Gastrointestinal and Renal

Question 1

Order

Answer 1

Observation
General appearance - pain, unwell, equipment, weight, jaundice/pallor
Hands and nails
Liver flap
Radial pulse
Eyes
Mouth
Neck - lymph nodes, esp Virchow's (gastric cancer) in left supraclavicular
Chest
Abdomen

Question 2

Hands and nails

Answer 2

Needle tracks - increased risk of hep B/C

Clubbing

Koilonychia - spoon shaped nails

Leukonychia - white nails

Palmar erythema (caused by chronic liver disease, polycythaemia, thryotoxicosis, sarcoidosis (or idiopathic))

Dupuytren’s contracture

Liver flap (CO2 flap) - in liver failure

Radial pulse

Question 3

Eyes

Answer 3

Jaundice in sclera

Pallor inside retracted eyelid

Question 4

Mouth

Answer 4

Angular stomatitis - bilateral fissures in corners of mouth

Glossitis - smooth, swollen, tender tongue

Dry mucous membranes

Oral ulcers

Candidal infection (white)

Telangectasia (spider veins) - may be hereditary haemorrhagic telangectasia

Brown discolouration of lips - Addison’s disease, Peutz-Jegher syndrome

Question 5

Chest

Answer 5

Spider naevi - blanch on pressure, then blood returns from outside in
- more than 5 - liver disease (esp alcoholic)

Gynaecomastia (in men) - liver cirrhosis (as liver involved in oestrogen metabolism)

Question 6

Abdomen - inspection

Answer 6

Distension, scars, excoriation (scratch marks - itchy skin in renal/liver failure), striae (stretch marks), caput medusae

Question 7

Abdomen - palpation

Answer 7

WATCHING FACE NOT ABDOMEN
(start away from site of pain)
(if pain, note: site, whether guarding, rebound tenderness)
(if mass, note: site, consistency, whether can get above or below it, shape, pulsatility, signs of inflammation)

• palpate 9 areas of abdomen superficially - tenderness and obvious masses
• then 9 areas more deeply - deep pain, masses, palpable organs or masses
• palpate liver - start right iliac fossa with hand parallel to costal margin, breathe in and out, if nothing felt move upwards until reach costal margin
• palpate spleen - start right iliac fossa and work towards left hypochondrium, breathe in and out, if in left hypochondrium and nothing felt, ask patient to roll towards you
• palpate kidneys - ballot up and down
• feel for AAA - palpate above umbilicus left midline, feel for expansile against hands (normal to feel pulsation). If suspected, confirm with both hands either side of mass to confirm moving outwards as well as up
• feel for inguinal hernias - with cough

Question 8

Abdomen - percussion

Answer 8

• liver (may need to also percuss out top border to confirm not just hyperexpanded chest)
• spleen
• shifting dullness - start at umbilicus, percuss away to flank until note is dull. Keep finger on point, patient roll towards you. Percuss back to umbilicus - if dull point now resonant, shifting dullness, ascites

Question 9

Abdomen - auscultation

Answer 9

Bowel sounds - present or absent (listen up to 1 min) or tinkling (mechanical obstruction)

Bruits - inferior to umbilicus and either side