CLIN SKILLS - GIT Exam

Question 1

general format of GIT exam

Answer 1

• intro + hand hygiene
• general inspection
• inspection: fingers, palms, arms
• inspection: eyes, mouth, neck
• chest inspection
• abdominal inspection
• palpation and percussion
• auscultation
• legs inspection
• conclusion + hand hygiene

Question 2

what to look for in GIT general inspection

Answer 2

• jaundice
• body build (cachexia)
• posture
• pigmentation
• pain
• pallor
• sweating
• vomit bag, feeding tube etc.

Question 3

what to check for in fingers (GIT)

Answer 3

• leukonychia (clusters of white spots) - liver disease e.g. hypoalbuminaemia, cirrhosis
• koilonychia (spoon-shaped nails - anaemia)
• clubbing (IBD, cirrhosis, cancer)
• muehrcke’s lines (white horizontal lines) - hypoalbuminaemia

Question 4

what to check for in palms (GIT exam)

Answer 4

• palmar erythema - liver disease
• pallor - spread palmar creases to check if they turn red (anaemia)
• dupuytren’s contracture - contraction of ring/middle finger: support hand and feel for thickened palmar fascia

Question 5

what to look for in arms (GIT exam)

Answer 5

• bruising (ecchymosis): petechiae (little dots) = coagulopathy, liver disease, drug/alcohol
• scratch marks: obstructive liver disease, kidney disease (pruritis - buildup of metabolic waste)
• hepatic flap (asterixis) - hold hands out like stop sign and cock wrists back (hold for 30s)
• fine tremor
• muscle wasting
• acanthosis nigricans = dark patches on armpit folds = insulin resistance

Question 6

what to check in eyes (GIT exam)

Answer 6

• jaundice
• conjunctival pallor - anaemia
• kayser-fleischer rings: copper rings around eye
• iritis (red eye)
• xanthelasma

Question 7

what to check in mouth (GIT exam)

Answer 7

• breath - sweet-smelling
• oral hygiene
• tongue - candidiasis/glossitis (iron, B12, folate deficiency)
• angular stomatitis - cracking/inflammation at the corners of the mouth (iron, B12, folate deficiency or infection)

Question 8

what to check in neck (GIT exam)

Answer 8

• salivary gland enlargement or tenderness - parotid and submandibular
• cervical L/N: submental, submandibular, tonsillar, preauricular, postauricular, occipital, superficial cervical, deep cervical, posterior cervical

Question 9

what to look for in chest inspection (GIT exam)

Answer 9

• spider naevi (veins that look like spiderwebs - increased oestrogen due to liver cirrhosis, pregnancy, contraceptive pill)
• gynaecomastia (male)
• hair loss (male)

Question 10

what to look for in abdominal inspection (GIT exam)

Answer 10

• skin - scars, scratch marks, lesions
• striae (stretch marks) - weight change, ascites, pregnancy, connective tissue disorders
• distension/swelling - ascites, IBS/IBD
• pulsation - AAA
• prominent paraumbilical veins (caput medusae) - portal HTN
• visible peristalsis
• cullen’s sign = bruising around the umbilicus (retroperitoneal haemorrhage that has gone to the skin = haemorrhagic pancreatitis)
• grey-turner’s sign = bruising around the flanks (retroperitoneal haemorrhage that has gone to the skin = haemorrhagic pancreatitis)
• hernia: get Pt to cough and look for protrusions thru abdominal wall

Question 11

what to palpate/percuss in GIT exam

Answer 11

• general - light then deep
• liver: palpate and percuss
• gallbladder - murphy’s sign
• spleen (both)
• kidneys
• bladder (both)
• aorta
• explain you would do inguinal lymph nodes, hernias, rectal exam
• ascites

Question 12

what to do for general first palpation (GIT exam)

Answer 12

• light + deep palpation of 9 regions (observe face)
• if pain, check for guarding (feeling abdominal wall contract), rigidity (no ‘give’ in abdominal wall), rebound tenderness (slowly press in and let go quickly), pain on coughing
• Roving’s sign = if palpation of LLQ causes pain in RLQ = appendicitis (cross-tenderness)

Question 13

how to palpate liver

Answer 13

• normally palpable: ask Pt to take deep breaths in and out, start in RLQ
• liver should be palpable on inspiration with side of R index finger
• as they breathe out, move hand closer to ribs and continue to move closer until you reach liver edge or costal margin
• in emphysema, liver can be pushed down (ptosed) by hyperinflated lungs

Question 14

how to palpate gallbladder

Answer 14

• Murphy’s sign: ask Pt to take deep breath in whilst hand is over RUQ
• if they catch their breath = cholecystitis

Question 15

courvoisier’s law

Answer 15

• a painlessly distended gallbladder + jaundice is unlikely to be gallstones, instead pancreatic cancer

Question 16

how to percuss liver

Answer 16

• percuss from iliac fossa towards ribs (midclavicular line) until it becomes dull = inferior liver border
• repeat downwards from clavicle to find superior liver border

Question 17

how to palpate spleen

Answer 17

• normally not palpable
• place L hand over L costal margin
• place R hand below umbilicus
• move R hand closer to L hand as they breathe in and out
• spleen should move towards R iliac fossa on inspiration

Question 18

How to percuss spleen

Answer 18

• ask Pt to take deep breaths
• percuss lowest IC space in L anterior axillary line - should be resonant
• if dull or becomes dull on inspiration - splenomegaly

Question 19

how to palpate kidneys

Answer 19

• not usually palpable but sometimes lower pole of R kidney can be felt in very thin ppl
• palpate flank (lumbar region) using bimanual ballottement - trapping kidney between hands anteriorly and posteriorly.
• push REALLY hard down w/ top hand, get them to take deep breath in and flick up with bottom hand on their back

Question 20

how to palpate bladder (GIT exam)

Answer 20

• not normally palpable if empty, and even if full may only be just palpable in the suprapubic region
• can be palpable if: full bladder, small children, obstructed urethra

Question 21

how to percuss bladder

Answer 21

• percuss down umbilicus to see if dull
• if resonant = urethra obstruction

Question 22

how to palpate aorta

Answer 22

• feel above umbilicus, seen to transmit pulsation to anterior abdominal wall in thin ppl

Question 23

how to feel for ascites

Answer 23

• percuss from umbilicus to lumbar region on both sides - should be normally resonant.
• if dull = fluid (mark the point), then roll Pt towards the fluid side and stay for 30-60 secs
• dull area should now be resonant = shifting dullness = ascites

Question 24

what to auscultate (GIT exam)

Answer 24

• bowel sounds: normally soft, gurgling, intermittent
• if loud or high pitched with tinkling = obstruction. complete absence for 4 mins = paralytic ileus
• bruits = above umbilicus 2cm either side of midline = narrowing of renal arteries or aorta
• PRESS REALLY HARD

Question 25

what to check for in legs (GIT exam)

Answer 25

- pitting oedema, bruising, scratches

Question 26

pneumoperitoneum

Answer 26

- sub-diaphragmatic air = always indicates perforated abdominal viscera

Question 27

charcot's triad

Answer 27

- jaundice - fever - RUQ pain ('colic' = contracting duct with a stone in it) - indicates ascending cholangitis