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Phase 2B Examination Findings > GI > Flashcards

GI Flashcards

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?

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?

A

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

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

22
Q

Constipation features?

A

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

23
Q

DDx for melena? Fresher blood?

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?

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
Q

What to inspect from bedside for?

A

Feeding tubes/ stoma bags/drains, general appearance; pain, agitation, confusion, body habitus; obese/ wasting, colour; obvious pallor= anaemia(GI bleed, jaundice (cirrhosis/ hepatitis)

26
Q

What to look for palms down?

A

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
Q

Palms up?

A

Temperature, Dupuytren’s contracture- fibrosis and shortening of palmar aponeurosis- alcoholism/ liver disease, pulse

28
Q

Arms?

A

Bruising- abnormal coagulation- liver failure
Petechiae- low platelets e.g. splenomegaly
Scratch marks- pruritus- cholestasis
Track marks- IVDU (hepatitis)

29
Q

Axillae?

A

Lymphadenopathy- malignancy/ infection
Hair loss- malnourishment/ iron deficiency anaemia
Acanthosis nigricans- hyperpigmentation seen in GI adenocarcinomas/ obesity

30
Q

Things to inspect on face? Eyes?

A

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
Q

Face? Mouth?

A

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
Q

Chest wall and posterior abdominal wall?

A

Spider naevi> 5= significant+ ass with chronic liver disease, gynaecomastia- liver failure, digoxin/ spironolactone
Hair loss- malnourishent/ iron deficient anaemia

Scars, swelling

33
Q

Lymph nodes?

A

Cervical= infection/ metastatic malignancy

Left SC fossa for Virchow’s node- gastric malignancy

34
Q

Inspect for what on abdomen?

A

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
Q

How to palpate the abdomen?

A

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
Q

Light palpation for what?

A

Tenderness- areas and severity
Rebound tenderness- worsened on releasing pressure= peritonitis
Guarding- localised/ generalised
Masses- large/ superficial may be noted

37
Q

During deep palpation and mass if felt, ask patient to do what?

A

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
Q

How to palpate the liver?

A

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
Q

How to test Murphy’s sign?

A

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
Q

How to palpate spleen?

A

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
Q

How to ballot kidneys?

A

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
Q

How to palpate bladder?

A

Suprapubic region- empty= not palpable

Enlarged= can be felt arising from behind pubic symphysis and will make patient want to urinate?= urinary retention

43
Q

How to palpate aorta?

A

Using fingers of both hands, just above umbilicus at border of aortic pulsation
Upwards= pulsatile, outward= expansile(AAA)

44
Q

How to percuss liver?

A

Up from RIF from resonant to dull, down from right chest to determine size, normal= just below nipple line

45
Q

Percuss spleen? Bladder?

A

Up from RIF moving towards left hypochondrium

Suprapubic region-dull= bladder

46
Q

If ascites suspected, test for shifting dullness?

A

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
Q

What to auscultate for?

A

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
Q

Further assessments?

A

ISHRUG= inguinal lymph nodes, stool sample, femoral and inguinal hernial orifices, rectal exam, urinalysis, external genitalia

49
Q

Kochers scar? Midline? Lanz incision? Groin incision? Left paramedian? Pfannenstiel? Vertical groin incision?

A 
Cholecystectomy
AAA, laparotomy 
Appendectomy 
Inguinal hernia 
Colectomy 
Cystectomy, prostatectomy
Femoral artery embolectomy

Phase 2B Examination Findings (8 decks)

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