebab "aling /m/m adalah as/"an alkohol kronis berat. 8ihat OHCMO, ".%L% /nt/k informasi lebih lan4/t. ekelom"ok kecil "asien da"at me0arisi "ankreatitis kronis melal/i gen a/tosomal dominan dengan "enetrasi yang tidak lengka". Fambaran klinis biasanya karena kek/rangan enAim "ankreas dan malabsor"si dan sakit kronis. M/ngkin ada eksaserbasi ak/t, menya4ikan sebagai "ankreatitis ak/t. Hilangnya f/ngsi endokrin "ankreas da"at menyebabkan diabetes. Zolangitis Em"ed/ se"sis. Bisarankan oleh : ; c CharcotRs triad: ; >: l nyeri k/adran kanan atas. l Bemam. l Penyakit k/ning. -nda 4/ga m/ngkin da"at mem"eroleh tanda M/r"hy 5".%L16. P.%'1 eliaka "enyakit Penyebab /m/m malabsor"si. Mem"engar/hi ! "ada tah/n %&&& di 9nggris 5! dalam 1&& di 9rlandia6. T,sel "enyakit a/toim/n dimediasi m/kosa /s/s hal/s ditandai oleh atrofi )ili dan limfositosis : J Rintra,e"itel dalam menangga"i kons/msi gl/ten. (nt/k "engobatan dan "rognosis, lihat OHCMO, ".%L%. Fl/ten adalah senya0a berat molek/l tinggi yang mengand/ng gliadins dan "e"tida. Bitem/kan dalam se4/mlah besar mendirikan mengand/ng gand/m, barley dan rye. Zontro)ersi ada lebih dari gand/m makan. Zlinis: Fe4ala l Zelelahan. l Malaise. l Biare ata/ steatorrhoea. l ketidaknyamanan "er/t dan kemb/ng. l 2erat badan. l Zecemasan. l Be"resi. l Peri"heral "araesthesia. Tanda,tanda l Otot 0asting. l M/l/t /lserasi. l s/d/t stomatitis. l -nkle edema 5alb/min ser/m rendah6. l "oline/ro"ati. l kelemahan otot. l tetany.

Terkait dengan Fangg/an tiroid a/toim/n, "enyakit hati kronis, al)eolitis fibrosing, /lcerati)e colitis, diabetes mellit/s tergant/ng ins/lin. Zem/ngkinan kom"likasi yang har/s di"erhatikan l limfoma /s/s Zecil 54arang6. l adenokarsinoma /s/s Zecil 54arang6. l (lcerati)e 4e4/nitis. l lienalis atrofi. l -nemia. l osteomalacia. l Osteo"orosis. l intoleransi laktosa sek/nder. P.%'? Gadang /s/s: kolitis /lserati)a 5(C6 eb/ah "enyakit kekamb/han kronis tidak diketah/i melibatkan etiologi "eradangan s/"erfisial m/kosa kolon, m/lai dari rekt/m ke "roksimal dan beker4a tan"a istirahat. 9le/m terminal m/ngkin akan ter"engar/h oleh : c back0ash ileitis: ; > ;. 8ihat 4/ga OHCMO, ".%??. Periode remisi m/ngkin tidak memberikan ge4ala sama sekali. Fe4ala l Biare 5sering dengan darah ata/ lendir6. l 2erat badan. l Bemam. l Hyeri abdomen. l Procitis da"at menyebabkan "erdarahan d/b/r, lendir, tenesm/s, dan sembelit. Zom"likasi yang har/s di"erhatikan: l 2erac/n megacolon. l Zek/rangan Aat besi anemia. l : J Rrisiko karsinoma kolorektal. l 7ist/la,formasi 54arang6. Gadang /s/s: Penyakit Crohn e"erti radang borok /s/s besar 5di atas6, ini adalah "enyakit "eradangan kronis "ada sal/ran "encernaan teta"i berbeda dari (C dalam ter4adi di mana sa4a lesi dari m/l/t ke an/s teta"i ter/tama di ile/m terminal dan ano,rekt/m. Patologi melibatkan /lserasi mendalam, : ; c cobblestoning: ; > m/kosa, "embent/kan fiss/ring dan abses dengan : ; c ski" lesions: ; > dan gran/loma non,caseating. 8ihat 4/ga OHCMO, ".%?O. Fe4ala Jika "enyakit ini terbatas "ada /s/s besar, ge4ala m/ngkin identik dengan (C. l 8oose kotoran ata/ diare 5biasanya tidak berdarah6. l -norexia. l Malaise. l 2erat badan. l Hyeri abdomen 5berbahaya, sering di k/adran kanan ba0ah6. l "erianal nyeri. l 2ersama nyeri.

Catatan tentang examination: ; k 5ini da"at ter4adi di (C 4/ga6 l a"htho/s m/l/t bis/l. l ()eitis. l -nemia. l arthro"athy. -cti)e CrohnRs disease l Zolik sering nyeri di fossa iliaka kanan. l Mei mengalami diare dengan darah dan lendir. l 2erat badan. l 2orborygm/s 5".%O%6. l M/ngkin teraba massa "eradangan di fosa iliaka kanan. l distensi abdomen. l # T obstr/ksi /s/s. P.%'L -cti)e CrohnRs colitis l "resentasi Miri" dengan radang borok /s/s besar. l "erianal "enyakit lebih m/ngkin menghasilkan fiss/ring dan "embent/kan fist/la. Zom"likasi yang har/s di"erhatikan l 7ist/la formasi 5dari /s/s "ada organ "er/t lain ata/ eksterior6. l Zecil : J Rrisiko karsinoma kolorektal 5ter/tama "ada "enyakit lama terbatas "ada /s/s besar6. l Zek/rangan )itamin 2!%. l Zek/rangan Aat besi. l -bses formasi. l trikt/r formasi. l infeksi sistemik. Ekstra,intestinal fit/r "enyakit inflamasi /s/s l sero,negatif arthro"athy sendi besar ata/ kecil 5"erifer "ergelangan tangan, non,deformasi, kh/s/snya "ada l/t/t, "ergelangan kaki, dan6. l sakroiliitis. l anterior /)etitis. l Eritema nodos/m. l Pyoderma gangrenos/m. l /reter bate. l 2at/ em"ed/. l sclerosing kolangitis. l cholangiocarcinoma. l kek/rangan giAi 5Osteo"orosisE OsteomalaciaE6 l malabsor"si garam em"ed/ l sek/nder /nt/k "engg/naan steroid 4angka "an4ang ata/ malabsor"si Osteo"orosis. l istemik amyloidosis. 9rritable /s/s sindrom,Goma 99 kriteria diagnostik etidaknya !% mingg/, yang tidak "erl/ bert/r/t,t/r/t, dalam !% b/lan sebel/mnya ketidaknyamanan "er/t ata/ sakit yang memiliki % dari 1 fit/r: l Gelief dengan defaecation.

l Onset terkait dengan "er/bahan frek/ensi tin4a. l Onset terkait dengan "er/bahan bent/k tin4a. Fe4ala lainnya yang mend/k/ng diagnosis 92 : l -bnormal tin4a frek/ensi 51Dhari* ata/ 1D0eek V6. l -bnormal bent/k tin4a 5kental D keras, longgar D berair6. l -bnormal bangk/ bagian 5tegang, /rgensi, rasa e)ak/asi tidak lengka"6. l Passage lendir. l Zemb/ng ata/ rasa distensi "er/t. P.%'O Para "asien t/a "enyakit gastrointestinal hadir sebagai s"ektr/m besar di t/a,t/a, meli"/ti n/trisi, "era0atan m/l/t, dan nafs/ di sam"ing berbagai "resentasi di4elaskan dalam bab ini. ementara banyak orang t/a menderita ge4ala gastrointestinal, sering karena "enyakit yang mendasari ata/ efek obat, mereka m/ngkin mal/ mendisk/sikannya. Pemikiran dan "enilaian holistik adalah yang ter"enting, dan inter)ensi sederhana da"at membayar di)iden. e4arah l Oral "era0atan: sering diabaikan, teta"i mer/"akan bagian k/nci dari "enilaian a"a"/n. Figi "als/ m/ngkin sakit "as ata/ hilang, dan kons/msi makanan da"at menderita sebagai konsek/ensinya, dan ra0at ina" r/mah sakit sangat rentan terhada" kehilangan gigi "als/ mereka. l Mengklarifikasi ge4ala dan diagnosa: -"akah "asien benar,benar memiliki /s/s iritasiE 58ihat di ba0ah.6 2anyak "asien da"at menggambarkan diri mereka sebagai memiliki diagnosa terseb/t, teta"i mel/angkan 0akt/ /nt/k men4elaskan a"a artinya ini. Per/bahan terkini dari kebiasaan b/ang air besar, bahkan di kem/dian hari har/s selal/ di"andang dengan dera4at alarm dan menyebabkan di"ertimbangkan. l embelit: sering da"at menyebabkan "en/r/nan yang seri/s "ada "asien dengan sembelit. Hal ini sering ce"at diatasi. l 2erat dan giAi: bertanya "ada diri sendiri menga"a "asien kehilangan berat badan. Gentang diagnosa yang l/as, teta"i meren/ngkan s/asana hati, kebiasaan diet, dan kemam"/an f/ngsional dalam "enilaian anda m/ngkin masalah tidak s/ka makanan bek/ disam"aikanU l Obat se4arah: selal/ mem"ertimbangkan efek sam"ing dari obat,analgesik dan sembelit, antibiotik bar/,bar/ ini, dan diare. Tanyakan obat tentang o)er,the,co/nter termas/k H -9B 5obat to"ikal 4/gaU6 Ban a"erients. l "ertarakan: bagian lain k/nci dari "enilaian ini, mencoba /nt/k membahas secara sensitif dan menent/kan a"akah ada faktor tambahan /nt/k setia" gangg/an F9, termas/k mobilitas, kognisi dan masalah "englihatan. 9ni bent/k ekor b/r/ng dengan se4arah f/ngsional yang "ernah "enting. Pemeriksaan l (m/m: melihat kel/ar /nt/k tanda,tanda berat memb/ang ; loss: j, b/r/k dll "as "akaian (nt/k "asien ra0at ina", grafik berat selesai dan "ertimbangan yang hati,hati m/ngkin meng/rangi bebera"a masalah giAi b/r/k dan "enyakit ak/t. l 8ihatlah di m/l/t: sebagai berbagai diagnosis sering terlihat. Pera0atan gigi tir/an har/s dinilai 5"embersihan miskin terkait dengan stomatitis ber/lang6, dan masalah lain se"erti candida oral 4elas. l Perhatikan: /nt/k tanda,tanda "enyakit sistemik yang m/ngkin men/n4/k ke "enyebab ge4ala

gastrointestinal 5misalnya bebera"a telangiectasia, "enyakit 4ant/ng kat/" di "erdarahan F96. l Memeriksa: menyel/r/h /nt/k limfadeno"ati. 9ngatlah /nt/k memeriksa ; hernial orifices: j"enyebab sakit "er/t bisa langs/ng ; ob)io/s:j dan di"erbaiki. l Pemeriksaan rektal: )ital,"er/bahan dalam kebiasaan b/ang air besar, Tarak, anemia kek/rangan Aat besi, simtomatologi kand/ng kemih sem/a men/n4/kkan ini. P.%'' Biagnosa tidak akan ter4a0ab l gangg/an /s/s 7/ngsional: cender/ng k/rang /m/m "ada orang t/a, 4adi selal/ mem"ertimbangkan masalah organik yang mendasari. "emeriksaan Endosko"i seringkali ditoleransi dengan baik dan memiliki hasil diagnostik yang baik. l se"sis bilier: adalah 1 s/mber yang "aling /m/m infeksi "ada orang t/a 5setelah se"sis dada dan /rin6, dan m/ngkin tidak banyak fit/r yang menya4ikan menon4ol di4elaskan sebel/mnya dalam bab ini. Cas"ada terhada" kem/ngkinan ini ketika mem"ertimbangkan diagnosa diferensial dan memilih antibiotik. Zami berterima kasih ke"ada Br Gichard 7/ller /nt/k menyediakan halaman ini.