Jaundice — not at medial or lateral corners of sclera ^[1]

• Why not at corners? The medial corner has yellowish subconjunctival fat (pinguecula) that mimics jaundice. The lateral corner has similar fatty tissue. True scleral icterus is best seen in the central part of the sclera under natural light.
• Jaundice becomes clinically visible when bilirubin > ~34 μmol/L (2 mg/dL)

Spider angioma — in SVC drainage area; rarely below nipples; also in oral and nasal mucous membrane. Occurs in: normal, cirrhosis, hepatitis, rheumatoid arthritis, pregnancies. ^[1]

• Anatomy: A central arteriole with radiating "legs" — blanches from the centre when pressed and refills centrifugally when released
• Why SVC distribution? Spider naevi are related to hyperestrogenism. The mechanism is debated, but oestrogen causes arteriolar vasodilation, and the SVC territory (face, neck, arms, upper chest) seems more susceptible
• Clinical significance: ≥5 spider naevi is more suggestive of liver disease than a few scattered ones. They also occur in normal people and in pregnancy (high oestrogen states)

Scattered telangiectasia — "Paper Money Skin." Same significance as spider angioma. Also in scleroderma. ^[1]

• Random dilated capillaries on the trunk, resembling the fine vascular network on old paper banknotes

Palmar erythema — occurs in: chronic liver disorder, rheumatoid arthritis, pregnancy, thyrotoxicosis, chronic febrile illness, chronic leukaemia. ^[1]

• Where exactly: Mainly the thenar and hypothenar eminences; spares the central palm
• Why: Hyperestrogenism → local vasodilation. Same mechanism as spider naevi
• Exam trap: Palmar erythema is NOT specific to liver disease — the differential is long

Clubbing of fingers and toes — 4 stages — associated conditions ^[1]

• GI causes: Cirrhosis, IBD (especially Crohn's), coeliac disease, GI lymphoma
• Other causes: Respiratory (lung Ca, bronchiectasis, empyema, IPF), cardiac (cyanotic heart disease, infective endocarditis), idiopathic/familial

Dupuytren's contracture — first affects 4th and 5th tendons. Occurs in: normal, cirrhosis (especially alcohol-related), diabetes mellitus, systemic fibrosclerosing syndromes. ^[1]

• Pathology: Fibrosis and thickening of the palmar fascia causing flexion contractures of the ring and little fingers
• Why alcohol? Chronic oxidative stress and acetaldehyde may promote fascial fibrosis. Also associated with repetitive trauma (manual labour)

White nails (leukonychia) — rare. ^[1]

• Why: Hypoalbuminaemia → white nail beds. The classic "Terry's nails" of cirrhosis show white proximal two-thirds with a normal distal strip
• In practice, leukonychia can also be from hypoalbuminaemia of any cause (nephrotic syndrome, malnutrition)

Flapping tremor — occurs in severe hepatocellular decompensation. ^[1]

• Technique: Ask the patient to extend their wrists with fingers spread, hold for 15–30 seconds. Positive = irregular, jerky downward flapping
• Mechanism: Failure of the liver to clear neurotoxins (especially ammonia) → disruption of normal postural control in the basal ganglia/cerebellum
• Also occurs in: Uraemia, CO₂ narcosis, hypokalaemia — so not exclusive to liver disease

Fetor hepaticus — probably of intestinal origin. Occurs in: severe hepatocellular decompensation, extensive collateral circulation. ^[1]

• A sweet, musty smell on the breath
• Mechanism: The failing liver cannot metabolise mercaptans (sulphur-containing compounds from gut bacteria). These enter the systemic circulation via portosystemic shunts and are exhaled

Changes of body hair distribution. Testicular atrophy with decreased libido and potency. Gynaecomastia — may be unilateral. Occurs in: healthy adolescence, chronic liver disease, chronic starvation, testicular tumours, drugs (spironolactone, digoxin, cimetidine). ^[1]

• Why: The cirrhotic liver cannot metabolise oestrogen → hyperestrogenism → feminization (loss of male-pattern hair, gynaecomastia, testicular atrophy, spider naevi, palmar erythema)
• Drug causes of gynaecomastia are commonly tested: spironolactone (anti-androgen effect), digoxin (oestrogen-like effect), cimetidine (anti-androgen)

Ankle pigmentation ± leg ulcers — associated with hypersplenism. Can regress after splenectomy. ^[1]

• Haemosiderin deposition from chronic haemolysis (hypersplenism destroys RBCs and platelets)

Signs of fluid retention. Easy bruising, purpura. ^[1]

• Fluid retention: ascites, peripheral oedema → hypoalbuminaemia + portal hypertension + secondary hyperaldosteronism
• Easy bruising: impaired synthesis of clotting factors (II, VII, IX, X) + thrombocytopenia from hypersplenism

Hepatic encephalopathy — grading: (1) confused, slurred speech; (2) drowsy, inappropriate behaviours; (3) stuporous, obeying simple commands; (4) coma; (5) deep coma, no spontaneous movements. ^[1]

Signs specific for obstructive jaundice — greenish jaundice, xanthelasma, xanthomas, scratch marks. ^[1]

Shape — normal, scaphoid, distended. If distended: fat, flatus, faeces, foetus, fluid (bulging flanks), abnormal swellings. ^[1]

The 6 F's (or "5Fs + abnormal swellings" as per the lecture) ^[1][3]:

Umbilicus — normal; depressed in fat abdomen; bulging/everted with increased intra-abdominal pressure, e.g., ascites (horizontal slit). ^[1]

• Buried → obesity (distension is subcutaneous)
• Everted/horizontal slit → raised intra-abdominal pressure (ascites, massive organomegaly)
• Pointing upwards → pelvic mass pushing it up ^[2]
• Sister Mary Joseph nodule → metastatic deposit at umbilicus (from intra-abdominal malignancy, often gastric/ovarian)

Movement — thoraco-abdominal respiration, epigastric pulsation (thin patients, transmitted pulsation), visible peristalsis in intestinal obstruction. ^[1]

• Visible peristalsis: Waves of movement across the abdomen, classically from left to right in gastric outlet obstruction (Gastric contractions moving L→R), or from right iliac fossa upward in small bowel obstruction
• Epigastric pulsation: Can be normal in thin individuals (transmitted aortic pulsation). Pathological if expansile (aortic aneurysm)

Striae — acute abdominal distension with subcutaneous bleeding (e.g., pregnancy, ascites). Dilated veins — obstructed IVC or portal hypertension. Note: (a) observe direction of flow; (b) increased prominence on standing up. Pigmentation — pregnancy, Addison's disease. ^[1]

How to determine direction of flow in dilated veins:

1. Place two fingers over a section of vein, compress and slide apart to empty the segment
2. Release one finger and observe which direction the vein fills from
3. Repeat, releasing the other finger
4. Portal HTN: flow radiates away from umbilicus; IVC obstruction: flow is all cranially directed

Hernial orifices — only expose patient's genital area when examining for hernias; ASK for permission first. Hernia more prominent on standing up. ^[1]

• Check inguinal and femoral regions with the patient coughing and standing
• Look for incisional hernias along scars (ask patient to raise head → increases intra-abdominal pressure)
• Look for umbilical/paraumbilical hernias

Get patient to relax (bend knees if necessary). Ask for presence of tenderness before touching abdomen. ^[1]

Start with a gentle general survey of the whole abdomen — to relax patient, to detect any gross abnormalities, to detect any mild tenderness. ^[1]

THE ESSENCE OF PALPATION: Ask patient to move his abdominal organs by deep breathing. Palpating hand kept still to "catch" descending organ(s). ^[1]

Step-by-step approach:

1. Warm your hands — cold hands cause guarding (exam fail!)
2. Ask: "Is there any pain anywhere?" → palpate the painful area LAST
3. Look at the patient's face constantly during palpation ^[3] — their expression tells you about tenderness before they verbalise it
4. Superficial palpation first (one hand, gentle, MCP joint movement only) → detect tenderness, masses, pulsation ^[2]
5. Deep palpation (two hands, the upper hand pressing on the lower) → deeper masses
6. Organ-specific palpation (liver, spleen, kidneys)

Tenderness, guarding, rigidity, rebound tenderness ^[2][3]

Note normal surface anatomy. Normal upper rectus muscles not to be mistaken for left lobe. Normal liver may be palpable on inspiration or be pushed down by thoracic abnormalities. ^[1]

Technique:

1. Start from the right iliac fossa (not from the costal margin — you might miss a massively enlarged liver!)
2. Place your hand flat with fingers pointing toward the right costal margin
3. Waiting position during inspiration — keep hand still, let the liver edge descend onto your fingers
4. Move hand upwards during expiration — advance ~2 cm toward the costal margin
5. Repeat until you feel the liver edge or reach the costal margin
6. Bimanual palpation may help: left hand behind the patient's right lower ribs, gently lifting upward to push the liver anteriorly ^[1]

Note: (1) limit of lower border — make measurements at mid-clavicular line and xiphisternum; (2) upper border. (1) and (2) make the span. N.B. liver can be larger than normal, can also be smaller than normal. (3) character of edge; (4) character of surface; (5) consistency; (6) any tenderness; (7) any bruit. ^[1]

Use finger tips. Palpate along line joining umbilicus to left anterior axillary fold. Large spleens have notches. ^[1]

• The line from the umbilicus to the left anterior axillary fold is Gardner's line — this traces the long axis of spleen enlargement

Technique:

1. Stand on the patient's right side
2. Place your right hand along Gardner's line, starting from below the umbilicus (to catch massive splenomegaly)
3. Ask the patient to breathe in deeply
4. Feel for the splenic tip descending onto your fingers
5. Move hand upward toward the left costal margin with each expiration

Methods to help detection of "difficult" spleens: (1) Turn patient towards right; (2) "Hook" spleen forward with hand at renal angle; (3) Percussion along line of palpation; (4) In presence of ascites, try "dipping" of the spleen (ballottement); (5) Spleen may "float" to a more lateral position in the presence of ascites. ^[1]

• Turning toward right tilts the spleen anteriorly and inferiorly toward your palpating hand
• Hooking method: Place your left hand behind the patient's left lower ribs and push forward while hooking your right hand under the costal margin
• Percussion: Percuss along Gardner's line — dullness suggests splenomegaly. Also percuss Traube's space (bordered by 6th rib superiorly, mid-axillary line laterally, left costal margin inferiorly) — normally resonant; dull if spleen is enlarged ^[5]
• A spleen must be ~3× its normal size before it becomes palpable clinically

Differentiation between spleen and left kidney: (1) Bimanual palpation for kidney; spleen is anterior; (2) Subcostal gap absent for spleen; (3) Percussion dull for spleen; (4) Notches for spleens > 10 cm. Both the spleen and the left kidney move with respiration. ^[1]

Bimanual palpation to "trap" rounded lower poles of kidneys on inspiration. Right kidney lower than left. ^[1]

Technique:

1. Left hand placed posteriorly in the renal angle (between 12th rib and erector spinae)
2. Right hand placed anteriorly below the costal margin
3. Ask patient to breathe in deeply
4. Push upward with the posterior hand while palpating anteriorly
5. Try to "trap" the lower pole between your two hands as it descends with inspiration
6. Ballottement: Flick the kidney forward from behind — feel it bounce against your anterior hand

• The right kidney is lower than the left (because of the liver above it) → right kidney is more commonly palpable in thin people
• Normal kidneys are usually NOT palpable unless the patient is very thin

Site, Size, Shape, Localization (abdominal wall, intra-peritoneal, retroperitoneal), Movement (with respiration and by itself), Tenderness, Consistency, Pulsation. ^[1]

The 8S approach to describing any abdominal mass (combining lecture + senior notes):

How to localize a mass:

• Abdominal wall: Ask patient to raise head/tense abdominal muscles → mass remains palpable (or becomes MORE prominent)
• Intra-peritoneal: Mass moves with respiration and becomes less palpable with tensed abdomen
• Retroperitoneal: Relatively fixed, does not move much with respiration, deep, overlying bowel may be resonant

• Start from the right lung (resonant) and percuss downward to find the upper border (normally 5th ICS MCL) — note where dullness begins
• Percuss upward from the iliac fossa to find the lower border
• Calculate the span (normally 10–12 cm at MCL)

• Percuss along Gardner's line
• Percuss Traube's space (should be resonant normally)
• Castell's spot (lowest left ICS along anterior axillary line): percuss during full inspiration — becomes dull if spleen is enlarged ^[5]

Shifting dullness at flanks — N.B.: (a) allow time for bowels to "float" after change of patient's posture; (b) can be detected only when at least 1 L of fluid is present. ^[1]

Shifting dullness technique:

1. Percuss from the midline (tympanitic due to gas-filled bowel floating on top of fluid) laterally toward the flank
2. Mark where the note changes from resonant to dull
3. Keep your finger on that spot and ask the patient to roll toward you (onto their side)
4. Wait a few seconds (allow fluid to redistribute and bowel to float up)
5. Percuss again at the marked spot → if now resonant, dullness has "shifted" → positive for ascites

Fluid thrill — use a 3rd hand in mid-line of patient to damp down transmission through abdominal wall. An insensitive test for fluid under tension. ^[1]

Fluid thrill technique:

1. An assistant places the edge of their hand firmly along the midline of the abdomen (to prevent transmission through subcutaneous fat)
2. Flick one flank sharply with your finger
3. Place your other hand on the opposite flank
4. Feel for a transmitted fluid wave (impulse)

• Important limitation: This test is insensitive and can be falsely positive in obese patients (hence the need for the assistant's hand). It is better for detecting large-volume ascites under tension

Physical Examination: General — fever, vital signs, hydration status. Abdomen — distension, tenderness, guarding, rebound tenderness, mass, bowel sound, hernia. Rectal and vaginal examination. ^[7]

• In any acute abdomen, the examination findings of guarding, rigidity, rebound tenderness, and absent bowel sounds point toward peritonitis — a surgical emergency
• Murphy's sign: Arrest of inspiration during palpation of the RUQ → acute cholecystitis. This is technically positive when the inflamed gallbladder descends onto your palpating fingers during inspiration, causing pain and involuntary cessation of breathing ^[2]

Shape of abdomen, Mass: location, size, mobility, regular, consistency etc. Tenderness? Ascites? ^[8]

• Pelvic masses (ovarian cysts, fibroids) arise from the pelvis → you can't "get below" them
• A large pelvic mass pushes the umbilicus upward

Examination of the Abdomen — Mass? Examination of the Scrotum — Both testis present? Undescended testis? ^[6]

• Always check for cough impulse at hernial orifices
• A hernia without cough impulse may be strangulated (a surgical emergency)

• An expansile pulsation (mass expands in all directions with each systole) in the epigastrium → abdominal aortic aneurysm (AAA)
• A transmitted pulsation (mass moves anteriorly only, pushed by the aorta behind it) → mass overlying the aorta (e.g. pancreatic mass)