Alimentary Examination

Question 1

Explain to the patient in words they can understand how you will examine their alimentary system?

Answer 1

‘Hello, today I’d like to examine your stomach and some other associated areas. This will involve me taking a look at your arms, hand, neck area and then on to your stomach where I will be feeling with my hands, tapping with my hand and then listening with my stethoscope. Is that ok?’

Question 2

How is the patient positined for examination of alimentary system?

Answer 2

Bed reclined at 45 degrees and adjust height

Question 3

What are the components of the general observation in alimentary examination?

Answer 3

Initial assessment - need for immediate intervention?

General observations - How comfortable/distressed is the patient

Environment - Vomit bowl? IV line?

Chart - If there is a NEWS chart, check it for any trends

Question 4

What are the components of examining the hands & arms in an alimentary examination?

Answer 4

Compare both hands and nails for:

1) Tar staining
2) Nail colour - leukonychia (white streaks), keulonychia (abnormal nail shape)
3) Clubbing - can be a sign of IBD, Cirrhosis
4) Palms - palmar erythema, pale palmar creases, dupuytrens contracture (alcohol)
5) Flapping tremor (liver flap-liver failure)
6) Fine tremor (alcohol withdrawal)

Look at arms for:

1) Bruising (liver dysfunction)
2) Scratch marks/pruritis (chronic cholestasis)

Question 5

What are the components of examining the head in the alimentary exam?

Answer 5

Look at the face for:

1) Parotid swelling (alcohol)

Look at the eyes for:

1) Jaundice
2) Anaemia

Look at the mouth for:

1) Angular stomatitis & sore red tongue (Iron deficiency anaemia)
2) Breath odour of liver failure

Question 6

What are the lymph nodes that should be inspected as part of the alimentary system?

Answer 6

Supraclavicular (Pay close attention to Virchow’s node on left supraclavicular area)

Deep and superficial cervical chain

Subtonsilar

Submandibular

Submental

Pre-auricular

Post-auricular

Occipital and posterior chain nodes

Question 7

How is the necklace region examined in alimentary system?

Answer 7

Check for:

1) Spider Naevi (liver failure)
2) Gynaecomastia in males
3) Loss of body hair in males

Question 8

How are the legs examined in the alimentary system?

Answer 8

Examine for:

1) Peripheral Oedema (liver failure)
2) Loss of body hair
3) Erythaema Nodusum (swollen fat under the skin, causing red and bumpy skin)

Question 9

How is the patients abdomen inspected for alimentary examination?

Answer 9

Inspection:

1) Scars of previous surgery or trauma
2) Visible pulsation of aorta
3) Does the abdomen move with respiration
4) Abdominal shape - scaphoid/obese
5) Stoma?
6) Distended veins (caput medusae)
7) Petechiae
8) Stretch marks
9) Abdominal distension

Question 10

How is the patients abdomen palpated for an alimentary examination?

Answer 10

Palpation Introduction:

Position - you must be able to lie your hand flat on the patients stomach with your arm in line with abdomen and your hand (adjust the bed if neccesary and sit on a seat)

Hand - Use the palmar surface of all the fingers of the right hand

• Ask if there is any pain in abdomen region before you begin!
• If there is pain, start palpation away from site of pain
• Warm hands as much as possible and watch patients face as you palpate

Light Palpation:

Light palpation over each of the 9 areas:

• Palpate for superficial masses
• Feel for any tender areas (pain to patient)
• Feel for any involuntary guarding (increased muscle tension)

Deep Palpation:

• Feel for areas of tenderness on deep palpation

1) Liver

• Feel for liver at costal margin in mid-clavicular line on full inspiration
• Use the radial edge of your right hand, starting the iliac fossa and moving upwards in a fan-like manner towards the liver when the patient is expiring (you should feel the liver when the patient is at the end of deep inspiration)

2) Spleen

• Located between 9th-11th ribs on LHS, posterior to mid-axillary line
• Like Liver palpation, move hand during expiration up diagonally towards left costal margin an step-wise manner

3) Kidneys

• Deep bimanual palpation
• Dominant hand on abdomen, other hand on loin area
• Patient takes deep breath in, and then on expiration press hand as close together as possible

Question 11

How is the patients abdomen percussed during the abdomen examination?

Answer 11

Liver:

• Begin Iliac fossa
• Move up towards right-costal margin
• Should be resonant in right-iliac fossa (gas filled bowel)
• Percussion note should become dull when edge of liver is reached

Spleen:

• Progress diagonally from right iliac fossa to left costal margin and note the change to a dull percussion note

Shifting dullness:

• Percuss from centre of abdomen out to flank until note becomes stony-dull (fluid)
• Keep your hand over this position and ask the patient to roll on to their side, and percuss over the same area
• If it has changed to a resonant sound, you have demonstrated shifting dullness

Fluid Thrill:

• Ask patient to place hand on midline of abdomen
• Flick one side of the abdominal wall, and with your other hand placed on the other side of the abdominal wall, a fluid thrill may felt if ascites is present

Question 12

How is the patients abdomen auscultated during the abdomen examination?

Answer 12

Listen for:

1) Bowel sounds (check in left lower quadrant, if hear here no need to check any where else)

2) Arterial bruits:

• Abdominal aorta
• Renal arteries (just above and lateral to umbilicus)