GI & GU

Question 1

What makes up a GI & GU exam

Answer 1

General signs & closer look at hands
Abdominal inspection
Palpate the aorta
Abdominal auscultation
Abdominal palpation
Palpate the liver
Palpate the spleen
Ballot the kidneys

Question 2

General signs

Answer 2

Obvious scars: may provide clues regarding previous abdominal surgery.

Abdominal distention: may suggest the presence of ascites or underlying bowel obstruction and/or organomegaly.

Pallor: a pale colour of the skin that can suggest underlying anaemia (e.g. gastrointestinal bleeding or malnutrition). It should be noted that healthy individuals may have a pale complexion that mimics pallor.

Jaundice: a yellowish or greenish pigmentation of the skin and whites of the eyes due to high bilirubin levels (e.g. acute hepatitis, liver cirrhosis, cholangitis, pancreatic cancer).

Hyperpigmentation: a bronzing of the skin associated with haemochromatosis.

Oedema: typically presents as swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites) and is often associated with liver cirrhosis

Stoma bag(s): note the location of the stoma bag(s) as this can provide clues as to the type of stoma (e.g. colostomies are typically located in the left iliac fossa, whereas ileostomies are usually located in the right iliac fossa).

Stretch marks: caused by tearing during the rapid growth or overstretching of skin (e.g. ascites, intrabdominal malignancy, Cushing’s syndrome, obesity, pregnancy).

Hernias: ask the patient to cough and observe for any protrusions through the abdominal wall (e.g. umbilical hernia, incisional hernia).

Question 3

Hands

Answer 3

Pallor: may suggest underlying anaemia (e.g. malignancy, gastrointestinal bleeding, malnutrition).

Palmar erythema: a redness involving the heel of the palm that can be associated with chronic liver disease (it can also be a normal finding in pregnancy).

Koilonychia: spoon-shaped nails, associated with iron deficiency anaemia (e.g. malabsorption in Crohn’s disease).

Leukonychia: whitening of the nail bed, associated with hypalbuminaemia (e.g. end-stage liver disease, protein-losing enteropathy).

Finger clubbing - inflammatory bowel disease, coeliac disease, liver cirrhosis and lymphoma of the gastrointestinal tract.

Cool hands may suggest poor peripheral perfusion.

Question 4

Six F’s

Answer 4

Abdominal distension: can be caused by a wide range of pathology including the six f’s (fat, fluid, flatus, faeces, fetus or fulminant mass).

Question 5

Palpate the aorta

Answer 5

Using both hands perform deep palpation just superior to the umbilicus in the midline.
Note the movement of your fingers:

Question 6

Palpate the aorta normal/abnormal signs

Answer 6

In healthy individuals, your hands should begin to move superiorly with each pulsation of the aorta.
If your hands move outwards, it suggests the presence of an expansile mass (e.g. abdominal aortic aneurysm).

Question 7

9 areas of the abdomen

Answer 7

Left hypochondriac region
Right hypochondriac region
Epigastric region
Left lumbar region
Right lumbar region
Umbilical region
Left inguinal region
Right inguinal region
Hypogastric region

Question 8

Left hypochondriac region

Answer 8

Area 3 as ur looking down on Pt (Below the costal cartilages)
The stomach
The top of the left lobe of the liver
The left kidney
The spleen
The tail of the pancreas
Parts of the small intestine
The transverse colon
The descending colon

Question 9

Right hypochondriac region

Answer 9

Area 1
The liver
The gallbladder
The small intestine
Small intestine
The right kidney

Question 10

Epigastric region

Answer 10

Area 2 (above the stomach)
The stomach
The liver
The spleen
The pancreas
Adrenal glands

GORD
HEART ATTACK
PEPTIC ULCER

Question 11

Left lumbar region

Answer 11

Area 6
A part of the descending colon
The tip of the left kidney

Question 12

Right lumbar region

Answer 12

Area 4
The tip of the liver
The gallbladder
The ascending colon

Question 13

Umbilical region

Answer 13

Area 5
The small intestine

Umbilical hernia

Question 14

Left inguinal region

Answer 14

Area 9
The descending colon
Sigmoid colon
The left ovary and the left fallopian tube in females.

Divavticultis

Question 15

Right inguinal region

Answer 15

Area 7
The appendix
The cecum
The right ovary and right fallopian tube in females.

Question 16

Hypogastric region

Answer 16

Area 8 (Below stomach)
The sigmoid colon
The urinary bladder
The uterus, the right and left ovaries and the fallopian tubes can be found in females

Question 17

Abdominal auscultation

Answer 17

Normal bowel sounds: typically described as gurgling (listen to an example in our video demonstration)

Tinkling bowel sounds: typically associated with bowel obstruction.

Absent bowel sounds: suggests ileus which is a disruption of the normal propulsive ability of the intestine due to a malfunction of peristalsis. Causes of ileus include electrolyte abnormalities and recent abdominal surgery. To be able to confidently state that a patient has ‘absent bowel sounds’ you need to auscultate for at least 3 minutes (this is unlikely to be the case in an OSCE given the time restraints).

Question 18

Auscultate over the aorta and renal arteries

Answer 18

To identify vascular bruits suggestive of turbulent blood flow:

Aortic bruits: auscultate 1-2 cm superior to the umbilicus, a bruit here may be associated with an abdominal aortic aneurysm.

Renal bruits: auscultate 1-2 cm superior to the umbilicus and slightly lateral to the midline on each side. A bruit in this location may be associated with renal artery stenosis.

Question 19

Abdominal Palpation

Answer 19

Pt flat, knees up, Lightly palpate each of the nine abdominal regions, assessing for clinical signs suggestive of gastrointestinal pathology.
Looking for any tenderness, voluntary/inventory guarding, rovisngs sign and masses.
Then repeat but now with more pressure to find deeper masses.

Question 20

Patho of test

Answer 20

Rebound tenderness: said to be present when the abdominal wall, having been compressed slowly, is released rapidly and results in sudden sharp abdominal pain. This is a non-specific, unreliable clinical sign that can, in some cases, be associated with peritonitis (e.g. appendicitis).

Voluntary guarding: contraction of the abdominal muscles in response to pain

Involuntary guarding/rigidity: involuntary tension in the abdominal muscles that occurs on palpation associated with peritonitis (e.g. appendicitis, diverticulitis).

Rovsing’s sign: palpation of the left iliac fossa causes pain to be experienced in the right iliac fossa. This sign was historically said to be indicative of appendicitis, but it is not reliable and at best indicates peritoneal inflammation of any cause affecting the left and/or right iliac fossa.

Masses: large or superficial masses (e.g. hernias) may be noted on light palpation.

Question 21

If any masses are identified during deep palpation, assess the following characteristics:

Answer 21

• Location: note which of the nine abdominal regions the mass located within.
• Size and shape: assess the approximate size and shape of the mass.
• Consistency: assess the consistency of the mass (e.g. smooth, soft, hard, irregular).
• Mobility: assess if the mass appears to be attached to superficial or underlying structures.
• Pulsatility: note if the mass feels pulsatile, suggestive of vascular aetiology (e.g. abdominal aortic aneurysm).

Question 22

If any masses are identified during deep palpation, assess the following characteristics:

Answer 22

• Location: note which of the nine abdominal regions the mass located within.
• Size and shape: assess the approximate size and shape of the mass.
• Consistency: assess the consistency of the mass (e.g. smooth, soft, hard, irregular).
• Mobility: assess if the mass appears to be attached to superficial or underlying structures.
• Pulsatility: note if the mass feels pulsatile, suggestive of vascular aetiology (e.g. abdominal aortic aneurysm).

Question 23

Palpate the liver

Answer 23

Begin palpation in the right iliac fossa, starting at the edge of the superior iliac spine, using the flat edge of your hand (the radial side of your right index finger).

Ask the patient to take a deep breath and as they begin to do this palpate the abdomen. Feel for a step as the liver edge passes below your hand during inspiration (a palpable liver edge this low in the abdomen suggests gross hepatomegaly).

Repeat this process of palpation moving 1-2 cm superiorly from the right iliac fossa each time towards the right costal margin.

As you get close to the costal margin (typically 1-2 cm below it) the liver edge may become palpable in healthy individuals.

Question 24

If you are able to identify the liver edge, assess the following characteristics:

Answer 24

Degree of extension below the costal margin: if greater than 2 cm this suggests hepatomegaly.

Consistency of the liver edge: a nodular consistency is suggestive of cirrhosis.

Tenderness: hepatic tenderness may suggest hepatitis or cholecystitis (as you may be palpating the gallbladder)

Pulsatility: pulsatile hepatomegaly is associated with tricuspid regurgitation. Could be caused by Hepatitis, leukaemia, myeloma

Question 25

Palpate the spleen

Answer 25

Begin palpation in the right iliac fossa, starting at the edge of the superior iliac spine, using the flat edge of your hand (the radial side of your right index finger).

Ask the patient to take a deep breath and as they begin to do this palpate the abdomen with your fingers aligned with the left costal margin. Feel for a step as the splenic edge passes below your hand during inspiration (the splenic notch may be noted).

Repeat this process of palpation moving 1-2 cm superiorly from the right iliac fossa each time towards the left costal margin.

Question 26

In healthy individuals, you should not be able to palpate the spleen

Answer 26

A palpable spleen at the edge of the left costal margin would suggest splenomegaly (for the spleen to be palpable at this location it would need to be approximately three times its normal size).
 Causes of splenomegaly:
 Portal hypertension secondary to liver cirrhosis
 Haemolytic anaemia
 Congestive heart failure

Question 27

Ballot the kidneys

Answer 27

Place your left hand behind the patient’s back, below the ribs and underneath the right flank.
Then place your right hand on the anterior abdominal wall just below the right costal margin in the right flank.
Push your fingers together, pressing upwards with your left hand and downwards with your right hand.
Ask the patient to take a deep breath and as they do this feel for the lower pole of the kidney moving down between your fingers. This bimanual method of kidney palpation is known as balloting.
 Repeat this process on the opposite side to ballot the left kidney.

Question 28

Causes of enlarged kidneys

Answer 28

If a kidney is ballotable, describe its size and consistency.
 In healthy individuals, the kidneys are not usually ballotable, however, in patients with a low body mass index, the inferior pole can sometimes be palpated during inspiration.

 Bilaterally enlarged, ballotable kidneys can occur in polycystic kidney disease or amyloidosis.
 A unilaterally enlarged, ballotable kidney can be caused by a renal tumour.