GI examination Flashcards
what do you look for in general inspection of abdo exam
vomiting bowls
IV
medication
consciousness level
distress
demeaner
pallor, jaundice, pigmentation (addisons)
loose skin folds
syndromes - cushings
examination of hands
clubbing
koilonychia
leukonychia
loss of lunula
dupuytren’s contracture
palmar erythema
fingertip capillary glucose monitoring marks
causes of clubbing
liver cirrhosis
IBD (crohn’s, UC)
malabsorption syndromes - coeliac
summarise koilonychia
spoon shaped nails
associated with IDA
summarise leukonychia
white nails
hypoalbuminaemia - perhaps from liver cirrhosis, protein losing entropathy (coeliac), heavy and prolongued proteinuria (nephrotic syndrome), protein calorie malnutrition (kwashiorkor)
describe the loss of lunula
loss of half moon at bottom of nail
signify chronic liver disease
dupuytren’s contracture
may be idiopathic
genetic
alcoholic liver disease
palmar erythema
oestrogenic effect
liver disease = reduced break down sex steroids = increased oestrogen = vasodilation
the increased oestrogen cause hyperdynamic circulation
happens in pregnancy
fingertip capillary glucose monitoring marks
dm
what is looked for in arm part of examination
asterixis (liver flap)
radial pulse - tachycardic
bruising - clotting abnormality secondary to liver disease
excoriations - pruritus, secondary to hyperbilirubinaemia (jaundice)
tattoos/needle track marks - risk of hep
offer to measure BP
summarise asterixis
extend wrists out for 15secs
nitrogen containing wast products eg ammonia go to liver for metabolism and excretion
ammonia in systemic circ crosses BBB - absorbed and metabolised by astrocytes = increase in glutamates and glutamine = increase in osmotic pressure and swelling (cytoxic brain oedema) = tremor
liver flap can be from chronic liver disease or CO2 retention
caused by hepatic encephalopathy
what is examined in the face part
conjunctival pallor - to see anaemia
scleral icterus
xanthelasma
kayser-fleischer rings
bilateral parotid swelling
how do you investigate conjunctival pallor
ask pt to look up and you pull eye down
shows anaemia eg from bleeding/malabsorption
summarise scleral icterus
pt look up, you retract lower lid
diffuse yellow sclera = jaundice (hyperbilirubinaemia)
sign of liver disease
(NB dont confuse with - small yellow spots of conjunctival degeneration = pinguecula seen at peripheral of sclera - benign, correlated to UV exposure - may be inflamed with pingueculitis
summarise periorbital xanthelasma
sign of primary billary cirrhosis
yellow deposits of cholesterol
hyperlipidaemia in cholestasis
summarise keyser-fleischer rings
seen with slit lamp
deposits of copper in wilson’s disease
summarise bilateral parotid swelling
due to sialoadenosis (non-inflammatory, non-neoplastic, enlargement, usually associated with systemic disease)
feature of chronic alcohol abuse, malnutrition and bulimia associated with recurrent vomiting
what is seen in the mouth examination
oral candidiasis - from chronic steroids
aphthous ulcers - crohn’s coeliac (IBD)
glossitis
angular stomatis = B12/folate/iron deficiency
osler-weber rendu = hereditory haemorrhagic telangiectasia (high risk of GI bleeding)
breath - alcohol, pear drops (DKA), foetor hepaticus (liver failure), faceculent in obstruction
summarise glossitis
sign of anaemia
beefy red tongue = B12/folate deficiency (also steroid inhalers, antibiotics, candidiasis
pale, smooth tongue (atrophic glossitis) = IDA
what is seen on neck examination
lymph nodes
gastric and pancreatic cancer cause enlargement of virchow’s node (L supraclavicular lymph node) = troisier’s sign
more generalised lymphadenopathy with hepatomegaly - lymphoma
while sat forward check back for excoriations and spider naevi
what is looked for on the chest
gynaecomastia
spider naevi
loss of axillary hair
all due to increased oestrogen levels in liver disease/pregnancy
summarise gynaecomastia
chronic liver disease = excess oestrogens = breast tissue in males, loss of chest hair and testicular atrophy
summarise spider naevi
oestrogenic effect
isolated telangiectases (dilated capillaries)
characteristically fill from a central feeding vessel
dound in distribution of SVC on upper trunk, arms and face
are spider naevi pathological
women may have up to five in normal health and more in preg (as well as palmer erythra)
but >5 is pathological - liver disease
what do you look for on back
skin lesions - immunosuppression
spider naevi
what do you look for on abdo inspection
scars
stomas
skin
BV
distension
incisional hernias - ask pt to cough
movement with respiration - absent in peritonitis
obvious pulsations
distended portal-systemic anastomosis
summarise scars
suggest surgical history eg laproscopy, pfannensteil in c-section
feel for incisional herniae - ask pt to raise head off bed and cough
summarise stomas
ileostomy in R iliac fossa and is formed as a spout - protect skin from alkaline nature of ileum’s contents
loop colostomy may be created to temporarily defunction the distal bowel - usually in transverse colon and has afferent and efferent limbs
colostomy usually flush and in L iliac fossa (contents not as harmful to skin)
comment on position bag, contents, spout and local irritation
describe skin on abdo inspection
seborrheic warts and haemangiomas (campbell de Morgan spots) are normal
note any striae, bruising or scratch marks
(striae from pregnancy/cushings)
describe bv on abdo inspection
caput medusae - portal hypertension, recanalisation of the umbilical veins along the falciform ligament produce distended (varicose) veins draining from teh umbilicus - distended portal-systemic anastomosis
obstruction of venae carva can cause distened tortuous veins
pancreatities can cause accumulation of blood
pulsatile AAA
spider naevi
decribe effect of pancreatitis on abdomen
grey-turner’s sign = flank bruising
cullen’s sign = periumbilical bruising
because of release of pancreatic enzymes
summarise distension of abdomen
fat
fluid
flatus
faeces
foetus
fulminant tumour
(stand from end of bed and note any asymettry/uniformity)
summarise abdomen screening tests
deep breath - if peritonism very painful
cough with head to the side and hands in the inguinal region - feeling for hernias
lift head of the pillow - look for diverication or paraumbilical/incisional hernias
summarise palpation
ask pain - start away from it
get to patient’s level and watch their face (get on 1 knee)
begin light then deep in all 9 areas
feel for tenderness, pain and masses
if masses do a lump examination
see if guarding - voluntary Iie distractable or involuntary - peritonitis
look for rebound tenderness (peritonitis)
what do you look for on deep palpation
(upper hand exerts pressure, lower hand feels)
masses
deep tenderness
if relevant Rovsing’s sign (appendicitis) and Murphy’s sign (cholecystitis)
how do you check for organomegaly of liver
start in R iliac fossa go up to hypochondrium
press in on exhale and let them inhale to bring liver to hand
if feel liver = liver enlargement/hyperinflation of lungs
hepatomegaly = metastasis/HCC, cirrhosis, hepatitis, RVF, leukaemia/lymphoma
how do you check for spleen enlargement
start in R iliac fossa and move to L hypochondrium (can augment with hand behind ribs on that side)
felt better if pt rolls onto R side with bent legs
press on exhale and feel on inhale
splenomegaly = lymphoma/leukaemia, myelofibrosis, malaria, portal hypertension, haemolysis
(spleen moves down on inspiration)
how do you palpate the kidneys
ballot each flank
ask pt to expire and press up into renal angle with posterior hand and press down with anterior hand - as pt breathes may feel it between hands
ballot by flexing the metacarpophalangeal joints of posterior hand - do flick, flick stop and repeat as necessary
how do you palpate AAA
2 hands into abdo above umbilicus - start laterally and move in
see if expansile = AAA
pulsitile mass can be normal
percussion for organomegally
percuss bottom up and top down for liver - in case false hepatomegaly if diaphragm is pushed down by eg hyperinflation in COPD
for spleen percuss up to spleen from R iliac fossa (dull percussion note of spleen only heard when enlarged) - percuss up to Traube’s space which is just above the L costal margin in mid-clavicular line
suprapubic percussion for bladder
shifting dullness - if distended with ascites percuss laterally from midline and find point of dullness - will be more medial than expect (suggests fluid in abdo cavity). Keep finger in this position and get pt to roll onto side. after 10s percuss same spot - if resonant, the shifting dullness = +ve = free fluid in abdo
fluid thrill for ascites - pt hand hard in abdo midline, tap one side and feel other side for the tap = ascites
percussion tenderness = peritonitis
tympanic = flatus
describe auscultation in abdo
ausculate in R lower quadrant at ileocaecal valve until heard
bowel sounds - normal in 2 places
tinkling = obstruction
absent = ileus ie bowels arent working (need to listen for 3mins to make diagnosis) or peritonitis
bruits - renal arteries and aorta (turbulent blood flow due to stenosis/aneurism) - 1cm superior and lateral to the umbilicus bilaterally
describe leg examination
examine for peripheral oedema, bruising, erythema nodosum (IBD, vasculitis, drugs, oral contraceptive pill, sarcoid, TB
to complete the exam
thank pt and cover them
'’to complete my exam I would examine the external herneal oridices, the external genitaloia and do a DRE’’
