The patient lies supine with arms by the side and with groin and hernial orifices exposed.
#Distended stomach in diabetic coma x ray skin
skin turgor and moistness of mucous membranes) should be assessed at this time, especially in the acute setting. Glossitis occurs in patients with iron, folate and vitamin B12 deficiency. Angular stomatitis (‘ perlèche’) is seen frequently in patients with iron deficiency and malnutrition.
A ketotic breath and coated tongue is suggestive of appendicitis or related conditions. The mouth is then examined for the smell of fetor hepaticus suggesting encephalopathy, mucosal thickening and ulceration, atrophy or erythema, gingivitis and angular stomatitis. The neck is examined for cervical lymphadenopathy, especially left supraclavicular nodal enlargement (Troisier’s sign) as a sign of metastatic node involvement from carcinoma of the stomach. The head and neck are then examined for abnormal pigmentation, spider naevi, xanthelasma of the eyelids, scleral jaundice or pallor and parotid enlargement. Asterixis is a flapping tremor best seen with the hands in extension and is found in patients with portal systemic encephalopathy. Palmar erythema, spider naevi and Dupuytren’s disease (palmar nodules, bands, contractures, pits and sinuses and knuckle pads) suggest alcoholic liver disease (Fig 7.2). Other changes such as leuconychia, indicating malnutrition and hypoproteinaemia, or koilonychia, suggesting iron deficiency, may be present. Nail changes include clubbing, which may be found in a number of gastrointestinal conditions, chronic liver disease, inflammatory bowel disease and malabsorption.
Acute renal pain is a very severe and constant pain. Biliary pain tends to plateau, after a gradual onset it is continuous but fluctuates in severity. Severe unremitting pain may be due to localised peritonitis because of appendicitis, cholecystitis or diverticulitis, or due to widespread peritonitis from visceral rupture or mesenteric ischemia. Inability to sleep because of pain suggests a surgical problem. Severity is also subjective and best assessed by the effect of pain on the patient, the response to the suggestion that an operation may be necessary and the necessity for and whether relief from analgesics already administered has occurred. Severe pain persisting without relief requires hospital admission. The need for narcotics to control upper abdominal pain is suggestive of renal or biliary pain. Constant pain often varies in severity during the course of the illness, but careful questioning will distinguish this from a true colic. Severe colicky pain that becomes constant suggests ischaemic bowel. The colicky pain of obstruction is usually more severe than is found with gastroenteritis. Colic associated with an urge to defaecate or pass flatus and with abdominal borborygmi is pathognomonic of intestinal colic due to obstruction or irritation. If periodic, is it a true colic? Colic causes a spasmodic, gripping abdominal pain that returns every few minutes with a crescendo rise and fall in intensity often described by women as similar to labour pains. It is important to establish whether the pain has been constant and unremitting since onset or is periodic. Patients often relate pain to previous or imagined occurrences (‘stabbed by a knife’, ‘struck by lightning’, ‘burning’).
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