1. Gastro examination

Question 1

general inspection gastro

Answer 1

colour (jaundice? anaemia?), perspiration, build
(wasting? obesity?), discomfort, breathing (rate, diaphragmatic or chest wall
breathing?), conscious level

Question 2

Nail changes iron defieceny anaemia

Answer 2

longitudinal ridging

koilonychia (spoon-shaped nails).

Question 3

mouth changes iron deficiency anaemia

Answer 3

Angular cheilitis
Atrophic glossitis

Question 4

hand signs gastro

Answer 4

Pallor of the palmar creases suggests anaemia

Palmar erythema (2° to increased circulating oestrogens in liver
disease)

Dupuytren’s contracture

Asterixis (liver flap)

Question 5

nail signs gastro

Answer 5

leukonycia partalis - usually normal or after chemo

leukonycia totalis - hypoalbuminaemia (e.g. nephrotic syndrome, liver failure, protein malabsorption and protein-losing enteropathies).

Koilonychia (spoon-shaped nails, suggesting chronic iron-deficiency)

longitudinal ridging suggesting IDA

Question 6

examination of forearms gastro

Answer 6

muscle wasting and for scratches suggestive of pruritis
(itching).

Question 7

examination of the eyes gastro

Answer 7

o Jaundice
o Anaemia (subconjunctival pallor)
o Xanthelasma
o Corneal Arcus
o Kayser-Fleischer rings (Wilson’s disease). These are brown rings that encircle
the iris, resulting from copper deposition.

Question 8

examination of skin gastro

Answer 8

telangectasia (HHT)
spider naevi
skin folds
stretch marks

Question 9

examination of mouth gastro

Answer 9

Telangiectasia
o Pigmentation (Peutz-Jegher syndrome, associated with small bowel
hamartomas)
o Angular stomatitis
o Glossitis
o Dehydration
o Halitosis (bad breath)
o Dental caries
o Ulcers

Question 10

how to ddx glossitis causes

Answer 10

Painful glossitis is seen in Vitamin B12 or folate deficiency whereas glossitis due to iron-
deficiency tends to be painless.

Question 11

causes angular stomatitis

Answer 11

caused by deficiency of Vitamin B6, B12, folate or iron.

Question 12

mouth ulcers cause gastro

Answer 12

can be associated with Vitamin B12 deficiency, iron-deficiency, Crohn’s disease, Coeliac disease

Question 13

chest wall examiantion gastro

Answer 13

Spider naevi
o Gynaecomastia (male breast development) – may be due to increased
circulating oestrogens in liver failure.

Question 14

what lymph node are you looking for gastro

Answer 14

Troisier’s sign is an enlarged left supraclavicular lymph node (Virchow’s node) due to a metastasis
from an intra-abdominal malignancy

Question 15

inspection of abdomen gastro

Answer 15

scars
skin folds
stretch marks
distension
Movement during breathing
Visible swellings and masses
o Visible peristalsis
o Visible aortic pulsation
o Distended veins (may indicate inferior vena cava obstruction or portal
hypertension)
Caput medusae
Hernias
cullens sign
grey-turners sign

Question 16

5Fs of abdominal distension

Answer 16

Fluid (ascites)
▪ Faeces (constipation)
▪ Flatus (subacute intestinal obstruction)
▪ Foetus (pregnancy)
▪ Fat (obesity)

Question 17

how do you determine if a mass is intra-abdominal

Answer 17

Determine whether masses are intra-abdominal by asking the patient to raise their head and shoulders off the pillow. Masses within the abdominal wall become more prominent when the recti are contracted, whereas intra-
abdominal masses become less prominent.

Question 18

what is courvosiers law

Answer 18

Courvoisier’s Law states that in the presence
of a palpable gallbladder, jaundice is not likely to be due to gallstones).

Question 19

normal palpation of liver

Answer 19

The liver can normally be palpated up to 1 cm below the right costal margin on deep inspiration.

The gallbladder is not usually palpable unless enlarged.

Question 20

normal palpation of spleen

Answer 20

not normally palpable unless enlarged.

Splenomegaly only becomes palpable once the spleen has enlarged
to 2-3 times its normal size.

Question 21

how to distinguish a kidney from spleen

Answer 21

To distinguish a palpable kidney from a spleen, you should attempt to insert
your hand between the upper pole of the kidney and the costal margin, which
can be done if the mass is renal but not if it is the spleen. Also, the spleen has
a notch which may be palpable; and the spleen is not ballotable.

Question 22

what is a positive murphys sign

Answer 22

If inspiration is prevented by the inflamed gallbladder
coming into contact with the examiner’s fingers, the test is considered positive.

A positive test also requires no pain on performing the manoeuvre on the patient’s left
hand side. This test is done when suspecting acute cholecystitis in a patient.

Question 23

what is castels method of assessing splenomegaly

Answer 23

With the patient in full inspiration and then full
expiration, percuss the area of the lowest intercostal space (eighth or ninth) in the left anterior axillary line. If the note changes from resonant on full expirationto dull on full inspiration, the sign is regarded as positive.

Question 24

to complete gastro exam…

Answer 24

Inguinal lymph nodes
o Stools – examine the stools if clinically indicated

o Hernial orifices (femoral and inguinal) (e.g. if there are signs of bowel obstruction).

o Rectal examination (always with a chaperone) (e.g. if there is suspicion of gastrointestinal bleeding).
o Urine – obtain urinalysis

o Genitalia (examine the male external genitalia). (e.g. to rule out testicular torsion as a cause of referred abdominal pain or an indirect inguinal hernia).A vaginal examination may beindicated in parous or sexually active females (only when clinically indicated
and always with a chaperone)

Question 25

what is Caput medusae

Answer 25

engorged paraumbilical veins associated with portal hypertension (e.g. liver cirrhosis).

Question 26

signs of pancreatitis o/e

Answer 26

Cullen’s sign: bruising of the tissue surrounding the umbilicus associated with haemorrhagic pancreatitis (a late sign).

Grey-Turner’s sign: bruising in the flanks associated with haemorrhagic pancreatitis (a late sign).

Question 27

location of stomas and clues

Answer 27

colostomies are typically located in the left iliac fossa,

ileostomies and urostomies are typically located in the right iliac fossa).

Question 28

if there is a stoma what should you assess

Answer 28

location - LIF or RIF?

contents - stool or urine

consistency - liquid (ileostomy) solid (colostomy)

spout - colostomies are flush to the skin with no spout whereas ileostomies and urostomies have a spout.

Question 29

if there is an abdominal mass, what should you assess?

Answer 29

Location: note which of the nine abdominal regions the mass located within.
Size and shape: assess the approximate size and shape of the mass.
Consistency: assess the consistency of the mass (e.g. smooth, soft, hard, irregular).
Mobility: assess if the mass appears to be attached to superficial or underlying structures.
Pulsatility: note if the mass feels pulsatile, suggestive of vascular aetiology (e.g. abdominal aortic aneurysm).

Question 30

if you can identify the liver edge, what should you assess

Answer 30

Degree of extension below the costal margin: if greater than 2 cm this suggests hepatomegaly.

Consistency of the liver edge: a nodular consistency is suggestive of cirrhosis.

Tenderness: hepatic tenderness may suggest hepatitis or cholecystitis (as you may be palpating the gallbladder)

Pulsatility: pulsatile hepatomegaly is associated with tricuspid regurgitation.

Question 31

causes of enlarged kidneys

Answer 31

Bilaterally enlarged, ballotable kidneys can occur in polycystic kidney disease or amyloidosis.

A unilaterally enlarged, ballotable kidney can be caused by a renal tumour.

Question 32

auscultation of abdomen

Answer 32

normal = gurgling

tinkling = bowel obstruction

absent = ileus - To be able to confidently state that a patient has ‘absent bowel sounds’ you need to auscultate for at least 3 minutes (this is unlikely to be the case in an OSCE given the time restraints).

Question 33

what may peripheral eodema be caused by specifically in gastro

Answer 33

hypoalbuminaemia (e.g. liver cirrhosis, protein-losing enteropathy).

Question 34

Presenting gatsro examination

Answer 34

Today I completed a gastrointetsinal exmaiantion on xyz.

On inspection there was xyz/ there were no signs of gatsrointetsinal disease

On palpation there was xyz +/- the abdomen was SNT, no organomegaly and no massess detected

On auscultation there was xyz / bowel sounds present and normal.

There were no other positive findings on exmaination

In summary these examination findings are most consistent with xyz.