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Phase 2B Examination Findings > GI > Flashcards

GI Flashcards

(49 cards)

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1
Q

Personal framework for a history?

A

Intro, PC, HPC, PRRRIC(E)= previous episodes, home remedies(or part of E in SOCRATES, risk factors, red flags, ideas, concerns, expectations, summarise and signpost, PMH- might ask about previous episodes, DH/ allergies, FH(expectations,) SH, E, summarise

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2
Q

PMHx for GI?

A

Previous GI problems, diagnoses/ treatments, previous surgery, gynae problems, urological problems, jaundice, anaemia, diabetes, malignancy
e.g. jaundice- past liver problems, anaemia= red flag, diabetic- continuous vomiting–> DKA?

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3
Q

Drug history(+ allergies)?

A

Recent change in meds? Recent course of ABs- c.difficile? Use of laxatives? Loperamide? Gaviscon? PPIs? NSAIDs- ulcers? Fe tablets- dark stool? Opiates- slower GI motility? Anticoagulants- increased risk of bleeding?

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4
Q

Social history?

A

Smoking, drinking, diet- recent meals, changes of diet, contact with someone with the same symptoms, recent travel

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5
Q

FHx? RFs?

A

Carcinomas? IBD? Malabsorption syndromes? Arthritis?
Smoking, recent dodgy takeaway
NSAID= peptic ulcer

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6
Q

GI presenting complaints?

A

Swallowing issues- dysphagia, feeling sick/ vomiting- nausea, indigestion- dyspepsia, abdominal pain, going yellow- jaundice, constipation/diarrhoea, blood in stool- melena?, weight loss

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7
Q

3 dysphagia types? Other Qs?

A

Dysphagia- difficulty swallowing, odynophagia- painful swallowing- oesophageal candidiasis, ulcers and growths, globus= lump in the throat, site- where is food getting stuck(in pharynx- might be NM, halfway down= carcinoma more likely,) onset= immediate, days to weeks/ months
Character= solids/ solids and liquids? (from solids–> solids and liquids= big red flag- growing tumour

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8
Q

More SOCRATES dysphagia?

A

Associated symptoms- reflux/ dyspepsia (chronic dyspepsia= oesophageal cancer, night time coughing- reflux at night; neuro issues, night time coughing/ dyspnoea, symptoms of neuro conditions
Timing- continuous/ intermittent, lasts how long, progressing, between meals= psychological cause
Exacerbating factors/ relieving- better/ worse after first few swallows
Severity- how affecting them?

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9
Q

PRRRICE? Red flags?

A

Anything like this before? Any diagnosis/ treatment?
Taken anything and if it helped or not? RFs?
Patient ideas and concerns
If carcinoma suspected- smoke/ drink, don’t wait until social hx
Reel off–> fatigue, anaemia, weight loss, appetite, blood in stool, fevers, night sweats, change in bowel habit?

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10
Q

Right iliac fossa pain? Left iliac fossa? Suprapubic? Flank? Epigastric? Right upper quadrant/ epigastric?

A 
Appendicitis, Crohn's 
Diverticulitis
Cystitis 
Pyelonephritis 
Peptic ulcer, pancreatitis 
Cholecystitis, hepatitis
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11
Q

Acute/ gradual onset pain, with remissions for weeks/ months? Sudden/ gradual? Constant with unpredictable periodicity? Acute?

A

Peptic ulcer
Pancreatitis
Cholecystitis
Diverticulitis, appendicitis

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12
Q

Gnawing pain? Sharp/ stabbing? Sharp/ colicy? Sharp/ burning? Dull ache/ cramping?

A 
Ulcer 
Appendicitis 
Cholecystitis 
Pancreatitis 
IBD
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13
Q

Radiation to the back? Right scapula? Development to widespread/ global pain?

A

Ulcer/ pancreatitis
Cholecystitis/ ectopic pregnancy
Pancreatitis, possibly diverticulitis

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14
Q

Associated symptoms examples?

A

Vomiting, fever, rigors, jaundice (cholecystitis)

Vomiting/ nausea, distension, shock (pancreatitis)

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15
Q

Intermittent pain? Continuous? 0.5-3 hours? 3-24 hours? 24+ hours?

A 
Renal colic, biliary colic, obstruction 
Itis 
Ulcer 
Cholecystitis 
Pancreatitis
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16
Q

Exacerbating and alleviating factors?

A

Hunger/ eating, spicy food, smoking/ alcohol, NSAIDs, fatty food
Eating, antacids, vomiting, leaning forwards

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17
Q

Mild to moderate, severe and very severe pain?

A

Ulcer
Cholecystitis
Pancreatitis

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18
Q

Dyspepsia red flags ALARM?

A

Anaemia, loss of weight, anorexia, recent onset, progressive, melena/ haematemesis, swallowing difficulty
>55 y/o–> upper GI endoscopy

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19
Q

Causes of acute pancreatitis?

A

Idiopathic, gallstones, ethanol, trauma, steroids, mumps, AI, scorpions, hyperlipidaemia, ERCP, drugs

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20
Q

Features of diarrhoea?

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A

Frequency, consistency, colour, incontinence, urgency, does it float/ smell bad, mucus, blood/pus, associated pain/ discomfort, travel, food/ ABs
Black= upper GI bleed, pain relieved by defecation= IBS, diarrhoea alternating with constipation= IBS, mucus= IBD, smell/ floating= coeliac

21
Q

DDx in the young? Older?

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A

Infective, IBS, coeliac disease, IBD, medication, hyperthyroidism

Neoplastic, diverticular disease, overflow secondary to constipation, medications, IBD- bimodal incidence

22
Q

Constipation features?

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A

Duration, is it absolute? Pain? Change in diet? Change in medication?

23
Q

DDx for melena? Fresher blood?

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A

Oesophageal varices, haemorrhagic peptic ulder, proximal polyp/ cancer, haemorrhagic infective GE
IBD, distal polyp/ cancer, diverticular haemorrhage, haemorrhoids, anal fissure

24
Q

Intro to GI exam?

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A

Wash hands, introduce, confirm patient, explain, consent, expose: general inspection of arms, face and chest before having feel in various areas of your tummy and listening with steth, chaperone, any pain?

25
What to inspect from bedside for?
Feeding tubes/ stoma bags/drains, general appearance; pain, agitation, confusion, body habitus; obese/ wasting, colour; obvious pallor= anaemia(GI bleed, jaundice (cirrhosis/ hepatitis)
26
What to look for palms down?
Clubbing= hepatic cirrhosis, IBD, coealic disease Koilnychia- chronic iron deficiency Leukonychia- patches= normal in minor trauma but striae affecting all nail beds can occur post chemo (totalis= hypoalbuminaemia caused by liver failure/ nephrotic syndrome/ protein malabsorption/ protein- losing enteropathies) Asterixis/ liver flap- coarse flapping tremor= liver failure with failure of ammonia metabolism to urea(hepatic encephalopathy), renal failure/ CO2 retention
27
Palms up?
Temperature, Dupuytren's contracture- fibrosis and shortening of palmar aponeurosis- alcoholism/ liver disease, pulse
28
Arms?
Bruising- abnormal coagulation- liver failure Petechiae- low platelets e.g. splenomegaly Scratch marks- pruritus- cholestasis Track marks- IVDU (hepatitis)
29
Axillae?
Lymphadenopathy- malignancy/ infection Hair loss- malnourishment/ iron deficiency anaemia Acanthosis nigricans- hyperpigmentation seen in GI adenocarcinomas/ obesity
30
Things to inspect on face? Eyes?
Eyes, face, mouth+ chest wall and posterior abdominal wall Xanthelasma- hypercholesterolaemia, Corneal arcus- hypercholesterolaemia, Scleral jaundice- haemolysis/ hepaitis/ cirrhosis/ biliary obstruction, Conjunctival pallor- anaemia, Kayser-Fleischer rings- Wilson's disease
31
Face? Mouth?
Telangiectasia- face, oral mucosa, GI tract, lungs, liver and brain--> recurrent haemorrhage Pigmentation- Peutz- Jegher syndrome ass with small bowel hamartomas Angular stomatitis- vitamin B12, folate/ iron deficiency Glossitis- painful= vitamin B12/ folate deficiency, painless= iron deficiency Oral candidiasis(white slough)= iron deficiency/ immunodeficiency Dehydration Halitosis(bad breath), dental caries, ulcers- vit B12/ iron deficiency, Crohn's, coeliac
32
Chest wall and posterior abdominal wall?
Spider naevi> 5= significant+ ass with chronic liver disease, gynaecomastia- liver failure, digoxin/ spironolactone Hair loss- malnourishent/ iron deficient anaemia Scars, swelling
33
Lymph nodes?
Cervical= infection/ metastatic malignancy | Left SC fossa for Virchow's node- gastric malignancy
34
Inspect for what on abdomen?
Shape and symmetry, visible peristalsis, scars; weight loss, gain+ striae, lesions Stomas; LIF= colostomy, RIF= ileostomy, RIF+ urine= urostomy Movement during breathing- diaphragmatic ceases with acute peritonitis Bruising from retroperitoneal bleed; Cullen's= umbilical? pancreatitis/ ruptured AAA, Grey Turner's= flanks? pancreatitis/ ruptured AAA Visible swellings/ masses- organomegaly/ malignancy Visible aortic pulsation- central and expansile- AAA? Distended veins; engorged paraumbilical veins (caput medusae)= portal HTN Abdominal distension(5Fs): fluid(ascites,) faeces(constipation,) flatus (subacute intestinal obstruction,) foetus(pregnancy,) fat(obesity)
35
How to palpate the abdomen?
Ask about any areas of pain and examine these last Kneel so you're level with the patient Observe the patient's face throughout for discomfort Light palpation of 9 regions, then deep palpation, liver palpation, Murphy's sign, spleen palpation, kidney ballotment, bladder, aorta
36
Light palpation for what?
Tenderness- areas and severity Rebound tenderness- worsened on releasing pressure= peritonitis Guarding- localised/ generalised Masses- large/ superficial may be noted
37
During deep palpation and mass if felt, ask patient to do what?
Raise head and shoulders off the pillow as masses become prominent when recti are contracted Assess location, size, shape, consistency, mobility+ pulsatility Stomach distended---> succession splash(shake briskly side to side+ listen for sloshing)
38
How to palpate the liver?
Start in RIF, take deep breaths On exhalation, hand feels for a 'step' as liver edge passes under hand Repeat 1-2cm closer to right hypochondrium if nothing felt Normally felt up to 1cm below right costal margin on deep inspiration If felt, note: degree of extension below costal margin, consistency of liver edge, tenderness= hepatitis, pulsatility= pulsatile enlarged liver can be caused by tricuspid regurgitation
39
How to test Murphy's sign?
Breathe out, then gently place hand below right costal margin in mid-clavicular line If inspiration is prevented by inflamed gallbladder coming into contact with fingers= +ve Requires no pain when performed on left side +ve= acute cholecystitis
40
How to palpate spleen?
Start in RIF, take deep breaths, on exhalation, hand palpates deeply to feel for step as splenic edge passes under hand, repeat 1-2cm closer to left hypochondrium if nothing felt
41
How to ballot kidneys?
Place left hand behind patient's back at right flank, right hand just below costal margin at right flank, press right hand's fingers deep into abdomen whilst pressing upwards with left hand Repeat on left kidney Right may be palpable in thin, normal people, left= rarely palpable
42
How to palpate bladder?
Suprapubic region- empty= not palpable | Enlarged= can be felt arising from behind pubic symphysis and will make patient want to urinate?= urinary retention
43
How to palpate aorta?
Using fingers of both hands, just above umbilicus at border of aortic pulsation Upwards= pulsatile, outward= expansile(AAA)
44
How to percuss liver?
Up from RIF from resonant to dull, down from right chest to determine size, normal= just below nipple line
45
Percuss spleen? Bladder?
Up from RIF moving towards left hypochondrium | Suprapubic region-dull= bladder
46
If ascites suspected, test for shifting dullness?
From centre towards left flank If dull heard, keep finger in position and ask patient to roll onto right side, wait 10 seconds and percuss, if resonant, percuss back towards umbilicus until becomes dull as dullness as shifted +ve so ascites
47
What to auscultate for?
Bowel sound- present and normal= gurgling, abnormal= tinkling(bowel obstruction,) absent(ileus/ perionitis) Bruits- aortic= just above umbilicus= AAA Renal= just above umbilicus laterally Femoral= just above medial thigh
48
Further assessments?
ISHRUG= inguinal lymph nodes, stool sample, femoral and inguinal hernial orifices, rectal exam, urinalysis, external genitalia
49
Kochers scar? Midline? Lanz incision? Groin incision? Left paramedian? Pfannenstiel? Vertical groin incision?
``` Cholecystectomy AAA, laparotomy Appendectomy Inguinal hernia Colectomy Cystectomy, prostatectomy Femoral artery embolectomy ```

Phase 2B Examination Findings (8 decks)

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