Flashcards in Examination: Basic Gastrointestinal Deck (40):
(GI) Step 1:
Prepare the patient
(GI) Step 2:
(GI) Step 3:
--> mental state
--> body habitus
--> muscle wasting
--> distressed/in pain
(GI) Step 4:
Examination of the hands
--> nails for leuconychia (white nail)
--> palmar erythema
--> anemic palmar creases
--> palmar fascia for Dupuytren's contracture
--> metabolic flap presence (asterixis)
(GI) Step 5:
Head and Neck
--> whites of eyes for jaunice
--> conjunctivae for anemia
(GI) Step 6:
Examination of the Chest
--> neck and chest for spider naevi
(GI) Step 7:
Inspection of the Abdomen - ask the patient to lie flat with one pillow and arms by their side
--> scars from past surgery
--> striae/stretchmarks (pregnancy; obesity)
--> distension or masses
--> collateral vessels around the umbilicus called caput medusae (occurs in cirrhosis of the liver with portal hypertension)
--> distended abdo wall veins (obstruction of the IVC)
(GI) Step 8:
Palpation of the abdomen- use your right hand; warm hands; dont hurt them
--> LIGHTLY to identify tenderness, guarding, rigidity, obvious masses
--> DEEPER to identify specific masses or organ enlargment
(GI) Step 9:
Examination of the Liver
--> palpate the lower R quadrant with flat hand on abdomen and parallel to the costal margin
--> apply firm pressure with fingers to feel for liver edge that moves downwards with inspiration (its being pressed down by the diaphragm)
--> Move your hand 2cm towards costal margin during expiration; palpate all the way along the coastal margin especially towards the epigastrium. It is confirmed by ercussing the liver from the lower R quadrant up to the right costal margin (percussion will change from resonant to dull when you reach the liver edge
--> Is the liver firm? are there masses?
--> To identify the upper liver border, percuss from above in the mid clavicular line. Start at the 3rd rib and move down one intercostal space at a time.
--> The upper edge is usually at the level of the 6th rib/5th intercostal space.
-->Measure the span of the liver with a tape measure. The liver span is measured in the midclavicular line. Normal liver span is 12-13 cm
(GI) Step 10:
Examination of the Spleen
--> palpate by positioning the right hand parallel to the costal margin, commencing at the right lower quadrant.
--> palpate as the patient inspires
--> move hand towards costal margin two cm at a time during expiration (also check along costal margin)
--> roll the patient 45 degrees towards you and palpate again on inspiration
--> position your left hand posterolaterally, applying counter pressure. THis allows you to gently move the lower ribs anteriorly and medially, making it easier to feel an enlarged spleen
--> usually a spleen cant be felt, it has to double in size to be felt. You also cannot feel the upper border of the spleen
(GI) Step 11:
Examination of the kidneys
--> done with both hands
--> the right hand is placed under the costal margin and the left is placed posteriorly in the loin region
--> the fingers of the left hand push the kidney anteriorly which the right hand applies psterior pressure.
--> an enlarged kidney can be balloted between the two hands
--> because the kidneys are retroperitoneal they are difficult to feel and may not be possible to feel the lower pole of the kidney in a thin patient
(GI) Step 12:
--> Ascites ( accumulation of fluid in peritoneal cavity commonly due to cirrhosis of the liver); presents as buldging planks, flank dullness,
--> Auscultation of bowel sounds (none in obstruction)
--> check groin for herniae
--> digital rectal examination
(GI) Step 13:
Complete the Examination
How do you test for the presence of a metabolic flap or asterixis?
--> ask the patient to hold both arms up with hands extended and arms outstretched.
--> hands need to be kept in the position for 15 seconds.
--> A flap is preset if there is a F/E movement at the wrists.
What does a metabolic flap suggest?
--> can be present in liver disease signifying hepatic encephalopathy which occurs when high levels of ammonia interfere with brain cell function
When are the whites of the eyes appearing jaundiced?
--> when serum bilirubin level is > 50 micromoles per litre
What are spider naevi or spider angioma?
--> consists of central arteriole with small vessels radiating from it.
--> pressure applied to the centre with obstruct the naevi and it will reperfuse when pressure relieved.
Where are spider naevi usually found?
--> usually found on neck, chest, arms and back in the distribution of the SVC
What are spider naevi a sign of?
--> chronic liver disease
--> oral contraceptive pill use
--> can occur in healthy people too
What is Gynaecomastia?
proliferation of glandular tissue in the male breast
When can gynaecomastia occur?
--> chronic liver disease
How do you examine for gynaecomastia?
--> thumb and index finger placed on either side of the breast and pinched to test in the breast tissue is firm or if it is just fat.
For abdominal inspection, how much abdomen should be exposed?
--> from the xiphisternum to the pubic region
What are the whites of the eyes called?
What is the scientific names for bruising?
- Petechiae --> small pinprick bruises
- Ecchymoses --> med to larger bruises
Why does bruising occur in liver disease?
Because there is a decrease in production of clotting factors 2, 7, 9, 10
What is the scientific name for jaundice?
Where should you look when palpating the abdomen? Why?
The patients face.
To identify pain/discomfort
Where are the liver and gallbladder situated?
Where is the upper limit and lower limit of the liver?
Upper: marked by the plane between the nipples
Lower: protrudes beneath the costal margin only on deep inspiration
Where does the gallbladder project?
- Below the liver at the point where the midclavicular line crosses the costal margin
Where is the stomach situated?
Where is the caecum and appendix located?
Where is McBurney's point?
- 1/3 of the way along a line from the right anterior superior iliac spine to the umbilicus
What does McBurney's point mark?
- both the site of the base of the appendix and the site of incision during appendicectomy
Where is the descending colon and sigmoid colon situated?
Where are the kidneys situated?
They project onto the back on either site of the midline and are related to the lower ribs.
Where is the left kidney in relation to the right kidney?
The left kidney is a little higher than the right and reaches as high as rib 11. The superior pole of the right kidney reaches as high as rib 12. THe inferior pole of both kidneys extends to approximately L3
Where is the level of L4 on the back?
- Relates to a line joining the iliac crests