GI examination

Question 1

what do you look for in general inspection of abdo exam

Answer 1

vomiting bowls

IV

medication

consciousness level

distress

demeaner

pallor, jaundice, pigmentation (addisons)

loose skin folds

syndromes - cushings

Question 2

examination of hands

Answer 2

clubbing

koilonychia

leukonychia

loss of lunula

dupuytren’s contracture

palmar erythema

fingertip capillary glucose monitoring marks

Question 3

causes of clubbing

Answer 3

liver cirrhosis

IBD (crohn’s, UC)

malabsorption syndromes - coeliac

Question 4

summarise koilonychia

Answer 4

spoon shaped nails

associated with IDA

Question 5

summarise leukonychia

Answer 5

white nails

hypoalbuminaemia - perhaps from liver cirrhosis, protein losing entropathy (coeliac), heavy and prolongued proteinuria (nephrotic syndrome), protein calorie malnutrition (kwashiorkor)

Question 6

describe the loss of lunula

Answer 6

loss of half moon at bottom of nail

signify chronic liver disease

Question 7

dupuytren’s contracture

Answer 7

may be idiopathic

genetic

alcoholic liver disease

Question 8

palmar erythema

Answer 8

oestrogenic effect

liver disease = reduced break down sex steroids = increased oestrogen = vasodilation

the increased oestrogen cause hyperdynamic circulation

happens in pregnancy

Question 9

fingertip capillary glucose monitoring marks

Answer 9

dm

Question 10

what is looked for in arm part of examination

Answer 10

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

Question 11

summarise asterixis

Answer 11

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

Question 12

what is examined in the face part

Answer 12

conjunctival pallor - to see anaemia

scleral icterus

xanthelasma

kayser-fleischer rings

bilateral parotid swelling

Question 13

how do you investigate conjunctival pallor

Answer 13

ask pt to look up and you pull eye down

shows anaemia eg from bleeding/malabsorption

Question 14

summarise scleral icterus

Answer 14

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

Question 15

summarise periorbital xanthelasma

Answer 15

sign of primary billary cirrhosis

yellow deposits of cholesterol

hyperlipidaemia in cholestasis

Question 16

summarise keyser-fleischer rings

Answer 16

seen with slit lamp

deposits of copper in wilson’s disease

Question 17

summarise bilateral parotid swelling

Answer 17

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

Question 18

what is seen in the mouth examination

Answer 18

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

Question 19

summarise glossitis

Answer 19

sign of anaemia

beefy red tongue = B12/folate deficiency (also steroid inhalers, antibiotics, candidiasis

pale, smooth tongue (atrophic glossitis) = IDA

Question 20

what is seen on neck examination

Answer 20

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

Question 21

what is looked for on the chest

Answer 21

gynaecomastia

spider naevi

loss of axillary hair

all due to increased oestrogen levels in liver disease/pregnancy

Question 22

summarise gynaecomastia

Answer 22

chronic liver disease = excess oestrogens = breast tissue in males, loss of chest hair and testicular atrophy

Question 23

summarise spider naevi

Answer 23

oestrogenic effect

isolated telangiectases (dilated capillaries)

characteristically fill from a central feeding vessel

dound in distribution of SVC on upper trunk, arms and face

Question 24

are spider naevi pathological

Answer 24

women may have up to five in normal health and more in preg (as well as palmer erythra)

but >5 is pathological - liver disease

Question 25

what do you look for on back

Answer 25

skin lesions - immunosuppression spider naevi

Question 26

what do you look for on abdo inspection

Answer 26

scars stomas skin BV distension incisional hernias - ask pt to cough movement with respiration - absent in peritonitis obvious pulsations distended portal-systemic anastomosis

Question 27

summarise scars

Answer 27

suggest surgical history eg laproscopy, pfannensteil in c-section feel for incisional herniae - ask pt to raise head off bed and cough

Question 28

summarise stomas

Answer 28

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

Question 29

describe skin on abdo inspection

Answer 29

seborrheic warts and haemangiomas (campbell de Morgan spots) are normal note any striae, bruising or scratch marks (striae from pregnancy/cushings)

Question 30

describe bv on abdo inspection

Answer 30

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

Question 31

decribe effect of pancreatitis on abdomen

Answer 31

grey-turner's sign = flank bruising cullen's sign = periumbilical bruising because of release of pancreatic enzymes

Question 32

summarise distension of abdomen

Answer 32

fat fluid flatus faeces foetus fulminant tumour (stand from end of bed and note any asymettry/uniformity)

Question 33

summarise abdomen screening tests

Answer 33

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

Question 34

summarise palpation

Answer 34

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)

Question 35

what do you look for on deep palpation

Answer 35

(upper hand exerts pressure, lower hand feels) masses deep tenderness if relevant Rovsing's sign (appendicitis) and Murphy's sign (cholecystitis)

Question 36

how do you check for organomegaly of liver

Answer 36

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

Question 37

how do you check for spleen enlargement

Answer 37

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)

Question 38

how do you palpate the kidneys

Answer 38

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

Question 39

how do you palpate AAA

Answer 39

2 hands into abdo above umbilicus - start laterally and move in see if expansile = AAA pulsitile mass can be normal

Question 40

percussion for organomegally

Answer 40

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

Question 41

describe auscultation in abdo

Answer 41

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

Question 42

describe leg examination

Answer 42

examine for peripheral oedema, bruising, erythema nodosum (IBD, vasculitis, drugs, oral contraceptive pill, sarcoid, TB

Question 43

to complete the exam

Answer 43

thank pt and cover them ''to complete my exam I would examine the external herneal oridices, the external genitaloia and do a DRE''