JUGULAR VENOUS PRESSURE (JVP)

The JVP is an important sign to look out for especially for the CVS station.

The JVP will indicate if there is presence of fluid overload. 

Students are expected to know how to measure the JVP and to identify the characteristic features of a JVP. The height of the JVP is measured from the manubriosternal angle (Angle of Louis) until the top of the JVP pulsation. 

An abnormal JVP is a measurement of > 3cm above the manubriosternal angle. 

The JVP is best assessed in good lighting so ensure that you have your pen torch ready for extra illumination.

JVP characteristics:

1. Visible but not palpable

2. Presence of double waveform

3. It is occludable at the base of the neck

4. There is hepatojugular reflux 

CCE.

HOW NOT TO SCREW UP YOUR ABDOMINAL SHORT CASE EXAM

When you hear the bell ring and you are directed to enter the examination room, do remember your manners and greet the examiners with a brief “Good morning” or “Good afternoon”. Never before in the history of the university was there a need for a “Good night sir”. In the excitement of the exams, time can be hazy and you may lose track of it. But stay grounded and always stay in touch with reality. That is why a good night sleep the day before is essential. You don’t want to be making a fool of yourself even before the examination begins.

Upon entering the room and after you have greeted the examiners, your name will be read out and you are supposed to verify that the candidate name read is indeed your name. After which, automatically proceed to the examination bed where the patient is seated or lying down. You will find the examination instructions pasted on the table. Read it carefully and take note of the patient’s designated name and also the exam question. 

For example, the question may read “Madam A has abdominal discomfort. Please examine her abdominal system.”

A short reminder on refraining from addressing patients with “aunty”, “uncle”, “pakcik” or “makcik’. We have been doing this habitually during our day to day practice and it is customary for us as this is a respectful way of addressing our senior patients. But for the purpose of major examinations, please use the patients’ designated names instead, to sound more formal.

After reading the instructions, proceed with positioning the patient to prepare for abdominal examination. Patients should be placed in full supine position whenever possible. The head can only be supported by one pillow (maximum) but if the patient is able to tolerate without any pillow, that would be best. Remember to expose the patient adequately as well. For male patients, if they are consenting, request the patient to remove the shirt completely. For female patients, perhaps it would be better to just expose the abdomen from xiphisternum all the way down to the suprapubic or pubic symphisis region for the sake of the patient’s modesty. For the purpose of this post, I will begin the examination from general inspection, then the peripheries before the abdomen itself.

General inspection, look for:

1. Overall patient condition i.e. restless, in discomfort or comfortable. Take note of any obvious dysmorphism e.g. Cushingoid appearance etc. and last but not least any obvious skin discolorations e.g. bronze skin (hemochromatosis or iron overload conditions e.g. thalassemia), sallow skin (chronic kidney disease may suggest polycystic kidney disease or obstructive uropathy or failed renal transplant case) or jaundiced skin.

2. Look at IV drips – blood product transfusion, antibiotics, dextrose infusion etc that may give a clue to the underlying abdominal diagnosis

3. Look at CBD bag at the bedside if any – pay attention to urine colour: tea coloured urine may suggest a liver or hematological disorder, hematuria may suggest an underlying coagulopathy (possible liver disorder related)

4. Look at temperature charts at bedside if any (may indicate an infective diagnosis)

 

Hand examination (as far as possible ask the patient to lift their own hands up, you may support the hands once they have done so). Pay particular attention to the following details:

1. Finger clubbing – lower your eyes to the nail fold or Lovibond’s angle to look for loss of angle, you may also do the Schamroth window test by opposing both thumbs or index fingers together to look for loss of diamond shaped window.

2. Leuconychia – this will indicate hypoalbuminemia which may be related to the patient’s nutritional status or underlying chronic liver disease (to differentiate this from pallor, in leuconychia, the nail bed blanching will not be visible through the nails as the nails are opacified in leuconychia)

3. Nail bed colour – may hint at anemia if there is pallor

4. Capillary refill time – indicator of adequate perfusion

5. Splinter hemorrhages – stigmata of endocarditis (relevant for the abdominal station as endocarditis may be associated with splenomegaly)

6. Koilonychia – suggestive of iron deficiency – indicates underlying chronic blood loss or gastrointestinal malignancy

7. Symmetrical deforming polyarthropathies (suggestive of Rheumatoid arthritis) – may be related to the abdominal station as RA may be associated with splenomegaly in a condition called Felty syndrome

8. Tendon xanthomas – suggestive of dyslipidemia (may be associated with Non Alcoholic Fatty Liver Disease (NAFLD) or Primary Biliary Cirrhosis (PBC))

9. Intrinsic muscle wasting – indicative of nutritional status (relevant to malabsorption or chronic disease e.g. GI malignancy)

10. Hepatic flaps – hepatic encephalopathy (a sign unlikely to be seen in the exams as patients are usually well and stable). Remember to ask the patient for any pain over the wrists before performing dorsiflexion of the hands and jerking the fingers backwards to stimulate the flapping movements. 

 

Upper Limbs:

1. Bruises/ petechiea – will suggest an underlying coagulopathy or thrombocytopenia

2. Scratch marks – elevated bilirubin levels or uremia may cause itching leading to scratch marks

3. Tattoos – may indicate a risk for viral hepatitis infection

4. Multiple needle prick marks – may suggest underlying abuse of intravenous substances (risk for viral hepatitis or retroviral infection)

5. BCG scar – tuberculosis is a differential for any chronic infection in our part of the world

6. Axillary hair – look for loss of axillary hair by abducting the shoulders a little (loss of axillary hair is seen in chronic liver disease, but need to differentiate from patient’s who regularly shave their armpits)

7. Tendon xanthomas over the elbows (may indicate underlying severe dyslipidemia)

8. Arteriovenous fistulas – indicate underlying end stage kidney disease. Need to consider polycystic kidney disease in the abdominal exam station. And also look out for renal transplantation scars later on during the examination.

 

Head and neck:

1. Eyes – look for conjunctiva pallor and sclera icterus. Also observe for xanthelasma (please do not mention Kayser- Fleishcer rings as those are only seen using slit lamp examination) and arcus senilis which may indicate underlying hyperlipidemia. 

2. Mouth – angular stomatitis (indicate iron deficiency or vitamin B deficiency), glossitis (B12 deficiency), oral thrush (immunocompromised state), gingitis and caries (predisposes to endocarditis which may be associated with splenomegaly, thus making it relevant for the abdominal station), gum hyperplasia (may indicate underlying exposure to drugs like cyclosporine – an immunosuppressant that is used for renal transplant patients (relevant to the abdomen station), phenytoin (anti epileptic drug which may also be relevant to the abdomen station) or acute myeloid leukemia)

3. Neck – look for dialysis catheters, enlarged cervical lymph nodes (I would suggest examining the cervical nodes after completing the abdominal examination when you are able to sit the patient up).

Chest:

1. Spider naevi – bear in mind it can also be found in normal persons. But if there are more than 3 spider naevi found, then chronic liver disease should be suspected first.

2. Gynecomastia – look for a disc like tissue swelling in the retro-areolar region in males. It is usually tender so be gentle while palpating for it. It may indicate underlying chronic liver disease but also indicate that the patient may be on certain drugs like spironolactone. Spironolactone is a common diuretic used for patients with decompensated liver cirrhosis with ascites.

 

Abdomen:

1. Symmetry of movement with respiration – for this step I would take a step or two back and inspect the anterior abdominal wall while asking the patient to take a deep breath in and then exhaling. This movement will enable me to look for any asymmetry of abdominal wall movements. This may indicate or suggest an underlying mass.

2. Peristaltic movements – this may indicate an underlying bowel obstruction; which is unusual for the medical examination (so do not look too hard for this sign)

3. Pulsations – visible pulsations may be relevant for the abdominal examination. A pulsatile mass adjacent to the midline will alert you of a possible underlying abdominal aortic aneurysm. You will need to palpate with caution to prevent rupturing the aneurysm.

4. Surgical scars – pay attention to midline laparotomy scars, laparoscopic scars (most often at the umbilicus region and at the left or right upper quadrants), peritoneal tapping scars and appendicectomy scars. Pay close attention to subcutaneous injection scars over the periumbilical regions which may hint at regular insulin use or iron chelation therapy use (both of which are relevant to the abdominal system).

5. Visible and dilated veins – usually caput medusa (may suggest underlying liver cirrhosis with portal hypertension)

6. Cough impulse – this maneuver is to examine for possible inguinal hernias. Although this step is included in the abdominal examination, this may not be so practical for the medical station.

7. Superficial palpation – this step is to elicit any abdominal tenderness or guarding which may indicate underlying peritonism. It is highly unlikely for students to encounter such a condition in the exams, therefore, I would suggest performing this step by palpating the abdomen in 4 quadrants instead of 9 quadrants.

8. Deep palpation – this step is more important as it is intended to identify abdominal masses. Therefore it is better to perform this step by palpating the abdomen in 9 quadrants.

9. Liver palpation – begin from the right iliac fossa (RIF) and progress superiorly toward the right subcostal margin. I would recommend taking control of the patient’s breathing by asking the patient to breathe in and breathe out on your command at a pace that is suited to the student. This will allow the student to better appreciate the movement of any liver that are moving with respiration. When the patient is inspiring (breathing in), the palpating hand should be kept still awaiting the inferior liver edge to hit the hand. When the patient is expiring (breathing out), the palpating hand should move superiorly towards the right subcostal margin if no liver edge is felt. Once the liver edge is felt, the palpating hand should keep still to mark the position of the liver edge. Using the left hand, the student can feel the surface of the liver and its consistency. Remember to try to get above the mass as well to verify that the mass is indeed the enlarged liver. After that, the measuring tape should be brought out and measurements taken from the inferior liver edge to the right subcostal margin along the right mid clavicular line. Once done, the right hand can feel along the inferior liver edge to determine if its regular or irregular margins and ill- or well-defined. This is followed by percussion beginning from the right iliac fossa, gradually moving superiorly until the position of the palpable liver mass earlier. The student should take note of the change in percussion note from resonant to dull over the liver mass. Remember to also percuss the upper right hemithorax and progress inferiorly towards the right subcostal margin to identify the superior margin of the liver. Once the percussion note is dull, that is the superior margin and the measuring tape is brought out again and measurement taken from the dull point towards the right subcostal margin along the right midclavicular line. The entire liver span would be a summation of the distance from the upper margin of liver to the right subcostal margin and the distance from the right subcostal margin to the inferior margin of the liver. 

10. Spleen palpation – begin from the RIF and move diagonally towards the left hypochondrium. As per liver palpation, advance towards the left hypochondrium every time the patient expires until you feel the splenic tip hitting your fingertips. Once you’ve felt the splenic tip contacting your fingertips, stop moving your palpating hand and remain still. Use your left hand to begin feeling the surface and consistency of the spleen and attempt to get above it. Following which, draw the measuring tape again and measure the spleen size starting from the left subcostal margin along the left midclavicular line extending diagonally towards the splenic tip. Then percuss from the right iliac fossa towards the splenic mass to appreciate the change in percussion note from resonant to dull upon reaching the splenic mass. To further verify the splenic mass, percuss also the Traube’s space. In the event the spleen is not palpable, then percuss the Traube’s space. If the Traube’s space is resonant, then it is unnecessary to palpate for the spleen in right lateral position. If the Traube’s space is dull, then should proceed with turning the patient to right lateral position and then re-palpate the spleen from the umbilicus towards the left hypochondrium. Bear in mind, other causes may contribute to a dull Traube’s space on percussion i.e. left pleural effusion or a stomach mass.

11. Kidney palpation – the kidneys are balloted to determine if they are enlarged. If there is a mass arising from the right or left lumbar, the student would be required to approach it like any lump and bump i.e. palpation of the edges, surface, consistency, measurement of size in two dimensions, attempting to get above and below the mass and also percussion. A kidney mass would have overlying resonant percussion note as it is a retroperitoneal structure and the bowel loops are lying anterior to it.

12. Ascites – if the abdomen is grossly distended, it is adequate to perform fluid thrill. If the abdomen is not distended or mildly distended only, then shifting dullness percussion should be performed to identify any underlying ascites. During shifting dullness, while the patient is on right lateral position, can take this opportunity to examine the sacral area for sacral oedema and also inspect the posterior superior iliac crests bilaterally for bone marrow aspiration scars. After completing the shifting dullness percussion, it is also possible to palpate for the spleen in right lateral position if the spleen was not palpable in supine position (if Traube’s space was dull to percussion note).

13. Inguinal lymphadenopathy – I would suggest taking the opportunity to examine the inguinal nodes for any nodal enlargement after turning the patient back to supine position upon completing the examination for ascites.

 

Neck:

After completing inguinal node examination, sit the patient up to examine the cervical nodes. Avoid palpating the jugular chain nodes on both sides at the same time. This is to avoid compressing the carotid sinus simultaneously which may cause vagal syncope. 

 

Respi:

While the patient is sitting up, take the opportunity to auscultate the lungs if time permits – look for crepitation to suggest pulmonary oedema or reduced breath sounds to suggest pleural effusion. These indicate the patient may be fluid overloaded as a result of hypoalbuminemia or as a complication of underlying chronic liver disease or end stage kidney failure.

Back:

While the patient is still sitting, move inferiorly to the sacral area after auscultating the lungs. Examine the sacral area for sacral oedema as well as look for bone marrow aspiration scars over the posterior superior iliac crest region. If this step has been performed earlier, then this step need not be repeated.

 

Lower limbs:

Lastly, move to the legs and while looking at the patient, compress the bony prominences over both ankles to look for pitting pedal oedema.

 

After completing all the above, offer to complete your examination by offering to perform:

1. Rectal examination – not every patient will require this unless indicated. Per rectal examination would definitely be required if the patient is pale, and the examination is to look for melena to suggest gastrointestinal hemorrhage.

2. External genitalia examination – offer to perform this examination if chronic liver disease is in your differential diagnoses. This examination is basically to look for loss of secondary sexual characteristics e.g. testicular atrophy or loss of pubic hair which may be a manifestation of chronic liver disease or in cases of iron overload (transfusion dependent thalassemias or hemochromatosis) resulting in pituitary dysfunction.

3. The student may also offer to perform any steps which the student thinks may contribute to the diagnosis that was not done during the examination due to time constraints.

Having completed the physical examination, the next step would be to SUMMARISE the relevant findings that will lead to the provisional or main diagnosis. After which, remember to offer several relevant differential diagnoses.

Without a proper set of provisional and differential diagnoses, it will be difficult to proceed with a proper discussion on investigations and treatment plan.

Good luck and keep practicing.

 

CCE.