Gastrointestinal System Assessment Flashcards
What are you assessing for when assessing the hands?
> Clubbing: Schamroth’s Window (BMJ, 2019).
> Koilonychia: inverted nails, Fe deficient (5.4%), haemachromatosis (49%) - Rathod & Sonthalia, 2020).
> Leukonychia (hypoalbuminaemia), Palmar Erythema, Spider Naevei: liver disease.
> Nicotine staining: cardio-resp disease.
> Osler’s Nodes: tender, purple/pink nodules on distal phalanges.
> Janeway Leision’s: erythematous papule’s palms/feet. (Parashar, 2022).
> Asterixis: T2RF, liver disease (think hepatic encephalopathy).
> Small Muscle Wastage: ^frail, T1 root damage by apical lung tumour (Macleod, 2018).
Arm assessment in relation to the GI System.
> Petechiae: vasculitis, chronic liver disease.
> Track marks: ^risk hepatitis.
> Spider Naevei: ^levels of oestrogen, can occur in pregnancy. 5+ cirrhosis.
> Bruising: clotting abnormalities, liver disease.
> Arteriovenous Fistulas: renal failure (metabolic/electrolyte abnormalities).
Face assessment in relation to the GI System.
> Conjunctiva: Anaemia, jaundice.
> Cholesterol: Xanthelasma, Arcus Senilis.
> Kayer-Fleischer Rings: dark/brown rings in eyes -> Wilson’s disease, abnormal copper processing in the liver.
> Malar Flushing: CO2 retention due to mitral valve stenosis.
How do you assess for Jugular Vein Distention?
> Pt at 45 deg.
> Turn head away from me.
> Measure height from sternal angel to height of JVD.
> Significant if >4cm.
> Hepatojugular reflex if unable to see ordinarily.
Assessing for Lymphadenopathy.
> Auricular, Cervical, Submandibular, Submental & Supraclavicular.
> Inflamed secondary to infection, malignancy (Maini & Nagali, 2022).
> Virchow’s Node: intra-abdominal Ca. Seen in pulmonary adenocarcinoma due to mets through the thoracic duct (Zdilla et al., 2019).
Abdominal Wall Inspection.
> Distention - F’s (Fat, Foetus, Fluid in Ascites, Flatus, Faeces, Free Fluid (bleeding).
> Scars & Stomas: surgery, abdo pathology hx.
> Spider Naevei: liver disease.
> Caput Medusa: portal HTN, liver disease (late sign).
> Cullen’s: acute pancreatitis (late), 37% mortality (Mookadam).
> Grey Turner’s: pancreatitis, retroperitoneal haem (AAA, trauma) - (Wong, 2021).
Why should you auscultate the abdomen before palpation or percussion?
> May falsely alter bowel sounds by dislodging faecal matter or gas.
> Evidence suggests it can put the pt at ease.
> Ferguson, 2019.
Abdominal Auscultation Findings.
> Normal - gurgling.
> Obstruction: tinkling, ^freq/vol/pitch.
> Absent: ileus, disruption of bowels normal propulsive ability due peristaltic malfunction, may suggest peritonitis. Bowel obstruction.
> Absent - must listen for 2-3 minutes per quadrant.
Abdominal Palpation.
> Light to deep.
> Tenderness & Rebound Tenderness: non-specific.
> Voluntary Guarding: abdo muscle contraction due to pain.
> Involuntary Guarding: invol tension of muscles on palpation, suggests peritonitis.
> Masses: hard (Ca?), assess mobility, consistency, pulsatile? DO NOT PALPATE A PULSATILE MASS!!!
Abdominal Percussion.
> 9 regions starting away from pain.
> Air in bowels will be hyperesonant.
> Stony dull in the suprapubic region - full bladder.
> Faecal loading in colon - dull.
> Shifting dullness - ascites?
Describe the tests for appendicitis.
> Rovsing’s Sign: palpate the LLQ -> RLQ pain (peritoneal irritation).
> Obturator: internal/external rotation of flexed R hip, RLQ pain, appendix is deep in hemipelvis.
> Psoas: R hip extension -> RLQ pain, lift leg against resistance.
> McBurney’s point: 1/3 of the way from the iliac crest between umbilicus. Palpation=pain+.
Describe the tests for acute cholecystitis.
> Murphy’s Sign.
> R costal margin, mid-clavicular, palpate & ask the patient to inspire.
> +ve sign if patient winces & stops inspiration due to irritation of the gall bladder.
> 80% diagnostic accuracy, 34% in the elderly. (Salati & Al Kadi, 2012).
Kidney Tenderness Assessment.
> Costovertebral Angle.
> Place hand at bottom of the 11th rib, hit your hand.
> Tender = +ve sign for pyelonephritis & ureteral stones.
> Journal of General and Family Medicine.
List some non-GI causes of abdominal pain.
> MI.
> Pleurisy.
> DKA.
> Ovarian Torsion.
> Testicular Torsion.
> Ectopic Pregnancy.
> (Macleod, 2018).
Pain Assessment in the GI System.
> SOCRATES.
> Referred Pain: pain away from site of origin due to interconnecting neural pathways (Murray, 2009).
> Migratory Pain: as in appendicitis.
Social history to gain in the GI system.
> Diet.
> Alcohol.
> Drugs.
> Food intolerance.
> Smoking.
> Stress (exacerbates IBS & Dyspepsia).
> Foreign Travel: D&V etc, Travellers Diarrhoea from Asia (NHS).
Aortic Dissection.
> S/S:
LOC, syncope, unequal BP/HR, sudden severe abdo/lower back pain, tearing/ripping, SOB, FAST symptoms.
> Obs:
red. GCS, red. BP, ^RR/HR, cold, clammy.
> IPPA:
bruising, pain on palpation, distention.
> Vomit/faeces:
haematemesis, Malena.
> Abnormal presentation:
discoloured legs.
> Stats:
50% dead before hospital (BMJ).
Ruptured Aortic Aneurysm.
> S/S:
Pulsatile mass, pale, clammy, LOC, abdo pain, dizzy, SOB, back pain into legs.
> Obs:
Red. GCS, ^HR/BP, red. BP, guarding, circulatory collapse.
> IPPA:
Cullen’s, pulsatile mass, hyporesonance.
> Vomit & Faeces:
Haematemesis, diarrhoea.
> Stats:
Nearly always fatal. 3000 deaths p/a in UK (NICE).
Pancreatitis.
> S/S:
RUQ/epigastric pain into back, N/V, fever, tachy, jaundice.
> Acute or chronic.
> Stats:
50% caused by gallstones.
25% caused by alcohol.
5% mortality rate.
(NICE).
Hepatitis.
> S/S:
Jaundice, fever, fatigue, red. appetite, N/V, abdo pain, dark urine, joint pain, haematemesis.
> Obs:
HTN in chronic. Hypotensive in acute. ^RR/HR.
> IPPA: Distention, tender, ascites, hepatomegaly.
> Neuro: toxins build up -> hepatic encephalopathy ( British Liver Trust).
Urinary Tract Infections.
> S/S:
Dark/foul smelling urine, haematuria, polyuria, dysuria, fever, signs of sepsis, confusion, delirium.
> Urosepsis:
31% of sepsis cases are urinary in origin.
20-40% overall mortality rate.
Incidence ^ w/ age.
(Dreger et al., 2015).
Appendicitis.
> S/S:
Umbilical to RLQ migratory pain, N/V, Diarrhoea, constipation, put themselves in foetal position.
> Tests:
McBurney’s point, Rovsing’s, Obturator, Psoas, Rebound Tenderness.
> Stats:
50,000 admissions p/a (NHS).
Cholecystitis.
> S/S:
Fever, N/V, clammy, jaundice, sudden sharp RUQ pain into R shoulder, deep insp worsens.
> Gallstones:
Often a trigger.
Risk Factors for GS - 5 F’s - female, fat, forty+, fertile, fair complexion.
> Fatty Meals:
Recent fatty meal can precipitate pain.
> Murphy’s:
80% accuracy, 34% in elderly - Salati & Al Kadi (2012).
Describe the term ‘acute abdomen’.
> Rapid onset of severe symptoms.
> That may indicate a life-threatening abdo pathology.
> Conditions inc:
Cholecystitis, appendicitis, pancreatitis, peptic ulcer, intestinal ischaemia, renal calculi, retention, AAA, torsions.
> Red Flags:
Hypotensive, red. GCS, shocked pt, systemically unwell, dehydrated, rigid abdo, haematemesis/melena, testicular/ovarian pathology.
Renal Calculi.
> S/S:
Depends on stone size, N/V, pain in flanks/groin (maybe intermittent), men may have testicle pain, fever, clammy, haematuria, UTI.
> Types:
Calcium most common, uric acid stones.
> Men 40+ high risk.
