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Physical examination 2B > GI Examination > Flashcards

GI Examination Flashcards

1
Q

What are the introductory steps to a GI examination?

A
  • Wash hands.
  • Put on PPE.
  • Introduce yourself to the patient.
  • Confirm patient’s name and DOB.
  • Explain the examination (especially what parts of the body will need exposing).
  • Obtain consent from the patient.
  • Offer presence of a chaperone.
  • Adjust bed head to 45.
  • Ask if the patient has any pain anywhere.
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2
Q

What comes after introduction in a GI examination?

A

General inspection:
- Inspect the area around the bed for relevant objects/equipment.
- Inspect the patient from the end of the bed.

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3
Q

What signs of GI disease can be picked up from examining the patient at the end of the bed?

A
  • Colour (Jaundice? Pallor?)
  • Perspiration (Fever?)
  • Build? (Muscle wasting/obesity?)
  • Discomfort?
  • Breathing? (Resp. rate? Depth of breath? Resp. effort?)
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4
Q

What comes after general inspection in a GI examination?

A

Inspection of the hands

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5
Q

What can be picked up from inspection of the hands?

A

Colour? (pallor, erythema)
Clubbing?
Leukonychia/leukonychia totalis?
Koilonychia? (nail spooning)
Spider naevi?
Dupuytren’s contracture?

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6
Q

What comes after general inspection of the hands?

A

Palpation of the hands

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7
Q

What does palpation of the hands entail?

A

Assess temperature of both hands simultaneously using the backs of your own hands.

Feel for symmetrical warmth.

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8
Q

What comes after palpation of the hands?

A

Flapping tremor test.

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9
Q

How is the flapping tremor test carried out?

A

Patient holds hands out in front with wrists and elbows extended.

Observe for “flapping tremor” approx 10 seconds.

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10
Q

What comes after the flapping tremor test?

A

Inspection of the forearms.

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11
Q

What can be picked up from inspection of the forearms?

A
  • Pruritus.
  • Muscle wasting.
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12
Q

What comes after inspection of the forearms?

A

Assessment of the pulse.

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13
Q

How is the pulse assessed?

A

Assess the radial pulse for 10-15 seconds. Assess rate, rhythm and character.

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14
Q

What comes after assessment of the pulse?

A

Inspection of the face.

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15
Q

What can inspection of the face pick up on?

A

Eyes:
- Kaiser-Fleischer rings (Wilsons)
- Corneal arcus (High BP, high cholesterol etc.)
- Xanthelasma (High cholesterol)
- Conjunctival pallor
- Conjunctival jaundice

Mouth:
- Dental hygiene.
- Plaque (potentially frequent vomiting)
- Pallor
- Dry mouth
- Angular stomatitis
- Glossitis
- Ulceration

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16
Q

What comes after inspection of the face?

A

Palpation of the lymph nodes.

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17
Q

Which node is specifically important when palpating the lymph nodes?

A
  • Left supracalvicular node.
  • Swelling in this node is a sign of intra-abdominal malignancy (Trosier’s sign)
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18
Q

What comes after palpation of the lymph nodes?

A

Inspection of the chest wall.

19
Q

What can be picked up on from chest examination?

A
  • Male gynaecomastia. (Liver failure?)
  • Spider naevi (Liver disease - will usually be more than 3, itchy and/or burning).
20
Q

What comes after examination of the chest?

A

Back examination.
Ask the patient to sit forwards if they are able.

21
Q

What can be picked up from examination of the back?

A
  • Surgical scars.
  • Swellings.
  • Spider naevi.
22
Q

What comes after inspection of the back?

A

Inspection of the abdomen.

23
Q

What can be picked up on from abdominal inspection?

A
  • Surgical scars.
  • Lesions.
  • Loose skin/ striations.
  • Distension (5 F’s: Fat, foetus, flatus, faeces, fluid; is it symmetrical distension?).
  • Breathing (should be diaphragmatic).
  • Visible masses/swellings.
  • Visible peristalsis (blockage?)
  • Visible aortic pulsation (Usually benign in skinny people, can be triple A).
  • Dilated veins (suggestive of portal HTN or LHF).
24
Q

What comes after abdominal inspection?

A

General abdominal palpation.

25
Q

How is general abdominal palpation carried out? What can be picked up on?

A
  • Palpate each of the nine sections of the abdomen lightly to assess for tenderness/firmness.
  • Palpate each section of the abdomen more deeply to assess for any underlying masses.
  • Look at the patients face whilst doing this to assess for any discomfort/tenderness.

NOTE: Ask the patient beforehand if there is any tenderness anywhere - if there is, palpate this part last.

26
Q

What comes after general abdominal palpation?

A

Specific palpations of the abdomen.

27
Q

What are the different specific things that can be palpated in the abdomen?

A
  • Succussion splash.
  • Liver palpation (+murphys sign?)
  • Spleen palpation.
  • Kidney balloting.
  • Bladder palpation (Not performed in OSCE but mention).
  • Aorta palpation.
28
Q

How/when is a succussion splash performed?

A

If patient has suspected ascites.

Shake the stomach rapidly from side to side and listen for a sloshing sound, indicative of fluid.

29
Q

How is the liver palpated? How is Murphy’s sign elicited.

A
  • Get patient to breathe deeply in and out.
  • Starting at the RIF, as they breathe in press firmly with the border of your hand into the abdomen to try and palpate a liver.
  • When they breathe out, reposition the hand more superiorly.
  • Keep repeating the process until a liver border is palpated or until the costal margin is reached.
  • Murphy’s sign +ve: Palpate deeply in the RUQ and get the patient to breathe deeply. A sudden stop of breathing due to pain is Murphy’s +ve, indicative of cholecystitis.
30
Q

How is the spleen palpated?

A
  • Get patient to breathe deeply in and out.
  • Same process as with the liver, except from RIF up to LUQ.
  • In a normal patient, the spleen should not be palpable.
31
Q

How are the kidneys balloted?

A
  • Place one hand anteriorly and palpate deeply in the RUQ/LUQ of the abdomen.
  • Place one hand posteriorly behind the kidney.
  • Use the posterior hand to “flick” the kidney upwards.
  • Normally, kidneys are not palpable. They might be felt in skinnier patients or those with swollen kidneys.
32
Q

How is the bladder palpated?

A
  • Warn the patient they may feel the urge to urinate.
  • Palpate suprapubically.
  • In a normal patient bladder should not be palpable.
33
Q

How is the aorta palpated?

A
  • Palpate with both hands symmetrically just superiorly either side of the umbilicus.
  • Normally, the hands should move up and down with aortic pulsations.
  • If the hands move in and out, suggestive of triple A.
    NOTE: Aorta may not be palpable in larger patients.
34
Q

What comes after specific abdominal palpation?

A

Percussion of the abdominal organs.

35
Q

How are the different abdominal organs percussed?

A

Percuss for the liver:
- From the lungs down - listen for resonant to dull change for upper border.
- From the RIF up - listen for resonant to dull change for lower border.

Percuss for the spleen:
- From RIF towards the LUQ.
- Normally, spleen cannot be percussed.

Percuss for the bladder:
- Percuss from umbilical cord towards the pubic symphysis.
- Resonant to dull change suggests the upper border of the bladder has been met.

36
Q

What comes after percussion of the abdominal organs?

A

Shifting dullness percussion.

37
Q

How is shifting dullness percussion carried out?

A
  • Percuss from the umbilical of the patient towards the left flank, listening for change from resonant to dull.
  • If dull note heard, roll patient towards you (onto their right hand side) whilst keeping percussing hand in place.
  • Wait 10 seconds for the fluid to redistribute, then percuss again in the same place. Listen for a resonant sound.
  • Percuss back in towards the umbilicus, listening for a now dull sound.
  • If a dull sound is then heard more medially, this is +ve for shifting dullness and indicative of ascites.
38
Q

What comes after shifting dullness percussion?

A

Auscultation of the abdomen.

39
Q

How is the abdomen auscultated?

A
  • Listen for bowel sounds in at least two places on the abdomen.
  • Listen to the aorta either side, approx. 1-2cm above the umbilicus.
  • On the same level as listening to the aorta, but in the mid-clavicular line, listen to the renal arteries.
40
Q

What comes auscultation of the abdomen?

A

Concluding the examination with the patient.

41
Q

How is the examination concluded with the patient?

A
  • Thank the patient for their time.
  • Ask them to redress (ask if they need any help?)
42
Q

What comes after concluding the examination with the patient?

A

Concluding the examination with the examiner.

43
Q

How should the examination be concluded with the examiner?

A
  • Wash hands.
  • Report key findings back.
  • List ISHRUG for further investigations.
44
Q

What is ISHRUG?

A

I - Inguinal lymph node palpation.
S - Stool sample (both visual and micro).
H - Hernial orifices palpation (inguinal and femoral).
R - Rectal examination.
U - Urinalysis.
G - Genital examination.

Physical examination 2B (13 decks)

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