GI/GU examination

Question 1

Position of GI anatomy

Answer 1

Spleen- underlies ribs 9,10 and 11 posterior to the mid axillary line

Question 2

General observation

Answer 2

Cachetic- loss of body weight and muscle mass, there may be weakness
– usually seen in patients with cancer, aids, copd, MS, heart failure, TB

Pallor- pale patients- many causes

Jaundiced- yellow skin
– liver cancer, hepatitis, leptospirosis, congenital

Question 3

Hands observation

Answer 3

Clubbing:
– cirrhosis, ulcerative colitis, crohns, chronic liver disease, IBD

Lekonychia (white spots on nails)
– deficiency of albumin due to liver disease is the primary cause

Kolionychias ‘spoon nails’
– anaemia, cirrhosis, necrotic syndrome, iron deficiency

Palmar erythema (redness on hands)
– primary- idiopathic, pregnancy, hereditary
– secondary- RA, chronic disease, contraceptive pill
—- normal in pregnancy but sign of chronic liver disease

Dupytrens contracture:
– benign, progressive fibroproliferative disorder of the fascia of the hands and fingers that can lead to disabling contractures
– cause is unknown, causes thickening of the skin, forming nodules which can be quite tender

Tremor:
– seen in liver failure
– can also be a sign of cardiovascular and respiratory problems as well

Question 4

Eyes general inspection

Answer 4

Jaundiced sclera

Conjunctival pallor (anaemia)

Keiser Fleischer rings
– signs of Wilsons disease

Question 5

General mouth inspection

Answer 5

Look at the mouth for:
– nutrition (tongue)
– breath- ketosis (pear drop?)- halitosis (bad breath?)
– thrush?
– hydration

Question 6

General skin inspection

Answer 6

Spider angiomas:
– cause- increased oestrogen levels in the blood
—- many pregnancy women, or women using hormonal contraception, have spider angiomas, due to high oestrogen levels in their blood
– individuals with significant hepatic disease may also show many spider angiomas

– if there are more than 5 spider naevi in the distribution of the inferior vena cava is a sign of chronic liver disease
—- however this can be normal in pregnancy

Question 7

Abdominal distension

Answer 7

Abdominal girth slowly increasing over months or years is usually due to obesity

• but in a patient with weight loss, it suggests intra-abdominal disease

Causes (the 6 F’s):
- fat
– flatus
– faeces
– fluid
– fetus
– functional

When considering fluid, you need to consider ascites:
– accumulation of fluid in the peritoneal cavity
causes:
– cirrhosis, heart failure, cancer, peritonitis

Question 8

Palpations

Answer 8

Palpation for the greater vessel:
- finding thoracic aorta:
— feel the beating aorta, looking for any AAA’s

• also auscultate for bowel sounds:
  – should hear no sound, you may hear borborygmi (sounds the bowels make as fluid moves through them).

Question 9

The different regions of the abdomen during examination

Answer 9

Right hypochondrium (top right)

Left hypochondrium (top left)

Epigastrium (above umbilicus, just below sternal region)

Right and left flank or lumbar region (either side of umbilicus)

Umbilicus region

Right and left iliac fossa

Hypogastric or suprapubic region (below umbilicus)

Question 10

Palpation of the different regions

Answer 10

Superficial palpation first, push with knuckles rather than fingers

– palpate from LIF to RIF

– look for tenderness, guarding, rigidity, any pain that the patient has

Question 11

Stomach pain locations

Answer 11

Right hypochondrium:
– gallstones, stomach ulcer, pancreatitis

Left hypochondrium:
– stomach ulcer, duodenal ulcer, biliary colic, pancreatitis

Epigastric:
– stomach ulcer, heartburn/indigestion, pancreatitis, gallstones, epigastric hernia

Right flank (lumbar region);
– Kidney stones, urine infection, constipation, lumbar hernia

Left flank (lumbar region):
– kidney stones, constipation, diverticular disease

Umbilicus region:
– pancreatitis, stomach ulcer, inflammatory bowel disease, umbilical hernia

Right iliac fossa:
– appendicitis, constipation, pelvic pain, inguinal hernia

Left iliac fossa:
– pelvic pain, groin pain, diverticular disease, inguinal hernia

suprapubic region:
– urine infection, appendicitis, inflammatory bowel disease, pelvic pain, diverticular disease

Question 12

Palpation of spleen, liver and kidneys

Answer 12

A normal finding is that you dont feel anything for these palpations
if you do feel something- normal is a hard slipper mass

– palpation of liver:
—- when the liver is enlarged it will enlarge straight down,
—- the upper border of the liver sits underneath costal space 5 so on expiration you can press down and feel if the liver has been enlarged
– may be able to lift up the right side to feel the liver more

– palpation of spleen:
—- when the spleen is enlarged it will come more towards the midline
—- may be able to lift the left side up towards you

– balloting of the kidneys:
—- lower pole can be in right or left flank, the right kidney is lower due to the diaphragm and kidney.

—- kidneys are not usually palpable, except from the inferior pole of the right kidney (maybe)
—- left kidney is rarely palpable, unless there is some enlargement or inflammation