Examination: Basic Gastrointestinal

Question 1

(GI) Step 1:

Answer 1

Prepare the patient

Question 2

(GI) Step 2:

Answer 2

Hand Hygeine

Question 3

(GI) Step 3:

Answer 3

General Inspection

• -> mental state
• -> alertness
• -> body habitus
• -> cachexia
• -> muscle wasting
• -> jaundice
• -> distressed/in pain

Question 4

(GI) Step 4:

Answer 4

Examination of the hands

• -> nails for leuconychia (white nail)
• -> clubbing
• -> palmar erythema
• -> anemic palmar creases
• -> palmar fascia for Dupuytren’s contracture
• -> metabolic flap presence (asterixis)

Question 5

(GI) Step 5:

Answer 5

Head and Neck

• -> whites of eyes for jaunice
• -> conjunctivae for anemia

Question 6

(GI) Step 6:

Answer 6

Examination of the Chest

• -> neck and chest for spider naevi
• -> gynaecomastia

Question 7

(GI) Step 7:

Answer 7

Inspection of the Abdomen - ask the patient to lie flat with one pillow and arms by their side

• -> scars from past surgery
• -> striae/stretchmarks (pregnancy; obesity)
• -> distension or masses
• -> collateral vessels around the umbilicus called caput medusae (occurs in cirrhosis of the liver with portal hypertension)
• -> distended abdo wall veins (obstruction of the IVC)

Question 8

(GI) Step 8:

Answer 8

Palpation of the abdomen- use your right hand; warm hands; dont hurt them

• -> LIGHTLY to identify tenderness, guarding, rigidity, obvious masses
• -> DEEPER to identify specific masses or organ enlargment

Question 9

(GI) Step 9:

Answer 9

Examination of the Liver
–> palpate the lower R quadrant with flat hand on abdomen and parallel to the costal margin

–> apply firm pressure with fingers to feel for liver edge that moves downwards with inspiration (its being pressed down by the diaphragm)

–> Move your hand 2cm towards costal margin during expiration; palpate all the way along the coastal margin especially towards the epigastrium. It is confirmed by ercussing the liver from the lower R quadrant up to the right costal margin (percussion will change from resonant to dull when you reach the liver edge

–> Is the liver firm? are there masses?

–> To identify the upper liver border, percuss from above in the mid clavicular line. Start at the 3rd rib and move down one intercostal space at a time.

–> The upper edge is usually at the level of the 6th rib/5th intercostal space.

–>Measure the span of the liver with a tape measure. The liver span is measured in the midclavicular line. Normal liver span is 12-13 cm

Question 10

(GI) Step 10:

Answer 10

Examination of the Spleen
–> palpate by positioning the right hand parallel to the costal margin, commencing at the right lower quadrant.

–> palpate as the patient inspires

–> move hand towards costal margin two cm at a time during expiration (also check along costal margin)

–> roll the patient 45 degrees towards you and palpate again on inspiration

–> position your left hand posterolaterally, applying counter pressure. THis allows you to gently move the lower ribs anteriorly and medially, making it easier to feel an enlarged spleen

–> usually a spleen cant be felt, it has to double in size to be felt. You also cannot feel the upper border of the spleen

Question 11

(GI) Step 11:

Answer 11

Examination of the kidneys
–> done with both hands

–> the right hand is placed under the costal margin and the left is placed posteriorly in the loin region

–> the fingers of the left hand push the kidney anteriorly which the right hand applies psterior pressure.

–> an enlarged kidney can be balloted between the two hands

–> because the kidneys are retroperitoneal they are difficult to feel and may not be possible to feel the lower pole of the kidney in a thin patient

Question 12

(GI) Step 12:

Answer 12

Other Manoeuvres

• -> Ascites ( accumulation of fluid in peritoneal cavity commonly due to cirrhosis of the liver); presents as buldging planks, flank dullness,
• -> Auscultation of bowel sounds (none in obstruction)
• -> check groin for herniae
• -> digital rectal examination

Question 13

(GI) Step 13:

Answer 13

Complete the Examination

Question 14

How do you test for the presence of a metabolic flap or asterixis?

Answer 14

• -> ask the patient to hold both arms up with hands extended and arms outstretched.
• -> hands need to be kept in the position for 15 seconds.
• -> A flap is preset if there is a F/E movement at the wrists.

Question 15

What does a metabolic flap suggest?

Answer 15

–> can be present in liver disease signifying hepatic encephalopathy which occurs when high levels of ammonia interfere with brain cell function

Question 16

When are the whites of the eyes appearing jaundiced?

Answer 16

–> when serum bilirubin level is > 50 micromoles per litre

Question 17

What are spider naevi or spider angioma?

Answer 17

• -> consists of central arteriole with small vessels radiating from it.
• -> pressure applied to the centre with obstruct the naevi and it will reperfuse when pressure relieved.

Question 18

Where are spider naevi usually found?

Answer 18

–> usually found on neck, chest, arms and back in the distribution of the SVC

Question 19

What are spider naevi a sign of?

Answer 19

• -> chronic liver disease
• -> pregnancy
• -> oral contraceptive pill use
• -> can occur in healthy people too

Question 20

What is Gynaecomastia?

Answer 20

proliferation of glandular tissue in the male breast

Question 21

When can gynaecomastia occur?

Answer 21

–> chronic liver disease

Question 22

How do you examine for gynaecomastia?

Answer 22

–> thumb and index finger placed on either side of the breast and pinched to test in the breast tissue is firm or if it is just fat.

Question 23

For abdominal inspection, how much abdomen should be exposed?

Answer 23

–> from the xiphisternum to the pubic region

Question 24

What are the whites of the eyes called?

Answer 24

Sclera

Question 25

What is the scientific names for bruising?

Answer 25

• Petechiae –> small pinprick bruises

- Ecchymoses –> med to larger bruises

Question 26

Why does bruising occur in liver disease?

Answer 26

Because there is a decrease in production of clotting factors 2, 7, 9, 10

Question 27

What is the scientific name for jaundice?

Answer 27

icterus

Question 28

Where should you look when palpating the abdomen? Why?

Answer 28

The patients face.

To identify pain/discomfort

Question 29

Where are the liver and gallbladder situated?

Answer 29

• RUQ

Question 30

Where is the upper limit and lower limit of the liver?

Answer 30

Upper: marked by the plane between the nipples
Lower: protrudes beneath the costal margin only on deep inspiration

Question 31

Where does the gallbladder project?

Answer 31

• Below the liver at the point where the midclavicular line crosses the costal margin

Question 32

Where is the stomach situated?

Answer 32

• LUQ

Question 33

Where is the caecum and appendix located?

Answer 33

• RLQ

Question 34

Where is McBurney’s point?

Answer 34

• 1/3 of the way along a line from the right anterior superior iliac spine to the umbilicus

Question 35

What does McBurney’s point mark?

Answer 35

• both the site of the base of the appendix and the site of incision during appendicectomy

Question 36

Where is the descending colon and sigmoid colon situated?

Answer 36

-LLQ

Question 37

Where are the kidneys situated?

Answer 37

They project onto the back on either site of the midline and are related to the lower ribs.

Question 38

Where is the left kidney in relation to the right kidney?

Answer 38

The left kidney is a little higher than the right and reaches as high as rib 11. The superior pole of the right kidney reaches as high as rib 12. THe inferior pole of both kidneys extends to approximately L3

Question 39

Where is the level of L4 on the back?

Answer 39

• Relates to a line joining the iliac crests

Question 40

Where is the spleen?

Answer 40

• posteriorly along the line of the left 9th to 11th rib. It follows the contour of the 10th rib and lies anterolateral to the left kidney extending around to the mid axillary line.