GI Flashcards
what questions should be asked in the presenting complaint of a GI history?
weight alteration; how much
energy levels; fatigue?
dysphagia; food, liquids, getting worse?
dyspepsia; indigestion, acidic, waster brash, sour taste, bloating
nausea/vomiting; frequency, content, blood, bright red, coffee grounds
abdominal pain; SOCRATES
abdominal swelling; timing
bowels; diarrhoea, sluggish motions, watery, timing, nocturnal, constipation, frequency, alterations
tenesmus
blood PR; fresh, dark, black, separate, mixed, volume, mucous, pus
what are the causes of weight loss?
problems of digestion and absorption
malignancy
hyperthyroidism
what are the causes of dysphagia?
neuromuscular; liquids more than solids, choking due to aspiration
stricture; solids more than liquids
progressive; stricture due to tumour
what are the causes of haematemesis and melaena?
peptic ulcers
gastric erosions
oesophagitis
may be associated with taking aspirin or anti-inflammatory drugs
describe the pain coming from hollow viscera
colic
crampy/paroxysmal
often poorly localised
related to peristalsis
describe the pain from peritoneal irritation
more ominous associated with peritonitis of any sort steady/constant not well localised not related to peristalsis patient often lies still with knees up
what are the causes of abdominal swelling?
flatus (gas); bowel obstruction faeces fat fluid foetus organomegaly
what are the causes of diarrhoea?
e. coli
malabsorption syndrome
IBD, tumour; pathology in the rectal area which disturbs the defecation reflex
what conditions are important to ask about in the past medical history and family history in a GI history?
bowel problems gallstones ulcers arthritis gynaecology problems
bowel cancer
IBD
describe the steps of an abdominal exam
exposure; nipples to symphysis pubis, flat bed
general inspection
superficial palpation
deep palpation
palpation for lower edge of liver
palpation for lower edge of spleen
palpation for kidneys
percussion for lower and upper edge of liver
percussion for lower edge of spleen
percussion for fluid level; shifting dullness, fluid thrill
auscultation
other examinations; external genitalia, hernia, groin, rectal
what is the cause of guarding?
inflamed viscus and peritoneum
local peritonitis
acute appendicitis
what is the cause of rigidity?
generalised peritonitis
what should you figure out if you feel the lower edge of the liver?
edge; smooth, irregular, pulsatile
distance from the liver edge and the costal margin
tenderness
consistency; hard or soft
what is the purpose of auscultation of the abdomen?
bowel sounds; 1 full minute
obstruction; tinkling bowel sounds
peritonitis; absent/reduced, widespread intra abdominal inflammation, loss of normal motility
bruits;
abdominal aorta; midline
renal arteries; right and left
describe the steps of an oral cavity exam
general inspection extra-oral examination; palpation; salivary glands cervical lymph nodes muscles of mastication temporomandibular joint consider cranial nerve/sinus examination
intra-oral examination; dentition mucosal surfaces gingiva hard and soft palate tongue floor of the mouth buccal mucosa oropharynx assess salivary flow
what are you looking for in a general examination of the face in an oral cavity exam?
face/neck
swelling
asymmetry
bruising
what are you palpating for in an oral cavity exam?
glands; enlarged tender firm fixed
how do you palpate the muscles of mastication and the temporomandibular joint?
temporalis; end to end and centric occlusal biting positions
masseter; palpate over the check area, ask to bite
temporomandibular joint; ask to bite, click indicates dysfunction
what are you looking for in an inspection of dentition?
identify incisor, canine, premolar and molar teeth
what are you looking in an inspection of mucosal surfaces?
inflammation; redness, swelling
ulceration
pigmentation
lesions
how do you inspect the tongue?
ask the patient to stick their tongue out; examine the dorsal surface
identify circumvallate papillae
how do you examine the floor of the mouth?
ask the patient to touch the roof of the mouth with their tongue
examine the ventral surface of the tongue
what are you looking for in an inspection of the buccal mucosa?
inflammation
ulceration
pigmentation
how do you examine the oropharynx?
is the mouth dry?
can saliva be expressed from the glands?
describe an examination of a hernia
introduction general inspection; clinical signs objects and equipment differentiation a hernia from other types of lumps; assess both sides differentiating hernia subtypes; position reducibility direct/indirect inguinal hernia scrotal examination finish exam; thank patient, summarise findings
what should be done in the introduction of a hernia exam?
wash hands and don PPE introduce yourself confirm patient details explain procedure get chaperone have bed at a 45 degree angle adequately expose the patients abdomen and inguinal region ask if they have any pain
what clinical signs are you looking for in a general inspection of a hernia exam?
pain obvious scars abdominal distension pallor cachexia hernia; cough
what objects or equipment are you looking for in a general inspection of a hernia exam?
stoma bag; colostomies LIF, ileostomies RIF
surgical drain; location, type/volume of contents
mobility aids
what features indicate a hernia of the groin?
single lump in the inguinal region positive cough impulse soft on palpation reducible; unless incarcerated unable to get above the lump painless; unless incarcerated bowel sounds; may be absent if incarcerated
what features indicate that a groin lump is not a hernia?
multiple lumps; lymphadenopathy hard/nodular consistency; malignancy able to get above the lump; scrotal mass transillumination; hydrocoele bruits on auscultation; arteriovenous malformation
how does the position of a hernia help differentiate from different subtypes?
above and medial to the pubic tubercle; inguinal
below and lateral to the pubic tubercle; femoral
how does reducibility of a hernia help differentiate from different subtypes?
reducible; can be flattened by changes in position or application of pressure
supine; observe spontaneous reducibility
manually reduce it with your fingers
reappear; standing, cough, remove pressure
urgent surgical review; tender, irreducible, may be strangulated
how do you determine if an inguinal hernia is direct or indirect?
locate the deep inguinal ring
manually reduce the hernia; press from the inferior aspect to the deep inguinal ring
once reduced; apply pressure over the deep inguinal ring and cough
reappears; direct inguinal hernia
does not reappear; indirect inguinal hernia
describe inguinal hernias
protrusion of abdominal contents
emerges at the superficial inguinal ring
most commonly superomedial to the pubic tubercle
describe femoral hernias
occur just below the femoral ligament
naturally occurring weakness in the abdominal wall; femoral canal
higher risk of strangulation and obstruction
usually inferolateral to the pubic tubercle and medial to the femoral pulse
describe umbilical hernias
occur at the umbilicus
common
can be large
low risk of strangulation
describe incisional hernias
occur at the sites of pervious operations/surgical incisions
tissue integrity has been compromised
describe a scrotal examination in a hernia exam
palpation of the scrotum; if a scrotal mass is seen, with the patients consent
inguinal hernia in the scrotum; will not be able to get above the mass
describe a stoma examination
introduction stoma assessment; site number of lumens spout effluent surrounding skin complications complete examination
what should be done in the introduction of a stoma exam?
wash hands
introduce
patient details
explain
expose abdomen
position the patient laying flat on the bed
ask if they have had any pain or recent changes in their stoma
describe the site of a stoma
colostomies; LIF
ileostomies; RIF
describe the number of lumens of a stoma
1 in RIF; end ileostomy or urostomy
1 in LIF; end colostomy
2 in RIF; loop ileostomy
2 in LIF; loop colostomy
describe the spouts of a stoma
present; ileostomy/urostomy
absent; colostomy
prevent skin irritations
describe the effluent of a stoma
semisolid faecal effluent; colostomy
liquid faecal effluent; ileostomy
urine; urostomy
describe the surrounding skin of a stoma
inspect for erythema, tissue breakdown, fistulation
what are the complications of a stoma?
parastomal hernia; reducible mass
infarction; necrosis, pain
prolapse; appears longer, increases when coughing or straining
retraction; skins below the level of the skin
haemorrhage
what should be done to complete a stoma examination?
thank patient
wash hands
summarise findings
full abdominal examination
what should be done to complete a hernia examination?
thank patient wash hands summarise findings testicular examination abdominal examination inguinal lymph node assessment
describe the steps of a rectal exam
introduction patient position inspection of anal area; bear down palpation; clench inspection of gloved finger conclusion; clean area
how should a patient be positioned in a rectal exam?
left lateral position
hips and knees well flexed
buttocks at the edge of the bed
what are you looking for in the inspection of the anal area?
inspect the anus and the perianal area; separate the buttock
skin tags; crohn’s
anall fissure
fistula-in-ano; red spouting area, in ulcerative colitis
anal warts
external piles
anal carcinoma; fumigating mass at the anal verge
pruritus ani; red, weeping, excoriated area
ask the patient to bear down; rectal prolapse
describe palpation in a rectal exam
lubricate index finger of right hand
place finger on anal verge and tell them you are going to insert finger
feel anterior, posterior and lateral aspects
men anteriorly; prostate
women anteriorly; cervix
ask patient to clench on finger; tests degree of anal tone
what are you looking for when feeling the prostate?
size; small, medium, large consistency; soft, firm, hard surface; smooth, irregular lobes; symmetrical, asymmetrical sulcus; present, absent
what are you looking for when feeling the cervix?
masses
tenderness
abnormal indentations
what are you looking for when inspecting the finger after removed from the rectum?
bright blood melaena mucous pus colour of faeces
describe the introduction of a rectal examination
wash hands introduce yourself identify patient gather equipment explain procedure and gain consent ask for a chaperone
describe the steps of abdominal x-ray interpretation
confirm details assess image type and quality; projection, exposure bowels and other organs bones calcification and artefact present the x-ray
what are you looking for when assessing the image type and quality?
projection; AP supine or AP erect
exposure; from diaphragm to pelvis, view both small and large bowel
CXR required for small bowel perforation; free gas under the diaphragm
what are you looking for the in bowels and other organs section of the abdominal x-ray interpretation?
differentiate between the small and large bowel
bowel diameter; small bowel 3cm, large bowel 6cm, caecum 9cm
small bowel obstruction
large bowel obstruction
rigler’s (double wall) sign
inflammatory bowel disease
other organs and structures
how do you differentiate between the small and lower bowel on an abdominal x-ray?
small bowel; central, large bowel frames it
valvulae conniventes; mucosal folds of the small bowel, cross the full width
haustra; large bowel pouches, not do completely transverse
describe the features of small bowel obstruction on an abdominal x-ray
dilatation >3cm
prominent valvulae conniventes; coiled spring appearance
causes; adhesion, abdominal hernias, intrinsic or extrinsic compression by neoplastic masses
describe the features of large bowel obstruction on an abdominal x-ray
sigmoid volvulus; coffee bean appearance
caecal volvulus; fetal appearance
causes; colorectal carcinoma, diverticular strictures, hernias, volvulus
describe rigler’s sign on an abdominal x-ray
both sides of the bowel wall become visible; pneumoperitoneum
free air under diaphragm on erect CXR
causes; perforated bowel, perforated duodenal ulcer, recent abdominal surgery
what are the features of inflammatory bowel disease on an abdominal x-ray?
thumb printing; mucosal thickening of the haustra due to inflammation and oedema
lead pipe colon; loss of normal haustra markings, chronic colitis
toxic megacolon; chronic dilatation without obstruction, colitis
describe the important features of other organs and structures on an abdominal x-ray
lungs; basal pneumonia can cause abdominal pain
liver
gallbladder; calcified gallstones, cholecystectomy clips
stomach
psoas muscle
kidney
spleen; LUQ, superior to left kidney
bladder; variable appearance depending on fullness
what are the bony structures usually visible on an abdominal x-ray?
ribs lumbar vertebrae sacrum coccyx pelvis proximal femurs
fractures, osteoarthritis, Paget’s disease, bony metastases
what are the causes of calcification or artefact on an abdominal x-ray?
calcified gallstones; RUQ renal stones, staghorn caliculi pancreatic calcification vascular calcification costochondral calcification contrast; following barium surgical clips jewellery; belly button rings
what questions should be asked in the presenting complaint of a urinary history?
hesitancy poor stream incomplete emptying terminal dribbling urgency frequency nocturia incontinence; stress, urge dysuria loin/back pain fever/rigors haematuria cloudy/malodorous urine polyuria anuria/oliguria sexual history
describe the symptoms and causes of urinary voiding problems
hesitancy
poor stream; stops and starts, stops completely, irritative, voiding dysfunction
incomplete bladder emptying
terminal dribbling
bladder outflow obstruction; BPH, stricture, meatal stenosis
describe the symptoms and causes of urinary storage problems
urgency frequency nocturia incontinence; stress incontinence, incontinence pads, volume, at night, after voiding urge incontinence
overactive bladder, BPH
what are the symptoms of renal disease
tiredness dyspnoea on exertion; anaemia, pulmonary oedema chest pain; anaemia, pericarditis nausea and vomiting ankle oedema abdominal swelling; ascites pruritius bone pain thirst
what questions should be asked during the past medical history of a urinary history?
neurology; MS, cerebrovascular disease HTN diabetes previous surgery; for urinary incontinence in women and prostatic hypertrophy in men, ureteric injury obstetric history
