Gastrointestinal

Question 1

What do you look for on general inspection of the patient?

Answer 1

Colour (jaundice/anaemia), perspiration, build/body habitus (wasting/obesity/distension), discomfort, scratch marks (from pruritis) breathing (rate, accessory muscles etc), conscious level

Question 2

What should you look for on examination of the hands?

Answer 2

Colour – palmar pallor (anaemia) vs erythema (liver disease/pregnancy)
Temperature
Clubbing - IBD, cirrhosis, coeliac
Leukonychia or Terry’s nails - hypoalbunimaemia in liver failure/enteropathy
Koilonychia - chronic iron deficiency
Spider naevi - liver disease
Dupuytren’s contracture - alcohol excess/FHx
Asterixis/flap - hold out in dorsiflexion for 15s - hepatic encephalopathy/uraemia/CO2 retention

Pulse

Question 3

What should you examine the eyes for?

Answer 3

Jaundice (yellow sclera) (haemolysis/hepatitis/cirrhosis/biliary obstruction)
Anaemia (subconjunctival pallor)
Xanthelasma - hyperlipidaemia
Corneal Arcus - as above
Kayser-Fleischer rings - copper deposits in Wilson’s disease

Question 4

What should you examine the face for?

Answer 4

Telangiectasia

Question 5

What should you examine the mouth for?

Answer 5

Telangiectasia
Pigmentation
Angular cheilitis/stomatitis (B6/12/folate/iron deficiency)
Glossitis (painful = B12 or folate deficiency, non painful = iron deficiency)
Dehydration
Halitosis
Dental caries
Ulcers (B12 or iron deficiencies, Crohn’s, coeliac)
Central cyanosis

Question 6

What should you examine the chest for?

Answer 6

Spider naevi
Gynaecomastia and loss of body hair (due to elevated circulating oestrogens in liver cirrhosis or with digoxin or spironolactone use)
Palpate lymph nodes in neck and axillae – Troisier’s sign = enlarged Virchow’s node (left supraclavicular) due to gastric/intra-abdo malignancy/mets

Question 7

What should you examine the abdomen for?

Answer 7

Firstly, patient must be lowered to flat and only use one pillow, if possible
Skin – scars, loose folds? (sudden loss) striae? (sudden gain) bruising (Cullen’s/Grey-Turners in pancreatitis/AAA rupture
Shape and symmetry, muscle wasting
Movement during breathing (less diaphragmatic breathing if peritonitis)
Visible masses, peristalsis, aortic pulsation etc
Distended veins - paraumbilical = caput medusae in portal HTN
Stomas - colostomy (LIF), ileostomy (RIF), urostomy (RIF) - attachment site, contents
5 F’s of distension

Question 8

What should you look for on general palpation of the abdomen?

Answer 8

Ask about pain, start opposite place, observe face throughout and mentally visualise underlying anatomy whilst palpating
Palpate the 9 regions of the abdomen wall gently and systematically whilst observing the patients face for signs of discomfort - feel for areas of tenderness, guarding, rigidity etc
Repeat the palpation using deeper palpation with 2 hands – feel for any masses – size, surface, shape, edge, consistency, tenderness?

Question 9

How do you palpate the liver?

Answer 9

Start palpating in the right iliac fossa (as hepatomegaly can reach down that far), ask the patient to take a deep breath in whilst you use the edge of your hand to palpate deeply and find any descending edge of the liver
Patient asked then to breathe out whilst you place your hand slightly closer to the costal margin, repeat until edge of liver found or not (in the healthy, won’t normally be easy to palpate, neither will the gall bladder)

Any tenderness on liver palpation - ?hepatitis
Pulsatile - tricuspid regurgitation

Question 10

How do you palpate the spleen?

Answer 10

Not normally palpable in the healthy patient
Palpation should begin in the right iliac fossa and advance towards the left costal margin (as this is the direction the spleen enlarges in), palpate in the same way as when looking for the liver

Question 11

How do you palpate the kidneys?

Answer 11

Examined by ballottement – anterior hand presses deeply to the left of the rectus sheath in the upper quadrant of the abdomen, posterior hand placed in the costovertebral angle and should be used to lift the kidney towards the anterior hand
Feel for masses – number, size, shape, consistency, pain etc

Question 12

How do you palpate the bladder?

Answer 12

Palpate down from umbilicus to suprapubic region, if full – pressure will make patient want to urinate

Question 13

How do you palpate the abdominal aorta?

Answer 13

Use the first two fingers of both hands to press in deeply, just superior to the umbilicus
Normally should be pulsatile but if is expansile i.e. pushes your fingers away then it suggests aneurysmal dilatation

Question 14

How do you percuss the abdomen?

Answer 14

Percuss in the same way as you palpate ie from the right iliac fossa upwards
Liver - percuss up from RIF and down from R chest - should sound from resonant to dull to resonant (from below to above)
Spleen – a with liver; percuss the lowest intercosal space (8/9th) in the left anterior axillary line when patient is in full inspiration and full expiration - the positive sign for splenomegaly is resonant on expiration and dull on inspiration
Bladder – dull note if enlarged

Question 15

How do you percuss for ascites?

Answer 15

Test for shifting dullness – percuss from the centre towards the left flank, if a dull note is heard – place your finger on the spot and roll the patient towards you, wait 10 seconds for fluid to redistribute
If note becomes resonant, percuss back towards the umbilicus until the notes becomes dull again

Question 16

What do you listen for on auscultation?

Answer 16

Are bowel sounds present and normal? Tinkling – obstruction, absent – ileus/peritonitis 
Femoral bruits (slightly higher than the level of the umbilicus and on either side, use the bell of the stethoscope) and aortic bruits

Question 17

How do you finish the examination?

Answer 17

(state you would perform ISHRUG) 
Inguinal lymph node examination
Stool sample
Hernial orifices (femoral and inguinal)
Rectal examination
Urine analysis
Genitalia 

+ BP + palpation/auscultation of femoral pulses

Question 18

What may cause distended veins (on the abdomen)?

Answer 18

IVC obstruction or portal HTN

Question 19

How do you determine whether a mass is intra-abdominal?

Answer 19

Ask 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 20

What is a succession splash?

Answer 20

Shake the stomach briskly from side to side whilst listening for a sloshing sound, indicates stomach distension

Question 21

What is Courvoisier’s Law?

Answer 21

In the presence of a palpable and non-tender gall bladder (not normally palpable), jaundice is NOT likely to be due to gallstones

One of the most likely differentials is pancreatic malignancy (but not pathognomonic)

Question 22

What is Murphy’s sign?

Answer 22

Inspiratory arrest when hands placed over right costal margin in the mid clavicular line, indicating an inflamed gallbladder. Also needs to be repeated on the other side – a positive test overall requires no inspiratory arrest on the left

Question 23

What are the names of different abdominal scars and what procedures do they reflect?

Answer 23

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