GI Examination Flashcards
What mnemonic is used to remember the causes of clubbing
CLUBBING
Name the causes of clubbing
C - cyanotic heart disease/cystic fibrosis
L - Lung cancer/lung abscess
U - Ulcerative colitis
B - Bronchiectasis
B - Benign mesothelioma
I - Infective endocarditis/idiopathic pulmonary fibrosis
N - Neurogenic tumours
G - Gastrointestinal disease
What are the GI causes of clubbing
Malnutrition - UC, chrons and coeliac
Cirrhosis
GI lymphoma
What sign is present in clubbing
Schamroth’s sign
Describe Schamroth’s sign
In clubbing - window obliterated as distal angle increases and becomes wider caused by uniform swelling
Summarise Dupuytren’s contractures
Development of cords within the palmar fascia leading to contracture and flexion deformity - often ring finger
Fibrosis and shortening of the palmar aponeurosis
Usually idiopathic or familial. Is a possible link to trauma, diabetes, epilepsy, alcoholism and liver disease
In a GI exam what is Dupuytren’s contracture a possible sign of
Excess alcohol
What are the possible causes of Dupuytren’s contractures
Excess alcohol
Manual work (vibrations)
Smoking (x3)
DM (1 in 5)
70% hereditary
Describe a liver flap
Asterixis
Metabolic encephalopathy
Cock hands backwards - 30 seconds
What is acanthosis nigricans a sign of
Insulin resistance
In a GI exam what is bruising a sign of
Synthetic liver failure
What is the key lymph node in a GI exam
Left supraclavicular node - marker of gastric cancer
What enlarged lymph node can be a marker of GI cancer
Left supraclavicular node
What is conjunctival pallor a sign on
Severe anaemia
Define conjunctival pallor
Paleness on anterior rim of conjunctiva
Describe Kayser Fleicher rings
Dark rings encircle the iris
Wilson’s disease - abnormal copper
Brown rings that encricle the iris - resulting from copper deposition.
Early stages is seen with a silt lamp - later can be seen with the naked eye
Define angular stomatitis
Inflammation around the corners of the mouth
Sore corners of mouth
May be caused by deficency of vitamin B6, B12, folate or iron
Define glossitis
Abnormal smooth red apparence of the tongue
Painless = iron de
Piandul glossitis = vitamin B12 or folate deficenct
What is glossitis associated with
Painful - Iron, B12, Folate deficiency - think malabsorption (IBD)
Painless - Iron deficency
What is oral candidiasis associated with
Immunosuppression
Define aphthous ulceration
Round/oval ulcers on mucus membrane inside the mouth
Name the causes of aphthous ulceration
Usually - Benign (stress, mechanical trauma)
Other - iron, B12, folate deficiency, chron’s disease
When would hyperpigmented macules on the face be seen
Peutz-Jeghers syndrome
Autosomal dominant genetic disorder = polyps in the GI tract
Associated with small bowel hamartomas
What is the cause of spider naevi
Increased levels of oestrogen
Name the causes of spider naevi
Liver cirrhosis
Normal in pregnancy and women taking oral contraceptive pill
What is the cause of gynaecomastia
enlarged breast tissue
Increased levels of oestrogen
Liver cirrhosis (liver failure)
Medications - digoxin, Spirolactone
When would you think spider naevi is caused by liver cirrhosis
> 5
Name 3 signs on the chest of increased oestrogen levels and what would this point towards
Spider naevi
Gynaecomastia
Decreased hair
Point towards liver cirrhosis
What are the causes of abdominal distension
6Fs
Fat, fluid, flatus, foetus, faeces, fulminant mass
What is the mnemonic for abdominal distension
6Fs
Fat, fluid, flatus, foetus, faeces, fulminant mass
Define caput medusae
Enlarged paraumbilical veins = portal hypertension (liver cirrhosis)
Name 2 late signs of haemorrhagic pancreatitis
Greys Turners sign
Cullens sign
Describe cullens sign
C bruising around umbilicus
Describe grey turners sign
T flank bruising
Name a stoma found on the right iliac fossa, spouted and liquid stool
Ileostomies
Name a stoma found on the right iliac fossa, spouted containing urine
Urostomies
What are the two types of stoma found on the right iliac fossa
Ileostomies
Urostomies
Name a stoma found on the left iliac fossa, flushed to the skin and containing stool
Colostomies
Why is a stoma spouted
Due to risk of damage to the skin if the contents make contact
Describe rebound tenderness
Wall compressed slowly
When released rapidly = sudden sharp pain
Non-specific. Unreliable
Describe voluntary guarding
Contraction of abdominal muscles in response to pain
Describe involuntary guarding
Involuntary tension of abdominal muscles occurring on palpitation of peritonitis
In what conditions may involuntary guarding be present
Appendicitis
Diverticulitis
Define Rovsing’s sign
Palpitation of left iliac fossa causes pain in right iliac fossa
Define Murphy’s sign
R. costal margin pain on deep inspiration causes halting on inspiration
Why does the Murphy’s sign occur
Gallbladder comes in contact with hand causing pain
Acute cholecystitis
Palpitation of the liver how far away from the liver suggests hepatomegaly
> 2cm
What does a nodular consistency of the edge of the liver indicate
Cirrhosis
What does hepatic tenderness suggest
Hepatitis or cholecystitis (may be gallbladder)
What is pulsatile hepatosmegaly caused by
Tricuspid regurgitation
On a GI exam is the gallbladder palpable
No
If palpable - enlargement secondary to biliary flow obstruction
What does tenderness of the gallbladder suggest
Cholecystitis
What does a distended painless gallbladder suggest
Pancreatic cancer
How does a gallbladder feel on palpitation
Palpitation at a r. costal margin in the mid-clavicular line
Well rounded mass that moves with respiration
Should a spleen be palpable on a GI examination
Healthy = not palpable
Palpable = 3x size
What level is bifurcation of the aorta
L4
What would pulsation of the bifurcation of the aorta on a GI examination suggest
Triple A
In a healthy person should the bladder be palpable
No
How do you percuss the spleen
RIF to left hypochondrium (left costal margin) whilst the patient takes deep breaths
When advance to the left costal margin - use right hand to palpate. Roll pateint slightly towards you - place left hand posterioly. This may bring a tip of a moderatley enlagred spleen towards you.
Only becomes palpable when 2-3x its normal size
How do you percuss the liver
RIF to right hypochondrium whilst taking a deep breath
Hand palpate deep feel for desceding edge being push down by diaphgram
Normal = liver palpate 1cm below the right costal margin on deep inspiration
Galllbladder = not usually palpable unless enlarged
How do you locate the liver by percussion
Move 1-2cm up until note changes from resonant to dull
Indicates the location of the lower liver border
How do you locate the spleen by percussion
Move 1-2cm until the note changes from resonant to dull - full inspiration then full expiration. Percuss area lowest intercostal space - 8th or 9th rib in left axillay line
Indicates location of the spleen
Should the spleen by able to be percussed on an abdominal exam
Healthy = not identifiable
Splenomegaly = identifiable
How do you percuss the bladder
Percuss downwards in the midline from umbilical region towards the pubic symphysis
What would a distended bladder feel like on percussion
Dull to percuss - allows approximate bladder’s upper border
When should shifting dullness be completed on an abdominal examination
Only if ascites
Describe how shifting dullness is examined
Percuss umbilical region to l. flank - dullness suggests the presence of ascites if fluid in the flank
Keep fingers where it became dull - ask to roll onto r. side (towards you for stability)
Keep patient there for 30 seconds - repeat percussion in same area
Describe what would be found on an abdominal examination if ascites where present
Area which was dull to percuss when laying down will be resonant when on side (dullness has shifted)
Describe the bowel sounds of a normal bowel
Gurgling every 6 seconds
Describe the sounds of a bowel obstruction
Tinkling bowel sounds
Describe the bowel sounds of an ileus (peristalsis)
Absent bowel sounds
How many minutes do you have to listen to bowel sounds to be confident of diagnosis
3 minutes
What do vascular bruits suggest
Turbulent blood flow
To find aortic bruits were do you auscultate
1-2cm superior to umbilicus - bruit associated with AAA
To find renal bruits were do you auscultate
1-2cm superior to umbilicus - slightly lateral to midline on each side
What is a renal bruit associated with
Renal artery stenosis
What Gi cause is associated with pitting oedema
Hypalbuminaemia due to liver cirrhosis (protein losing enteropathy)
What mnemonics is used to complete a GI examination
SHURG
Describe SHRUG
Stool sample
Hernia orifices (femoral and inguinal)
Rectal examination
Urinalysis
Genitals
+ inguinal lymph nodes
What does pallor of the palmar suggest
Anaemia
What is the cause of palmar erythema
Increased circulating oestrogens in liver failure
What are the different forms of leukonychia
Leukonychia partialis
Terry’s nails/leukonychia totalis
Leukoncyhia partialis - small isolated patches - seen on trauma. If striae effects all nails - chemotherapy
Leukonchia totalis - due to hypoalbuminae
Describe leukonychia partialis
Small isolated white patches or striae - normal in normal response to minor trauma to the germinal matrix
If affects all nails may be following a course of chemotherapy
Describe leukonychia totalis/Terry’s nails
Whitening of the entire nail occurring in hypoalbuminemia
Name the possible causes of leukonychia totalis/terry’s nails
Due to hypoalbuminemia
Nephrotic syndrome
Liver failure
Protein malabsorption
Protein-losing enteropathies
What is the formal name for spoon shaped nails and what is the cause
Koilonychia
Suggests chronic iron deficiency
Describe the examination of hands in a GI examination
Examine the front and back of the hands
Nails
Temperature
Asterixis
Pulse and BP
Forearms - muscle waiting and scratching
Describe how asterixis are investigated on a GI examination
Hyperextend wrists and maintain position for 15 seconds
Coarse flapping tremor suggests liver failure with failure of ammonia metabolism to urea
Can be seen in renal failure and respiratory failure in CO2 retention
In a GI examination what are you checking the forearms for
Muscle wasting
Scratches - suggestive of pruritis (itching)
What other name is given to asterixis
Liver flap
Name 5 things you are looking for on an eye examination
Jaundice
Subconjunctival pallor
Xanthelasma
Corneal arcus
Kayser-Fleischer rings
Define xanthelasma
Yellow bumps on or near eyelid caused by cholesterol deposits
Define corneal arcus
Lipid accumulate in peripheral cornea - forms grey ring around iris
In early stages of Kayser-Fleischer rings due to Wilson’s disease how are they best seen
Slit lamp
Define Telangiectasia
Small dilated blood vessels - looking on GI examination on the face
Name features that you would be looking for on a GI examination
Telangiectasia
Pigmentation
Angular stomatitis
Glossitis
Dehydration
Halitosis (bad breath)
Dental caries
Ulcers
Define halitosis
Bad breath
What can angular stomatitis (sore corners of the mouth) be caused by
Deficiency of vitamin B6., B12, folate or iron
What can painful glossitis (abnormal smooth red appearance of the tongue) be caused by
Deficiency seen in vitamin B12 or folate
What can painless glossitis (abnormal smooth red appearance of the tongue) be caused by
Iron-deficiency
What are two features that are examined on a GI examination of the chest
Spider naevi
Gynaecomastia
Define gynaecomastia
Male breast development
May be due to increased circulating oestrogens in liver failure
Define Troisier’s sign
Enlarged left supraclavicular lymph node (Virchow’s node) due to metastasis from an intra-abdominal malignancy
Define Virchow’s node
Left supraclavicular lymph node
What would be a sign of weight gain in an abdominal examination
Striae (stretch marks)
Name what is inspected for on the abdomen on a GI examination
Scars, skin, skin lesions
Shape and symmetry
Movement during breathing
Visible swellings and masses
Visible peristalsis
Visible aortic pulsation
Distended veins
What may distended veins in an abdominal inspection
May indicate inferior vena cava obstruction or portal hypertension
What would the movement of the chest wall during breathing in an abdominal inspection suggest
Diaphragmatic ventilation usually ceases with acute peritonitis and ventilation is then via movement of chest wall
Breakdown the definitions of the 5F’s of abdominal distention
Fluid (ascites)
Faeces (constipation)
Flatus (subacute intestinal obstruction)
Foetus (pregnancy)
Fat (obesity)
What should be done on an abdominal examination if the stomach appears distended
Succussion splash
Shake the stomach brisky from side to side whilst listening for a sloshing sound
How large must be spleen be to be palpable on palpation
2-3x its normal size
Define Courvoisier’s Law
States that in the presence of a palpable gallbladder + jaundice is NOT likely to be gallstones
Which kidney is rarely palpable even in thin people
Left
If aorta is expansile what would this suggest
Aneurysmal dilation
Define Murphy’s sign
Breathe out
Gently place hand below the right costal margin in the midclavicular line (approximate location of gallbladder)
Positive = inspiration is prevented due to inflamed bladder coming into contact with examiners fingers
Where is the superior border of the liver
6th rid mid-inspiration
What could cause the liver to be displaced downward which would give the false impression of hepatomegaly
In respiratory diseases e.g. emphysema
Using the Castell’s method to percuss the spleen what would be a positive sign
Note changes from resonant on full expiration to dull on full inspiration
What is a resonant note on full expiration when percussing the spleen likely to be due to
Air-filled stomach or splenic flexure of colon
When percussing the spleen what would be a sign of splenomegaly
Dull percussion will be present when the inferior pole reaches the 8th or 9th intercostal space
If an elderly patient presents with epigastric pain - what test should be commenced? What is a key differential?
Troponin
Inferior MI may present with epigastric pain
Name the differentials associated with epigastric pain
Oesophagitis
Gastritis
Myocardial infarction
Peptic ulcer
Pancreatitis
Name the differentials of right upper quadrant pain
Cholecystitis
Cholangitis
Biliary colic
Hepatitis
Duodenal ulcer
Pneumonia
Name the differentials of left upper quadrant pain
Sphenic pain - enlargement, infarction, rupture
Name the differentials of right iliac fossa pain
Appendicitis
Chron’s disease
Ectopic pregnancy
Renal stones
Mesenteric adenitis
Torsion of ovarian cyst
Name the differentials of left iliac fossa pain
Diverticulitis
Ectopic pregnancy
Renal stone
Mesenteric adenitis
Torsion of ovarian cysts
Name the differentials of flank pain
Renal colic
Pyelonephritis
Name the differentials of suprapubic pain
Urinary tract infection
Testicular torsion
Miscarriage
Pelvic inflammatory disease
What are the risk factors of GI
Pre-existing Gi diseases
Family history of Gi disease
Alcohol
Smoking
Recreational drugs
Diet
What is the key family history you are asking for in a GI examination
Familial adenomatous polyposis
