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Phase 2b Sheffield Medicine > Gastrointestinal History and Examination > Flashcards

Gastrointestinal History and Examination Flashcards

1
Q

What things should you do in the introduction of a GI exam?

A

● Wash your hands and don PPE
● Introduce yourself with name and role
● Confirm the patients name and date of birth
● Briefly explain the exam in patient-friendly language
● Gain consent for the examination
● Adjust the bed to 45 degrees and ask the patient to lie upon the bed
● Adequately expose the patient’s abdomen for the examination from the waist up (offer a blanket if needed)
● Exposure of the patient’s lower legs is also helpful to assess for peripheral oedema.
● Ask the patient if they have any pain before commencing the exam

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2
Q

What signs should you look out for when conducting the general inspection in a GI exam?

A

● Age
● Confusion
● Pain
● Obvious scars
● Abdominal distension
● Pallor
● Jaundice
● Hyperpigmentation
● Oedema
● Cachexia
● Hernias

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3
Q

Why is a patients age helpful when conducting a GI exam?

A

● The patient’s approximate age is helpful when considering the most likely underlying pathology, with younger patients more likely to have diagnoses such as inflammatory bowel disease (IBD) and older patients more likely to have chronic liver disease and malignancy.

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4
Q

Why may a patient be confused and in need of a GI exam?

A

● Often a feature of end-stage liver disease, known as hepatic encephalopathy.
Pain: if the patient appears uncomfortable, ask where the pain is and whether they are still happy for you to examine them.

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5
Q

What may abdominal distention be suggestive of when completing a general inspection in a GI exam?

A

● May suggest the presence of ascites or underlying bowel obstruction and/or organomegaly.

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6
Q

What is pallor and why may it be relevant during the general inspection of a GI exam?

A

● A pale colour of the skin that can suggest underlying anaemia (e.g. gastrointestinal bleeding or malnutrition). It should be noted that healthy individuals may have a pale complexion that mimics pallor.

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7
Q

What is jaundice and what may it suggest when completing the general inspection portion of a GI exam?

A

● A yellowish or greenish pigmentation of the skin and whites of the eyes due to high bilirubin levels (e.g. acute hepatitis, liver cirrhosis, cholangitis, pancreatic cancer).

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8
Q

What is hyperpigmentation and what may it be suggestive of when completing the general inspection portion of a GI exam?

A

● A bronzing of the skin associated with haemochromatosis.

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9
Q

What may oedema be suggestive of when associated with a GI exam?

A

● Typically presents as swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites) and is often associated with liver cirrhosis in the context of an abdominal exam.

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10
Q

What is cachexia and what may it be suggestive of when completing the general inspection portion of a GI exam?

A

● Ongoing muscle loss that is not entirely reversed with nutritional supplementation. Cachexia is commonly associated with underlying malignancy (e.g. pancreatic/bowel/stomach cancer) and advanced liver failure.

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11
Q

What objects and/or equipment may you look out for when completing a general inspection during a GI exam?

A

● Stoma bag
● Surgical drains
● Feeding tubes
● Other medical equipment
● Mobility aids
● Vital signs
● Fluid balance
● Prescriptions

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12
Q

What useful information may a stoma bag provide when completing the general inspection portion of a GI exam?

A

● Note the location of the stoma bag(s) as this can provide clues as to the type of stoma (e.g. colostomies are typically located in the left iliac fossa, whereas ileostomies are usually located in the right iliac fossa).

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13
Q

What useful information may a surgical drain provide when completing the general inspection portion of a GI exam?

A

● Note the location of the drain and the type/volume of the contents within the drain (e.g. blood, chyle, pus).

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14
Q

What should you do next after having a general inspection of the patient in a GI exam?

A

● Inspection of the hands

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15
Q

What areas of the hands should be inspected in a GI exam?

A

● Palms
● Nails signs
● Finger clubbing
● Asterixis

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16
Q

What clinical signs should you look out for on the palmar surface of a patients hand during a GI exam?

A

● Pallor
● Palmar erythema
● Dupuytren’s contracture

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17
Q

What may pallor suggest when inspecting a patients hands during a GI exam?

A

● May suggest underlying anaemia (e.g. malignancy, gastrointestinal bleeding, malnutrition).

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18
Q

What may palmar erythema suggest when inspecting a patients hands during a GI exam?

A

● A redness involving the heel of the palm that can be associated with chronic liver disease (it can also be a normal finding in pregnancy).

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19
Q

What clinical signs should you look out for on the nails of a patients hand during a GI exam?

A

● Koilonychia
● Leukonychia

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20
Q

What is leukonychia and why may it be relevant during the inspection of the nails during a GI exam?

A

● Whitening of the nail bed, associated with hypoalbuminaemia (e.g. end-stage liver disease, protein-losing enteropathy).

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21
Q

What is koilonychia and why may it be relevant during the inspection of the nails during a GI exam?

A

● Spoon-shaped nails, associated with iron deficiency anaemia (e.g. malabsorption in Crohn’s disease).

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22
Q

Describe the pathophysiological process of finger clubbing?

A

● Finger clubbing involves uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed.

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23
Q

What GI diseases may finger clubbing present with?

A

● Inflammatory bowel disease
● Coeliac disease
● Liver cirrhosis
● Lymphoma of the gastrointestinal tract

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24
Q

How would you assess for finger clubbing in a GI exam?

A

● Ask the patient to place the nails of their index fingers back to back.
● In a healthy individual, you should be able to observe a small diamond-shaped window (known as Schamroth’s window).
● When finger clubbing develops, this window is lost.

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25
Q

What is dupuytren’s contracture?

A

● Dupuytren’s contracture involves thickening of the palmar fascia, resulting in the development of cords of palmar fascia which eventually cause contracture deformities of the fingers and thumb.

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26
Q

Why may dupuytren’s contracture be relevant in a GI exam?

A

● There are a number of factors that have been associated with the development of Dupuytren’s contracture including genetics, excessive alcohol use, increasing age, male gender and diabetes.

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27
Q

How would you assess for dupuytren’s contracture during the hand inspection portion of a GI exam?

A

● Support the patient’s hand and palpate the palm to detect bands of thickened palmar fascia that feel cord-like.

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28
Q

After inspecting the palms, nails and finger clubbing, what is the final sign that should be inspected for in the hands during a GI exam?●

A

● Asterixis

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29
Q

What is asterixis?

A

● Asterixis (also known as ‘flapping tremor’) is a type of negative myoclonus characterised by irregular lapses of posture causing a flapping motion of the hands.

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30
Q

What would asterixis be suggestive of when completing a GI exam?

A

● In the context of an abdominal examination, the most likely underlying cause is either hepatic encephalopathy (due to hyperammonaemia) or uraemia secondary to renal failure.
● CO2 retention secondary to type 2 respiratory failure is another possible cause of asterixis.

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31
Q

How would you assess asterixis in a patient during the inspection portion of a GI exam?

A

● Ask the patient to stretch their arms out in front of them.
● Then ask them to cock their hands backwards at the wrist joint and hold the position for 30 seconds.
● Observe for evidence of asterixis during this time period.

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32
Q

What would you palpate on a patients hands during a GI exam?

A

● Temperature
● Radial pulse
● Dupuytren’s contracture

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33
Q

How would you assess temperature of the hands during a GI exam?

A

● Place the dorsal aspect of your hand onto the patient’s to assess temperature.

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34
Q

What would a normal and abnormal finding be when assessing temperature of a patients hands during a GI exam?

A

● In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion.
● Cool hands may suggest poor peripheral perfusion.

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35
Q

How would you assess a patients radial pulse during a GI exam?

A

● Palpate the patient’s radial pulse, located at the radial side of the wrist, with the tips of your index and middle fingers aligned longitudinally over the course of the artery.
● Once you have located the radial pulse, assess the rate and rhythm.

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36
Q

What clinical signs would you look out for the inspecting the patients arms during a GI exam?

A

● Bruising
● Excoriations
● Needle tract marks

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37
Q

Why may arm bruising be an important clinical sign when inspecting a patients arms during a GI exam?

A

● May suggest underlying clotting abnormalities secondary to liver disease (e.g. cirrhosis).

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38
Q

What are excoriations and what may they be suggestive of when inspecting the arms during a GI exam?

A

● Scratch marks that may be caused by the patient trying to relieve pruritis. In the context of an abdominal examination, this may suggest underlying cholestasis.

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39
Q

Why may needle tract marks be an important clinical signs when inspecting a patients arm during a GI exam?

A

● Important to note as intravenous drug use can be associated with an increased risk of viral hepatitis.

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40
Q

What clinical signs would you look out for when inspecting a patients axillae during a GI exam?

A

● Acanthosis nigricans
● Hair loss

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41
Q

What is acanthosis nigricans why may it be an important clinical sign when inspecting a patients axillae during a GI exam?

A

● Darkening (hyperpigmentation) and thickening (hyperkeratosis) of the axillary skin which can be benign (most commonly in dark-skinned individuals) or associated with insulin resistance (e.g. type 2 diabetes mellitus) or gastrointestinal malignancy (most commonly stomach cancer).

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42
Q

Why may hair loss in the axillae be an important clinical sign when inspecting a patient during a GI exam?

A

● Loss of axillary hair associated with iron-deficiency anaemia and malnutrition.

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43
Q

What would you ask the patient to do when inspecting the face during a GI exam?

A

● Ask the patient to gently pull down their lower eyelid and inspect for signs suggestive of gastrointestinal pathology

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44
Q

What clinical signs should you look out for when inspecting a patients eyes during a GI exam?

A

● Conjunctival pallor
● Jaundice
● Corneal arcus
● Xanthelasma
● Kayser-Fleischer rings
● Perilimbal infection

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45
Q

What is corneal arcus and what would it be suggestive of when inspecting the eyes during a GI exam?

A

● A hazy white, grey or blue opaque ring located in the peripheral cornea, typically occurring in patients over the age of 60. In older patients, the condition is considered benign, however, its presence in patients under the age of 50 suggests underlying hypercholesterolaemia.

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46
Q

What is xanthelasma and what would it be suggestive of when inspecting the eyes during a GI exam?

A

● Yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia.

47
Q

What are Keyser-Fleischer rings and what would they be suggestive of when inspecting the eyes during a GI exam?

A

● Dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues (including the liver causing cirrhosis).

48
Q

What is perilimbial injection and what would it be suggestive of when inspecting the eyes during a GI exam

A

● Inflammation of the area of conjunctiva adjacent to the iris. Perilimbal injection is a sign of anterior uveitis, which can be associated with inflammatory bowel disease. Other clinical features of anterior uveitis include photophobia, ocular pain and reduced visual acuity.

49
Q

What clinical signs should you look out for when inspecting a patients mouth during a GI exam?

A

● Angular stomatitis
● Glossitis
● Oral candidiasis
● Aphthous ulceration
● Hyperpigmented macules

50
Q

What would you ask the patient to do when trying to inspect the mouth during a GI exam?

A

● Ask the patient to open their mouth and inspect for signs suggestive of gastrointestinal pathology

51
Q

What is angular stomatitis and what may it be suggestive of when inspecting the mouth during a GI exam?

A

● A common inflammatory condition affecting the corners of the mouth. It has a wide range of causes including iron deficiency (e.g. gastrointestinal malignancy, malabsorption).

52
Q

What is glossitis and what may it be suggestive of when inspecting the mouth during a GI exam?

A

● Smooth erythematous enlargement of the tongue associated with iron, B12 and folate deficiency (e.g. malabsorption secondary to inflammatory bowel disease).

53
Q

What is oral candidiasis and what may it be suggestive of when inspecting the mouth during a GI exam?

A

● A fungal infection commonly associated with immunosuppression. It is characterised by pseudomembranous white slough which can be easily wiped away to reveal underlying erythematous mucosa.

54
Q

What is aphthous ulcerations and what may they be suggestive of when inspecting the mouth during a GI exam?

A

● Round or oval ulcers occurring on the mucous membranes inside the mouth. Aphthous ulcers are typically benign (e.g. due to stress or mechanical trauma), however, they can be associated with iron, B12 and folate deficiency as well as Crohn’s disease.

55
Q

What may hyperpigmented macules be suggestive of when inspecting the mouth during a GI exam?

A

● Pathognomonic for Peutz-Jeghers syndrome, an autosomal dominant genetic disorder that results in the development of polyps in the gastrointestinal tract.

56
Q

Describe the drainage of the left supraclavicular lymph node and why enlargement may be suggestive of underlying GI pathology?

A

● The left supraclavicular lymph node (known as Virchow’s node) receives lymphatic drainage from the abdominal cavity and therefore enlargement of Virchow’s node can be one of the first clinical signs of metastatic intrabdominal malignancy (most commonly gastric cancer)

57
Q

Describe the drainage of the right supraclavicular lymph node and why enlargement may be suggestive of underlying GI pathology?

A

● The right supraclavicular lymph node receives lymphatic drainage from the thorax and therefore lymphadenopathy in this region can be associated with metastatic oesophageal cancer (as well as malignancy from other thoracic viscera).

58
Q

What clinical signs may you see when completing an inspection of the chest during a GI exam?

A

● Spider naevi
● Gynaecomastia
● Hair loss

59
Q

What are spider naevi and what may they be suggestive of when inspecting the chest during a GI exam?

A

● Skin lesions that have a central red papule with fine red lines extending radially caused by increased levels of circulating oestrogen.
● Spider naevi are commonly associated with liver cirrhosis, but can also be a normal finding in pregnancy or in women taking the combined oral contraceptive pill.
● If more than 5 are present it is more likely to be associated with pathology such as liver cirrhosis.

60
Q

What may gynaecomastia be suggestive of when inspecting the chest during a GI exam?

A

● Enlargement of male breast tissue caused by increased levels of circulating oestrogen (e.g. liver cirrhosis). Other causes include medications such as digoxin and spironolactone.

61
Q

What may hair loss be suggestive of when inspecting the chest during a GI exam?

A

● Can be caused by increased levels of circulating oestrogen.
● General malnourishment can also result in hair loss.

62
Q

What position should the patient be in when you inspect the abdomen during a GI exam?

A

● Position the patient lying flat on the bed, with their arms by their sides and legs uncrossed for abdominal inspection and subsequent palpation.

63
Q

What clinical signs may be seen when you inspect the abdomen during a GI exam?

A

● Scars
● Abdominal distension
● Caput medusae
● Striae (stretch marks)
● Hernias
● Cullen’s sign
● Grey-Turner sign

64
Q

What are the 6 f’s that can cause abdominal distension?

A

● Fat
● Fluid
● Flatus
● Faeces
● Fetus
● Fulminant mass

65
Q

What is caput medusae and what may they be suggestive of when completing an inspection of the abdomen during a GI exam?

A

● Engorged paraumbilical veins associated with portal hypertension (e.g. liver cirrhosis).

66
Q

What are striae and what may they be suggestive of when completing an inspection of the abdomen during a GI exam?

A

● Stretch marks caused by tearing during the rapid growth or overstretching of skin (e.g. ascites, intrabdominal malignancy, Cushing’s syndrome, obesity, pregnancy).

67
Q

How would you elicit protrusion of an abdominal hernia?

A

● Ask the patient to cough and observe for any protrusions through the abdominal wall (e.g. umbilical hernia, incisional hernia).

68
Q

What is Cullen’s sign and what may it be suggestive of when completing an abdominal inspection during a GI exam?

A

● Bruising of the tissue surrounding the umbilicus associated with haemorrhagic pancreatitis (a late sign).

69
Q

What is Grey-Turner’s sign and what may it be suggestive of when completing an abdominal inspection during a GI exam?

A

● Bruising in the flanks associated with haemorrhagic pancreatitis (a late sign).

70
Q

What characteristics of a stoma should be assessed during an abdominal exam?

A

● Location
● Contents
● Consistency of stool
● Spout (colostomies are flush to the skin with no spout whereas ileostomies and urostomies have a spout).

71
Q

What would you do before commencing with abdominal palpation during a GI exam?

A

● The patient should already be positioned lying flat on the bed.
● Ask the patient if they are aware of any areas of abdominal pain (if present, examine these areas last).
● Kneel beside the patient to carry out palpation and observe their face throughout the examination for signs of discomfort.

72
Q

Where would you both lightly and deeply palpate on the abdomen during a GI exam?

A

● Palpate each of the nine abdominal regions, assessing for clinical signs suggestive of gastrointestinal pathology

73
Q

What clinical signs may be observed when palpating the abdomen during a GI exam?

A

● Tenderness
● Rebound tenderness
● Voluntary guarding
● Involuntary guarding / rigidity
● Rovsing’s sign
● Masses

74
Q

What is the difference between voluntary and involuntary guarding?

A

● Contraction of the abdominal muscles in response to pain
● Involuntary tension in the abdominal muscles that occurs on palpation associated with peritonitis (e.g. appendicitis, diverticulitis).

75
Q

What is Rovsing’s sign and what may it suggest when performing palpation during a GI exam?

A

● Palpation of the left iliac fossa causes pain to be experienced in the right iliac fossa.
● This sign was historically said to be indicative of appendicitis, but it is not reliable and at best indicates peritoneal inflammation of any cause affecting the left and/or right iliac fossa.

76
Q

What should you say to the patient before moving on from superficial palpation of the abdomen?

A

● Warn the patient this may feel uncomfortable and ask them to let you know if they want you to stop.
● You should also carefully monitor the patient’s face for evidence of discomfort (as they may not vocalise this).

77
Q

If any masses are felt during deep palpation of the abdomen during a GI exam, what characteristics should be assessed?

A

● Location
● Size and shape
● Consistency
● Mobility
● Pulsatility

78
Q

Describe in steps how you would palpate the liver on a patient in a GI exam?

A
  1. Begin palpation in the right iliac fossa, starting at the edge of the superior iliac spine, using the flat edge of your hand (the radial side of your right index finger).
  2. Ask the patient to take a deep breath and as they begin to do this palpate the abdomen. Feel for a step as the liver edge passes below your hand during inspiration (a palpable liver edge this low in the abdomen suggests gross hepatomegaly).
  3. Repeat this process of palpation moving 1-2 cm superiorly from the right iliac fossa each time towards the right costal margin.
  4. As you get close to the costal margin (typically 1-2 cm below it) the liver edge may become palpable in healthy individuals.
79
Q

If you are able to palpate the liver edge during a GI exam, what characteristics should be assessed?

A

● Degree of extension below the costal margin
● Consistency of the liver edge:
● Tenderness
● Pulsatility

80
Q

When assessing the liver edge in a GI exam, what would an abnormal finding be for the degree of extension into the costal margin?

A

● If greater than 2 cm this suggests hepatomegaly.

81
Q

When assessing the liver edge in a GI exam, what would an abnormal finding be for the consistency of the liver edge?

A

● A nodular consistency is suggestive of cirrhosis.

82
Q

When assessing the liver edge in a GI exam, what would tenderness suggest?

A

● Hepatic tenderness may suggest hepatitis or cholecystitis (as you may be palpating the gallbladder)

83
Q

When assessing the liver edge in a GI exam, what would pulsatility be suggestive of?

A

● Pulsatile hepatomegaly is associated with tricuspid regurgitation.

84
Q

List as many causes of hepatomegaly as possible?

A

● Hepatitis (infective and non-infective)
● Hepatocellular carcinoma
● Hepatic metastases
● Wilson’s disease
● Haemochromatosis
● Leukaemia
● Myeloma
● Glandular fever
● Primary biliary cirrhosis
● Tricuspid regurgitation
● Haemolytic anaemia

85
Q

What organs/structures should be specifically palpated in a GI exam, once you have palpated the 9 regions of the abdomen?

A

● Liver
● Gallbladder
● Spleen
● Kidneys
● Aorta
● Bladder

86
Q

Where would you palpate the gallbladder during a GI exam?

A

● Palpation of the gallbladder can be attempted at the right costal margin, in the mid-clavicular line (the tip of the 9th rib).

87
Q

What will the gallbladder feel like if it is enlarged during a GI exam?

A

● If the gallbladder is enlarged, a well-defined round mass that moves with respiration may be noted.

88
Q

What would tenderness of the gallbladder suggest when palpating during a GI exam?

A

● Tenderness suggests a diagnosis of cholecystitis

89
Q

What would painless distension of the gallbladder suggest when palpating during a GI exam?

A

● Distended painless gallbladder may indicate underlying pancreatic cancer (particularly if also associated with jaundice).

90
Q

How would you assess for Murphy’s sign in a patient during a GI exam?

A
  1. Position your fingers at the right costal margin in the mid-clavicular line at the liver’s edge.
  2. Ask the patient to take a deep breath.
91
Q

What would a positive Murphy’s sign be and what would this suggest during a GI exam?

A

● If the patient suddenly stops mid-breath due to pain, this suggests the presence of cholecystitis.

92
Q

Would the gallbladder be palpable in a normal patient during a GI exam?

A

● In healthy individuals, the gallbladder is not usually palpable.
● If the gallbladder is palpable it suggests enlargement secondary to biliary flow obstruction (e.g. pancreatic malignancy, gallstones) and/or infection (e.g. cholecystitis).

93
Q

Describe how you would palpate a patients spleen during a GI exam?

A
  1. Begin palpation in the right iliac fossa, starting at the edge of the superior iliac spine, using the flat edge of your hand (the radial side of your right index finger).
  2. Ask the patient to take a deep breath and as they begin to do this palpate the abdomen with your fingers aligned with the left costal margin. Feel for a step as the splenic edge passes below your hand during inspiration (the splenic notch may be noted).
  3. Repeat this process of palpation moving 1-2 cm superiorly from the right iliac fossa each time towards the left costal margin.
94
Q

Would the spleen be palpable in a normal patient during a GI exam?

A

● In healthy individuals, you should not be able to palpate the spleen.
● A palpable spleen at the edge of the left costal margin would suggest splenomegaly (for the spleen to be palpable at this location it would need to be approximately three times its normal size).

95
Q

List as many causes of splenomegaly as possible?

A

● Portal hypertension secondary to liver cirrhosis
● Haemolytic anaemia
● Congestive heart failure
● Splenic metastases
● Glandular fever

96
Q

Describe how you would ballot a patients kidneys during a GI exam?

A
  1. Place your left hand behind the patient’s back, below the ribs and underneath the right flank.
  2. Then place your right hand on the anterior abdominal wall just below the right costal margin in the right flank.
  3. Push your fingers together, pressing upwards with your left hand and downwards with your right hand.
  4. Ask the patient to take a deep breath and as they do this feel for the lower pole of the kidney moving down between your fingers. This bimanual method of kidney palpation is known as balloting.
  5. If a kidney is ballotable, describe its size and consistency.
  6. Repeat this process on the opposite side to ballot the left kidney.
97
Q

What could be the cause of bilaterally enlarged kidneys?

A

● Bilaterally enlarged, ballotable kidneys can occur in polycystic kidney disease or amyloidosis.

98
Q

What could be the cause of unilaterally enlarged kidneys?

A

● A unilaterally enlarged, ballotable kidney can be caused by a renal tumour.
● Or you may be feeling the third kidney if an individual has received a kidney transplant.

99
Q

Describe how you would palpate the aorta on a patient during a GI exam?

A
  1. Using both hands perform deep palpation just superior to the umbilicus in the midline.
  2. Note the movement of your fingers.
100
Q

What would a normal and abnormal finding be when you palpate the aorta during a GI exam?

A

● In healthy individuals, your hands should begin to move superiorly with each pulsation of the aorta.
● If your hands move outwards, it suggests the presence of an expansile mass (e.g. abdominal aortic aneurysm).

101
Q

What should you do before palpating the bladder on a patient during a GI exam?

A

● Before performing bladder palpation, allow the patient the opportunity to go to the toilet.
● Warn the patient that palpation may be uncomfortable and bring about the sudden urge to pass urine.

102
Q

What is the next step in a GI exam after concluding the palpation section of the abdominal contents?

A

● Percussion of the liver
● Percussion of the spleen
● Percussion of the bladder
● Assess shifting dullness

103
Q

Describe how you would percuss the liver during a GI exam?

A
  1. Percuss upwards 1-2 cm at a time from the right iliac fossa (the same position used to begin palpation) towards the right costal margin until the percussion note changes from resonant to dull indicating the location of the lower liver border.
  2. Continue to percuss upwards 1-2 cm at a time until the percussion note changes from dull to resonant indicating the location of the upper liver border.
  3. Use the knowledge of the upper and lower border of the liver to determine its approximate size.
104
Q

Describe how you would percuss the spleen during a GI exam?

A

● Percuss upwards 1-2 cm at a time from the right iliac fossa (the same position used to begin palpation) towards the left costal margin until the percussion note changes from resonant to dull indicating the location of the spleen
● In the absence of splenomegaly the spleen should not be identifiable using percussion.

105
Q

Describe how you would percuss the bladder during a GI exam?

A

● Percuss downwards in the midline from the umbilical region towards the pubic symphysis. A distended bladder will be dull to percussion allowing you to approximate the bladder’s upper border.

106
Q

Describe how you would percuss for ascites using shifting dullness during a GI exam?

A
  1. Percuss from the umbilical region to the patient’s left flank. If dullness is noted, this may suggest the presence of ascitic fluid in the flank.
  2. Whilst keeping your fingers over the area at which the percussion note became dull, ask the patient to roll onto their right side (towards you for stability).
  3. Keep the patient on their right side for 30 seconds and then repeat percussion over the same area.
  4. If ascites is present, the area that was previously dull should now be resonant (i.e. the dullness has shifted).
107
Q

How would you assess bowel sounds during a GI exam?

A

● Auscultate over at least two positions on the abdomen to assess bowel sounds

108
Q

What would tinkling bowel sounds suggest during a GI exam?

A

● Tinkling bowel sounds: typically associated with bowel obstruction.

109
Q

What would absent bowel sounds suggest during a GI exam?

A

● Suggests ileus which is a disruption of the normal propulsive ability of the intestine due to a malfunction of peristalsis.
● Causes of ileus include electrolyte abnormalities and recent abdominal surgery.
● To be able to confidently state that a patient has ‘absent bowel sounds’ you need to auscultate for at least 3 minutes

110
Q

Aside from bowel sounds, what else should you auscultate for during a GI exam?

A

● Auscultate over the aorta and renal arteries to identify vascular bruits suggestive of turbulent blood flow

111
Q

Describe how you would listen for aortic bruits in a GI exam?

A

● Auscultate 1-2 cm superior to the umbilicus, a bruit here may be associated with an abdominal aortic aneurysm.

112
Q

Describe how you would listen for renal bruits in a GI exam?

A

● Auscultate 1-2 cm superior to the umbilicus and slightly lateral to the midline on each side. A bruit in this location may be associated with renal artery stenosis.

113
Q

What is the final step in a GI exam?

A

● Assess the patient’s lower legs for evidence of pitting oedema which may suggest hypoalbuminaemia (e.g. liver cirrhosis, protein-losing enteropathy).

114
Q

What further assessments or investigations could be completed after conclusion of a GI exam?

A

● Check hernial orifices’ (signs of bowel obstruction)
● Perform a DRE (GI bleeding suspicion)
● Perform an examination of the external genitalia (rule out testicular torsion or an indirect inguinal hernia)

Phase 2b Sheffield Medicine (17 decks)

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