GIT EXAM and history Flashcards
Describe a general appearance in GIT Exam
GENERAL APPEARANCE
- Jaundice - scleral icteraus
- obvious weight loss or wasting (cachexia)
- temperature
- Mental status - hepatic encephalopathy
- SKIN -
1) IBD - pyoderma gangrenosum, erythema nodosum, clubbing, mouth ulcer
2) Haemochromatosis - bronze skin - skin pigmentation
3) bowel cacner -acanthosis nigracans - brown to black velvety elevation found in the axillae and nape of the neck - also seen with t2dm, acromegaly and other endocrinoapthies
4) Peutz-jeghers syndrome - freckle like spots (discrete brown black lesions around the mouth and the buccal mucosa and on the fingers and toes associated with hamartomas - present with bleeding and or intussuscpetion)
Describe HAND exam in GIT
HANDS
- Nails - leuconychia - chronic liver disease and anything that results in hypoalbuminaemia leads to leuconychia or opacification of the nail bed.
- Clubbing - IBD - cirrhosis
- Plamar erythema - raised oestrogen levels.
- Dupuytrens contracture - visible and palable contraction of the palma fascia - alcoholism not liver disease
- Hepatic flap (asterixis) - stretch fingers and extend in front for 15 seconds.
ARMS/General
- bruising/ petichaeia - scratch marks (pruritus -hyperbili)
- spider naevi - found in the area drained by the SVC - arms neck and chest wall - central arterial with numerous small vessels - occlude with central pressure –> 2-3 normal more is not – cirrhosis and alcohoism
Describe face and neck exam in GIT
FACE
- Eyes for sclearal icterus and pale conjunctiva, kayser fleischer rings (copper)
- Parotid enlargement which can be seen with alcoholism
- Poor dentition
- Fetor hepaticus (sweet) - indiciative of severe hepatocellular disease
- Leukoplakia - whit coloured thickening of the mucosa of the tongue and motuh - condition is premalignant and is caused by the s’s (Sore teeth (bad dentition), smoking, spirits, syphilisi and sepsis)
- Glossitis - smooth and erythematous toungue – due to nutritional deficiencies - iron folate and vit b -
- Macrglossia may occur in congenital disorders such as down syndrome and endocrinopathy such as acromegaly
- Angular stomatitis also is caused by vitamin defiencies
- Candidiasis espeicially oesophageal can be a sign of severe underying immunodepression.
NECK and chest
- Lymph nodes expecially left supraclavicular which can be prominent with advanced GIT or lung CA - VIRCHOWs node
- Gynaecomastia
Describe abdominal exam in GIT
INSPECTION
- Apperance - do they appear unwell are they holding very still with shallow breathing - peritonitis
- Scars
- Stoma
- Generalised abdominal distension -(Fat, flutus, fluid, faeces, filthy big tumour)
- localised swelling such as hernia
- If large prominent veins dierection of flow should be ascertained - severe portal hypertension will flow away from the umbilicus where as severe IVC obstruction will flow upwards towards the heart as the legs drain into the abdo to avoid the IVC
- Skin lesions - zoster, bruising from grey turners or cullnes.
PALPATION
- 1) assure adequate analgesia as ideally abdomen will be not tense
2) palpate all 9 areas for pain and tenderness - Light then deep palpation - looking for guarding (can be voluntary or involuntary -peritonitis) Rigidity is constant involuntary contraction of the abdo muscles and is indicitive of peritoneal irritation. Rebound tenderness or percussion tenderness
3) Liver - palpation for liver edge - hand aligned parallel to the costal margin and begining in the right iliac fossa ask patient to inhale and exhale moving hand superiorly 2cm every breath until liver edge is felt - if identified fell edge of liver for texture- once liver edge felt percussion for full measurement - normal span is 13 cm - Causes of normal size but palable liver edge include - liver ptosis due to emphysema and asthma or a subdiapraghmatic collection
- assess for pulsitivity of the liver
4) Gall bladder - murphy’s sign
5) Spleen - two handed technique left hand is placed posterolaterally over the left lower ribs and the right hand is placed on the abdomen below the umbilicus - if not palpable the patient is rolled onto the right side toward the examiner
6) Kidneys - Bimanual balloting
7) Other mass - stomach and duodenum (pyloric stenosis) , Aorta - measure width of palpation, bowel,
8) testicle and iguinal region
PERCUSSION
1) percuss for liver and spleen size
2) percussion of renal angle can illicit pain
3) ascites - shifting dullness - dull percussion in the flank can be present with as little as 2 litres of ascitic fluid
- if dullness detected in the flanks the patient should be rolled and left for 30-60 seconds and percussion again if dullness has shifted indicative of ascitic fluid
- fluid thrill
AUSCULTATION
1) bowel sounds - absence of bowel sounds indicates paralytic ileus - obstructed bowel produces a louder and higher pitched sound with a tinkling quality
2) venous hum - conitnuous low pithced soft murmur - rarely found may indicate portal hypertension
- hepatic bruit - non continuous higher pitched well localised. This is usually due to hepatocellular cancer but may occur in acute alcoholic hepatitis, AVM
- renal bruit
OTHER
Examination of faeces - melena, haematochezia, steatorrhoea
Examination of vomitus - coffee grounds , haematemesis, faeculent
Describe examination for hernia
Examination with the patient standing if possible
INSPECTION
- scars from previous surgeries
- look for obvious lumps
- prior to palpation the patient is asked to turn the head away from the examiner and cough looking for a cough impulse
PALAPTION
- finger placed over the pubic tubercle and the patient is again asked to cough and a palpable expansile impulse is sought.
- Patient is then asked to lie flat and repeated
- attempts to reduce hernia
- in males an inguinal hernia may descend through the external ring immediatley above the pubic tubercle into the scrotum. Gentle invagination of the scrotum with the tip of a gloved litter finger in the external ring may be performed
- if scrotal hernia suspected important to attempt to get above mass if able to likley primary intrascrotal and not a hernia
Describe examination for hernia
Examination with the patient standing if possible
INSPECTION
- scars from previous surgeries
- look for obvious lumps
- prior to palpation the patient is asked to turn the head away from the examiner and cough looking for a cough impulse
PALAPTION
- finger placed over the pubic tubercle and the patient is again asked to cough and a palpable expansile impulse is sought.
- Patient is then asked to lie flat and repeated
- attempts to reduce hernia
- in males an inguinal hernia may descend through the external ring immediatley above the pubic tubercle into the scrotum. Gentle invagination of the scrotum with the tip of a gloved litter finger in the external ring may be performed
- if scrotal hernia suspected important to attempt to get above mass if able to likley primary intrascrotal and not a hernia
Describe the rectal examination
Consent
patient lies on side with knees drawn up to abdomen left lateral position
INSPECTION
1) Thrombosed external haemorrhoids
2) skin tags
3) rectal prolapse
4) anal fissues
5) fistula
6) condylomata acuminata (anal warts)
7) carcinoma
8) pruritus ani
TEST
1) strain
- watch perineum look for signs of incontinence or leakage of faces or mucus
- internal haemorrhoids may prolpase
2) anal wink
- stroke anus with a cotton pad in all four quadrants around the anus usually results in brisk anal contraction
PALPATION
-lubricated gloved finger
-if excruitating at begin suggest anal fissure and may not be able to be completed.
During entry sphnicter tone should be assessed as normal or reduced/absent
-palpation of the prostate/cervix - hard nodule suggest cancer, nil sulcus suggest enlargement
-ask patient to squeeze for a further test of anal tone
