GI Examination Flashcards
Before examination
- Correct hand hygiene
- PPE
- introduce yourself
- Identify patient and gain consent
How should the patient be positioned?
- Positioned lying down flat with arms by side to relax abdominal muscles
- Shirt removed for inspection of abdomen and chest
Observation
- Demeanour (in pain/ cachexia/ muscle wasting)
- Colour
- Nutritional state
- Bruising
- Scratch marks
- Medical appliances ( IV cannulas and infusions noted)
Hand Inspection
-Clubbing (inflammatory bowel disease and cirrhosis)
-Leukonychia (horizontal white bands under fingernails)
-Palmar erythema
==liver cirrhosis
-Dupuytren’s contracture (nodular thickening of connective tissue in palm of hand, easily felt than seen in early stages, lead to fixed flexion of ring and pinky finger= vibrating tools, excess alcohol))
-Asterixis (bilateral flapping tremor, wrists extended, jerking with exaggerated movement= metabolic encephalopathies with liver cirrhosis and CO2 retention)
Face Inspection
- Scleral jaundice (pull down eyelid)
- Xanthelasma (yellowish deposits around eyelids= primary biliary cirrhosis)
- Conjunctival pallor (anaemia)
- Mouth ulcers (Crohn’s/ coeliac)
- Perioral pigmentation (multiple intestinal polyps in Peutz-Jeghers Syndrome)
- Telangiectasia on lips and nose= GI bleeding/ HHT
Chest Inspection
-Spider Naevi (abnormal dilated blood vessels appearing as red spots, pressure blanches, refills from centre outwards, more than 3 in liver cirrhosis, pregnancy)
-Gynaecomastia
-Axillary hair loss
==liver cirrhosis
-Supraclavicular lymph node (left drains thoracic duct so whole abdomen, enlarged in intrabdominal malignancy)
Abdomen Inspection
-Scars (midline laparotomy, RUQ cholecystectomy, R iliac fossa Appendiscectomy, extending around flank Nephrectomy, several small keyhole Laparoscopic)
=Mercedes Benz scar for liver transplant
=Pfannensteil incision for obstetric/ gynaecological surgery (U at lower belly)
-Stomas
-Distention
-Masses
-Visible veins (portal hypertension/ obstruction of vena cava)
=Caput medusa
-Abdominal movement
*end of bed/ side/ squat so level with abdomen with deep breaths)
The Quadrants
- Epigastrium, L+R hypochondrium
- Central periumbilical, L+R lumbar region
- Suprapubic region, L+R iliac fossa
Abdomen palpitation
-Superficial (watch face for signs of pain, softness, abnormal masses, areas of tenderness)
-Deep (masses)
-Organomegaly (liver, spleen and kidneys)
=Systematic way, clockwise, examine painful area last
Liver Organomegaly
- Located under rib cage on RHS side
- Enlarges towards R iliac fossa
- Start at level of umbilicus and parallel to anticipated liver edge
- As patient breathes in, press firmly
- As liver descends, felt as light tap at side of index finger
- Move up towards costal margin/ follow contour to midline to follow extent
-Percuss to define upper and lower borders of liver
=palpable liver either enlarged or pushed down by hyper-inflated lungs
=Usually resonate, enlarged liver is dull (resonate to dull)
-Start below liver, dull note lower margin, down from sternal angle for upper margin (6th rib anteriorly)
Spleen Organomegaly
- Under rib cage on left, enlarges towards right iliac fossa
- Start at level of umbilicus, directed hand towards LUQ
- If not palpable, roll to right side
- Use left hand to support rib cage, right hand to palpate, percussion if enlarged spleen suspected (not routine)
Kidney Organomegaly
- For right kidney, left hand under patient in flank region and right hand on top
- Push down on right hand, flick left briskly to feel kidney between hands
Percussion
-Liver
-Spleen
-Bladder
-Shifting dullness (ascites)
=percuss from midline away (until dull)
=Hold finger in same position and roll patient away
=Percuss again, if transition point has moved, suggests presence of free moving fluid
Fluid thrill
- For suspected ascites
- Ask patient to press firmly in midline to prevent wave transmitting through fat
- Tap flank firmly with fingertips, feel for transmitted impulse in other flank (easily palpable= ascites)
Auscultation
-Bowel sounds
=frequency and character
=Diminished or absent- peritonitis
=Frequent high pitched tinkling sounds- intestinal obstruction
-Bruits
=enlarged liver (tumours, alcoholic hepatitis)
=Listen to heart to exclude transmitted sounds from cardiac murmur
