Abdominal / GI Exam. Flashcards
ABDOMINAL EXAMIANTION
By the time you start your examination, especially on the ward, some of your patients may have respiratory distress as a result of the ascites.
So even if you come and meet them with their head propped up, you ask them if they are comfortable with you dropping the head back.
POSITION
• The abdominal examination is performed with the patient lying supine with their heads resting on pillow (if any).
FROM THE FOOT OF THE BED
• General Habitus
- Obvious abdominal distention
- Distended vein in the abdomen
- Obvious lower limb swelling.
- Wasted?
- Looks chronically ill?
- For GI exam you need to check if the patient is arousable or not? In the case of encephalopathy
You will be able to see that some people are very drowsy, etc., you can state that from the foot of the bed.
KNOW THE STAGES OF THE ENCEPALOPATHY
HAND
• Check for Finger clubbing
• Interosseous guttering
• Dupuytren’s contracture: you need to palpate along the tendons in the palm getting to the fingers.
• Palmar erythema
• Asterixis: Let patient stretch arms forward and palm facing forward and let patient close eyes.
WRIST
• Pulse
ELBOW
• Check for blood pressure.
AXILLARY
• For some people you do axillary examination for GI even though technically, the axillary doesn’t really drain any lymph node. But since it is included in the exam you have to do the axillary lymph nodes examination.
HEAD
• Hair: color and texture, easily pluckable?
• Eye: check for jaundice and pallor
• Jaw: Palpate the sides for enlargement of the parotid glands.
Position: Ask patient to sit up.
NECK
• Check for submandibular which helps with the parotic gland enlargement. Check supraclavicular and infraclavicular lymph nodes. Remember the Virchow’s node is located at the left supraclavicular.
CHEST
Inspection
• In males, inspect the chest for gynecomastia. You may have enlargement of the breast but it does not necessarily mean gynecomastia. If there is gynecomastia you will feel a bud in there when you palpate.
You examine the breast just like you do for a female. Patient will have one hand raised then you palpate the four quadrants and then the nipple feeling for a bud. If it is enlarged, then you say there is an enlargement of the mammary gland or the breast. But you won’t call it gynecomastia unless you can palpate the bud.
• Note for any distended vein on the chest.
ABDOMEN
Inspection
Inspect. WE NEED TO SEE YOU INSPECTING.
• For some people they may have had procedures done for them that you only pick up if you look on their sides rather than looking at just the abdomen.
• Is abdomen, uniformly distended or asymmetrically distended.
o Uniformly distended – mostly likely ascites.
o Asymmetric distension or enlargement may mean there is a mass that is in there, depending on where the bulge is you are thinking if it is a spleen or liver. You may even have a liver and spleen enlargement and it will still be asymmetric.
• Inspect the hernia orifice. – Look for any bulging.
Palpation.
• After inspecting the hernia orifice, you look for a palpable coughing pulse by palpating the hernia.
• Tell the patient to cough, if you feel anything there, then it is a palpable coughing pulse.
1. Superficial Palpation
• While looking at the patient’s face you are looking for areas of tenderness in the 9 regions. Don’t palpate more or less than 9 times. Don’t forget to look at the face of the patient.
2. Deep palpation
• Again in all 9 regions. Some examiners prefer you use one hand for the superficial palpation and you put your other hand on the palpating hand for the deep palpation.
• The deep palpation is looking for other masses. In a patient with distended abdomen, you may have to press lightly because they may be in pain.
3. Organ specific palpation
• You can ask for a chair if available.
o Liver & spleen: Once you identify the mass, you must go around to see the edges(regular or irregular), consistency (hard, firm), surface (nodular, smooth). You need to measure the size.
o Size: After you have palpated for the mass below the costal region, you percuss the chest for the upper border of the liver for the liver span. WHETHER YOU PALPATE THE LIVER OR NOTE YOU MUST MEASURE THE LIVER SPAN. In this case, you percuss until you get to dull and then you continue percussing until it changes from dull tympanic then you measure the span.
o Spleen: the spleen enlarges diagonally, so with your right hand beginning in Right lower quadrant, palpate superficially towards the left upper quadrant. Once you palpate the spleen, you identify the mid clavicular line and trace it along to the subcostal region and use it as a reference point to measure. So you measure the spleen to two reference points, (1) along the midclavicular line and (2) below the costal margin. So you need to find the mid-clavicular line and below the subcostal margin you measure the distance of the spleen in centimeters.
o WE DON’ T WANT TO SEE THE CENTIMETER PART OF THE TAPE MEASURE ON TOP, YOU ALWAYS MEASURE WITH THE INCHES PART AND WHEN YOU ARE DONE YOU TURN TO READ THE CENTIMETER.
o Bimanual palpation of the kidney
• If you patient have distended veins on the abdomen, you must check the flow of the distended veins (MAYBE NOT NECESSARY FOR PA’s).
NOTE: In patients with dilated abdominal wall veins due to cirrhosis, the direction of blood flow is away from the umbilicus (radiating like a star from the umbilicus), whereas in vena caval obstruction, the direction of blood flow is either completely above downward (superior vena caval obstruction) or completely below upward (inferior vena caval obstruction).
Summary:
Palpation is hernia orifice, nine regions (light and deep palpation), organ specific palpation
Percussion:
• Shifting dullness
• You don’t percuss from one side to the other because you will be wasting the patients time. You have to percuss from up to onside. So you start percussing from the umbilicus down to the left side. And tell your patient to turn towards. As they are turning, don’t take your hand off the patient, it should remain there. Wait for a while after the patient has turned before you start percussing.
WHAT WE ARE LOOKING AT IS YOUR PERCUSSING TECHNIQUE.
If your patient abdomen is grossly distended, nothing makes sense to do shifting dullness. You can go straight to do fluid thrills. You need someone to put the hand in the middle of the abdomen. Don’t ask the patient to do that. Ask the examiner to assist you. Place your left palm on the left side of the abdomen and then use the right hand to flick the right side of the abdomen, and fell the fluid in your left hand. EVEN IF YOU DON’T FEEL, SAY YOU FEEL IT.
Auscultation
• THERE ARE PARTICLAR REGIONS WE WANT YOU TO AUSCULTATE.
• McBurney’s point : 2/3 of an imaginary line drawn from the umbilic to the anterior superior iliac spine.
o You are listening for:
▪ Frequency
▪ Pitch
• Renal arteries: About 1cm lateral to the umbilicus.
• Abdominal aorta: a little above the umbilicus.
• Whatever masses you find in the abdomen you have to auscultate. For example you have to auscultate the liver and spleen if they are enlarged.
EXTRA EXAMINATIONS TO COMPLETE.
• Ask to do a DRE. (In both male and female).
• In the male patient you ask to examine the Genitalia. (here you are looking at the size of the testicle: in chronic liver disease, there will be conversion of testosterone to estrogen, so the males will have reduced size of their testicle)
