Pick ‘n’ Mix Week 1 February 2023

Estimated Reading Time: 5 minutes

We are really grateful to Trudie Pestell for sharing this fabulous education initiative that she has been producing for University Hospital Southampton Emergency Department for a while.

Each week we will bring you some clinical pearls to add in to your knowledge and understanding with links to other resources as well as an OSCE of the week. This week has an abdominal theme.


Jaundice refers to a clinical sign – yellowing of the skin/sclera/mucous membranes, caused by bile pigment deposition


The body metabolises RBC after 120 days. Initially, the red cells are broken down into globin and biliverdin by the spleen. From here, the biliverdin is reduced to unconjugated bilirubin, which then travels to the liver, bound to albumin. The liver enzymatically converts the unconjugated bilirubin to conjugated bilirubin. This then gets excreted in the bile into the small intestine. Further excretion occurs in the faeces, and in the urine resulting in Jaundice can be broken down into pre-hepatic, intra-hepatic and post hepatic

Increased red blood cell destruction

  • Malaria
  • Transfusion reaction
  • Sickle cell anaemia
  • Haemolytic anaemic syndrome
  • Spherocytosis
  • Haemolytic anaemia

Anything which affects the liver’s functioning

  • Alcohol
  • Drugs – paracetamol, flucloxacillin, steroids
  • Hepatitis
  • Leptospirosis
  • Wegener’s, Wilson’s, Gilbert’s
  • Primary biliary cirrhosis
  • Neonatal jaundice
  • Obstetric cholestasis

Anything that impairs excretion or causes obstruction after the liver

  • Cancer
  • Strictures
  • Pancreatitis
  • Primary schlerosing cholangitis
  • Gallstones
  • Drugs – amitryptiline, co-amoxiclav, verapamil

Important features in the History

  • Drug history and occupation
  • Alcohol intake
  • Tattoos and intravenous drug use
  • Risk factors for HIV
  • Needlestick injuries
  • Recent transfusion
  • Recent foreign travel

Remember to ask…

  • Stool and urine colour
  • Family history
  • Weight loos and night sweats
  • Itching and rashes


  • Stool and urine colour
  • Family history
  • Weight lose and night sweats
  • Itching and rashes

Investigations (if history indicates)

  • Full blood count, blood film
  • Liver function tests, amylase, transferrin, GGT, paracetamol level
  • Coagulation screen
  • Urinalysis for bilirubin
  • Pregnancy test
  • Abdominal ultrasound
  • CT scan Acute liver failure – nystagmus, ataxia, asterixis

First follow the ABC of resuscitation – they may well be very unwell, with signs of sepsis or even septic shock.

Each cause will need its own specific treatment, and some patients may even be able to be managed as an outpatient.

The case of runner’s tummy pain

The beginning:

A 40 year old female, who is a keen runner, attends your ED with a day history of increasing abdominal pain and nausea which started after her half marathon yesterday. She has now started vomiting and complains of increased distension. 

Her observations are currently all within the normal range.

As she hasn’t passed faltus for some time and her abdomen is distended an abdominal Xray was performed

This is a caecal volvulus. There is a great article about this here

Use this to practise your abdominal examination. Remember there are resources for lots more system examinations here.

“”Hello, my name is Phil I am one of the medical students.”

“Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

“Are you comfortable? Do you need any pain relief or a drink?”

“I have been asked to examine your gastrointestinal system. This will involve looking at your hands and face and chest, then examining your abdomen. Is this ok with you?”

“Would you like a chaperone present?”

“Please can you take your top off?”

“I will ensure the bed is at 45 degrees” 

“I will talk out loud as we go”

“If at any time you want me to stop or you are in pain, let me know”

“Can you briefly tell me why you have come to hospital?”

“I am looking at the…”


  • comfort level
  • jaundice
  • abdominal distension
  • abdominal drains or scars 
  • spider naevi; caput medusa and gynaecomastia
  • anasarca


  • drains

“I am feeling for…”

  • warmth
  • clamminess
  • the pulse (rate; rhythm; quality)

“I am looking for…”

  • clubbing 
  • leucknoycia
  • palmar erythema 
  • Dupuytren’s contractures 
  • liver flap

Other observations

  • Blood Pressure
  • Respiratory Rate
  • Oxygen saturations
  • Temperature
  • Blood glucose

“I am looking for evidence of…”

  • conjunctival pallor (“Please look up I will gently lower your bottom eye lids.”)
  • cngular stomatitis of lips 
  • cral ulcers (Please open your mouth and stick out your tongue.”)
  • lymph nodes (“I need to feel your neck for any swellings. I will stand behind you to do this.”)
  • Virchow’s node can be found in the left supraclavicular fossa and may be a sign of intraabdomminal malignancy

“Now I need to examine your abdomen. Are you ok to lie flat? If at any time you are in pain or want me to stop let me know.”

“I will examine the patient from their right side; at their level; looking at the patient for any signs of discomfort.”


  • Closer inspection (don’t forget the left flank)


  • Light then deep all quadrants for: guarding; rigidity; etc
  • Organs: liver; spleen; kidney; bladder
  • Aorta


  • Organs: liver; spleen; bladder
  • Ascites (shifting dullness)


  • Bowel sounds
  • Femoral bruits

“Thank you. That is the end of the examination”

“Do you need any help getting dressed?”

“In summary my working differential diagnosis is…”

To complete my examination (scenario dependent) I would like to:

  • Examine the the axilla; groin;  the hernial orifices; perform a rectal examination and testicular exam (male patients)
  • Obtain a
    • urinalysis
    • chest x-ray/abdominal x-ray/CT scan
    • blood tests (state which ones) 

“Does that sound reasonable to you? Do you have any questions or concerns?”

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.