CLIN GIT Exam - Week 5 Flashcards
GIT Exam Intro
Perform examination from RHS.
1. HH
2. Greet pt
3. Introduce yourself
4. Identify pt
5. Explanation of examination & confidentiality
6. Discuss exposure – to the waist (w gown for female pts)
7. Obtain consent
8. Clarification – ask give the pt the opportunity to ask any questions
9. Position – sitting & later lying at 45 degrees/lying flat
10. Privacy – gown suitable
11. Ask whether the pt is comfortable
GIT Exam GI
a. Jaundice
b. ‘Noting body habitus’
c. Mental state
d. Signs of distress
e. Fever/sweating
f. Pain/discomfort
13. Vital signs
14. Weight
15. Mental state
GIT Exam Skin
a. Pigmentation
b. Addisonian-type pigmentation
c. Peutz-Jeghers syndrome
d. Acanthosis nigricans/albicans nigricans
e. Rendu-Osler-Weber syndrome
f. Porphyria cutanea tarda
g. Systemic sclerosis
h. Pigmentation/darkening of the skin
GIT Exam Fingernails
a. Look
i. Peripheral cyanosis
ii. Leukonychia
iii. Muehrcke’s lines
iv. Blue lunulae
v. Clubbing
vi. Xanthlesmata
GIT Exam Palmar Creases
a. Look
i. Erythema
ii. Pale creases
iii. Dupuytren’s contracture
GIT Exam Hands
a. Look
i. Hepatic flap
ii. Tremor
GIT Exam Arms
a. Look
i. Bruising
1. Petechiae
2. Ecchymoses
ii. Scratch marks /pruritis
iii. Spider naevi
GIT Exam Eyes
a. Look
i. Sclera
ii. Conjuctiva
iii. Kayser-Fleischer rings
iv. Xanthelasmata
v. Periorbital purpura
vi. Iritis
GIT Exam Mouth
a. Look
i. Breath
ii. Teeth
iii. Oral mucosa
iv. Gum hypertrophy
v. Pigmented lesions
vi. Peutz-Jeghers syndrome
vii. Telangiectasia
viii. Tongue
1. Lingua nigra
2. Leucoplakia
3. Glossitis
4. Macroglossia
ix. Mouth ulcers
1. Aphthous ulceration
x. Angular stomatitis
xi. Pharynx
xii. Salivary gland enlargement
1. Parotid glands (normally, not palpable)
a. Put gloves on
b. Ask pt to clench teeth
c. Feel behind the masseter muscle
d. Feel for a parotid calculus at Stensen’s duct orifice (opp. 2nd molar)
2. Submandibular gland
a. Put gloves on
b. Place index finger on floor of the pt’s mouth beside the tongue
c. Feel btw it and your fingers placed behind the body of the mandible
xiii. Cervical lymph nodes
1. Submental: Behind the tip of the mandible
2. Submandibular: Midway between the tip and the angle of the mandible
3. Tonsillar: At the angle of the mandible
4. Preauricular: In front of the ear
5. Postauricular: Superficial to the mastoid process/behind the ear
6. Occipital: Base of skull - posteriorly
7. Superficial cervical: Superficial to the sternomastoid (one side at a time)
8. Deep cervical: Hook your fingers around each side of the sternomastoid muscle (one side at a time)
9. Posterior cervical: Along the anterior edge of the trapezius – in line w ear
10. Supraclavicular: In the angle between the clavicle and the sternomastoid.
a. Comment on L supraclavicular lymph node
xiv. Axillary lymph nodes
GIT Exam Chest
a. Look
i. Spider naevi
ii. Gynaecomastia (males)
iii. Hair loss (males)
GIT Exam Abdomen Inspection
i. Symmetry
ii. Scars
iii. Striae
iv. Distension
v. Contours
vi. Cullen’s sign/Umbilicus
vii. Veins
viii. Pulsations
ix. Visible peristalsis
x. Abdominal contour & shape w breathing
1. Lower yourself until the ant abdo wall is at your eye level
GIT Exam Abdomen Palpation & Percussion
b. Palpation (light -> deep pressure) – over 9 regions
Ensure that you perform this part of the examination whilst looking at the pt’s face.
i. Ask pt to point to any area that is tender & leave this region until last to examine
ii. Reassure pt & have warm hands
iii. Observe for:
1. Areas of guarding/rigidity
2. Cross tenderness
3. Rebound tenderness
4. Pain on coughing
iv. Comment on presence/absence of above
v. Liver
1. Start in the R iliac fossa
2. Ensure fingers are parallel to the R costal margin
3. Move the MC joints of your fingers up by 1-2cm each time
4. Ask pt to breath in and out each time you reposition your fingers/palpate
5. Feel liver on edge of R index finger OR palpate R costal margin
c. Percuss
i. Liver
1. Measure liver span
a. Start at R iliac fossa, mid-clavicular line moving upwards towards the liver until the note becomes dull.
b. Then, percuss down mid-clavicular line from 3rd intercostal space until the note become dull.
d. Palpate
i. Spleen (normally, not palpable)
1. Attempt to palpate spleen
2. If not palpable, ask pt to roll R side
3. Palpate again diagonally from umbilicus
e. Percuss
i. Traube’s space
1. Percuss 2 x intercostal spaces
2. Ask pt to breath out
a. Should be resonant
3. Ask pt to breath in
a. Should be resonant
f. Palpate
i. Kidneys (normally, not palpable/felt on balloting)
1. Curl one hand under pts and firmly grip posterior ribs
2. Apply pressure directly above other hand on ant abdo wall
3. Ask pt to inspire and make flapping motion w posterior hand
ii. Gallbladder (normally, not palpable )
1. Place R hand perpendicular to the R costal margin
2. Palpate from medial to lateral below R costal margin and ask pt to breath in and out w hands vertical
3. Murphy’s sign
a. Place hands over R costal margin w hands on slight angle
b. Ask pt to take a deep breath
iii. Abdominal Aorta
iv. Para-aortic lymph nodes
v. Appendix
1. Rovsing’s sign
a. Palpate LLQ
vi. Bladder
g. Percussion
i. Abdomen
ii. Bladder
iii. Colon
iv. Ascites
1. If region of the abdomen is dull on percussion, test for:
a. Roll pt & wait 30sec
b. Repercuss to check whether percussion is more resonant &
c. Assess for fluid thrill
i. Ask pt to place hand perpendicular along midline @ umbilicus level
ii. Place L hand on L side of pt’s hand and apply light pressure
iii. Flick ant abdo wall on R side of pt’s hand
v. Peritonism tenderness
vi. Hernial orifices & testes
1. Tense abdominal muscles
a. Ask pt to try to sit up
vii. PR
GIT Exam Abdomen Auscultation
i. Bowel sounds
ii. Bruits
1. Aortic
2. Renal
a. Listen 2-2.5cm on either side of the midline.
3. Splenic
4. Arterial systolic over the liver
5. Epigastric
6. Femoral arteries
iii. Hum
a. Listen over the liver and midway btw xiphoid process & umbilicus
iv. Friction rubs
1. Liver
2. Spleen
GIT Exam Legs
a. Look
i. Oedema
ii. Grey-Turner’s sign
Neurological disturbances may indicate what GIT pathology
Hepatic encephalopathy, decompensated advanced cirrhosis, fulminant hepatitis.
Pigmentation may indiciate
Chronic liver disease.
‘Sunkissed’ pigmentation of the nipples, palmar creases, pressure areas & mouth may indicate
Malabsorption
Freckle-like spots around the mouth, on the buccal mucosa, fingers & toes may indicate
Small bowel and/or colon haematomas.
Acanthosis nigricans/albicans nigricans may indicate
(Black sandy skin rash) may indicate insulin resistance.
Peripheral cyanosis may indicate what GIT pathology
Chronic liver disease.
Leukonychia may indicate
Nail bed opacification -> only a rim of pink nail bed present at the top of the nail may indicate hypoalbuminaemia (this could be caused by chronic kidney disease).
Muehrcke’s lines may indicate
Transverse white lines across fingernails may indicate hypoalbuminaemia.
Blue lunulae may indicate
Wilson’s disease
Clubbing may indicate
Cirrhosis, inflammatory bowel diseases, coeliac diseases, malabsorption states, liver cirrhosis, CF.
Xanthelasmata may indicate
Cholesterol deposition.
Erythema may indicate
Chronic liver disease, thyrotoxicosis, rheumatoid arthritis, polycythaemia, chronic febrile diseases, chronic leukaemia, hyperthyroidism. NB: Can also be normal (e.g., in women, pregnancy).
Pale creases may indicate
Anaemia
Dupuytren’s contracture may indicate
Alcoholism.
Hepatic flap may indicate
Liver failure, cardiac failure, respiratory failure, renal failure, hypoglycaemia, hypokalaemia, hypomagnesaemia, barbiturate intoxication.
Evidence of significant bruising may indicate what GIT pathology
Chronic liver disease.
Petechiae may indicate
Chronic excessive alcohol consumption -> bone marrow depression -> thrombocytopaenia.
What are ecchymoses and what may they indicate?
Large bruises which may indicate clotting abnormalities.
What may scratch marks indicate?
Pruritis. May indicate hyperbilirubinaemia -> obstructive or cholestatic jaundice.
Spider naeiva may indicate
Appear on pathway of SVC and may indicate liver cirrhosis, viral hepatitis, pregnancy.
Yellow dislocoration of the sclera may indicate
Jaundice - hyperbilirubinaemia.
Yellow, keritanised areas of the sclera may indicate
Bitot’s spots - severe vit A deficiency due to malabsorption/malnutrition.
Pale conjunctiva may indicate
Anaemia.
Appearance of Kayser-Fleischer rings may indicate
Brownish-green rings which occur at the periphery of the cornea, caused by excess copper deposition and may indicate Wilson’s disease.
Xanthelasmata may indicate what type of cirrhosis.
May indicate primary biliary cirrhosis.
Periorbital purpura may indicate
Amyloidosis.
Iritis may indicate
Inflammatory bowel disease.
Pigmented mouth lesions may indicate
May indicate heavy metal presence, drugs, Addison’s disease, Peutz-Jeghers syndrome, malignant melanoma.
Appearance of Peutz-Legher’s syndrome and what may it indicate
Freckle-like spots around the mouth, on the buccal mucosa, fingers & toes may indicate small bowel and/or colon hamartomas.
Telangiectasia appearance and may indicate
Dilated, small blood vessels on the lips and tongue may indicate Rendu-Osler-Weber syndrome/hereditory haemorrhagic telangiectasis (an autosomal dominant hereditary vascular disorder associated w GI bleeding).
Lingua nigra may indicate
Black tongue may indicate use of bismuth compounds, but generally benign.
Leucoplakia may indicate
White-coloured thickening of the mucosa of the tongue & mouth and may indicate smoking, alcohol, sepsis, syphilis or poor dental hygiene.
Glossitis may indicate
Smooth appearance of the tongue which may be caused due to papillae atrophy and may indicate iron, folate, vit B deficiency.
Macroglossia may indicate
Enlargement of the tongue may occur in congenital conditions (e.g., Down syndrome) or in endocrine disease, tumour infiltration, amyloid infiltration in amyloidosis.
Mouth ulcers may indicate
Small painful vesicle on the tongue or mucosa which may break down to form a painful, shallow ulcer which heals w/out scarring and may indicate Crohn’s disease or coeliac disease. HIV patients may also present w mouth lesions. May also occur as normally in pts.
Angular stomatitis may indicate
Cracks at the corners of the mouth may indicate vit B, folate, iron deficiencies.
Gynaecomastia in males may indicate
Chronic liver disease.
Hair loss in males may indicate
Chronic liver disease, liver cirrhosis.
Wide & purple striae may indicate
Cushing’s syndrome, ascites.
Pink striae may indicate
Pregnancy, recent weight gain.
Cullen’s sign appearance & may indicate
Faint bluish hue may indicate extensive haemoperitoneum, acute pancreatitis.
Visible peristalsis may indicate
May occur normally in very thin people or may indicate intestinal obstruction. Pyloric obstruction due to peptic ulceration or tumour may cause visible peristalsis whereas obstruction of the distal SB may cause similar movement in a central, ladder pattern.
Rebound tenderness may indicate
Slow compression of abdominal wall leads to rapid release and sudden stab of pain and may indicate peritonitis.
Hepatomegaly may indicate
Metastases, alcoholic liver disease, R heart failure, hepatocellular cancer, hemochromatosis, haematological disease, fatty liver disease, hepatitis, biliary obstruction, HIV infection.
Normal liver span
<13cm.
Hepatosplenomegaly may indicate
Chronic liver disease w portal hypertension, haematological disease, infection, infiltration, connective tissue disease, acromegaly, thyrotoxicosis.
Boundaries of Traube’s space
L costal margin, L anterior axillary line, L 6th rib.
Palpable gall bladder w & w/out jaundice may indicate
W jaundice may indicate carcinoma of the head of the pancreas, carcinoma in the ampulla of Vater, gallstone formation in the common bile duct.
W/out jaundice may indicate mucocele or empyema of the gallbladder, carcinoma of the gallbladder, acute cholecystitis.
What will a distended GB feel like on palpation?
Rounded mass which moves downwards on inspiration.
If a GB is distended, which law should be first consulted?
In a pt w painless jaundice & enlarged GB, the cause is unlikely to be gallstones and therefore, presumes the cause to be an obstructing pancreatic/biliary neoplasm until proven otherwise.
If a pt’s breath catches during the Murphy’s sign maneuver, what does this indicate
If pt’s breath catches, may indicate inflamed gallbladder & cholecystitis.
What is a positive sign for Rovsing’s and what may this indicate?
+ve result if RUQ pain increases and may indicate appendicitis.
Enlargement of the bladder may indicate
Enlargement may indicate uterine mass, prostrate obstruction, pregnancy.
How is ascites detected?
‘Shifting dullness’ on percussion.
Loud, high-pitched bowel sounds w tinkling quality upon auscultation may indicate
Bowel obstruction.
Absence of bowel sounds for how long may indicate paralytic ileus.
4 minutes.
Renal bruit may indicate
Renal artery stenosis.
Arterial systolic bruit over the liver may indicate
Hepatocellular cancer, alcoholic hepatitis, arteriovenous malformation, transiently after a liver biopsy.
Epigastric bruits may indicate
May indicate chronic intestinal ischaema or in the absence of pathology.
Bruits vs hums
Occurs in veins, whereas bruits occur in arteries.
Appearance of Grey-Turner’s sign & what might this indicate
Discolouration, bruising, ecchymosis of the flanks may indicate acute pancreatitis.
In what direction does the spleen enlarge?
Inferiorly & medially.
