Professional Documents
Culture Documents
Work from:
Hands
Up to face
Down to chest
Down to abdomen
Down to lower legs
GI-Abdominal Exam
Disclaimer: This is by no means a comprehensive list, but is based on Macleod’s, EEMEC
exam videos and ICP tutorials.
WINDEC. Introduce self. Explain exam. Ask for patient’s permission to perform exam.
GENERAL OBSERVATION
Ensure patient is flat on the bed with arms by their side, shirt removed.
GENERAL INSPECTION
Build, colour, demeanour, nutritional state, bruising, scratch marks
Surrounding equipment e.g ECG electrodes, O2 equipment
Hands
- Clubbing - palpate either side of nail
associated with cardiovascular disease such as infective endocarditis, cyanotic
congenital heart disease, as well as chronic liver disease and IBD.
increased fluctuance of nail, loss of nailbed angle, increasing
curvature of nail
- Leukonychia – horizontal white bands on nails: Assoc. w/ liver cirrhosis
- Palmar erythema – red palms: Assoc. w/ liver cirrhosis
- Dupuytren’s contracture – nodular thickening in connective tissue of palm. Causes
fixed finger flexion: Assoc. w/ excess alcohol, but also vibrating tool use
- Asterixis - Check for flapping tremor – ask patient to extend hands and point fingers
to ceiling – a tremor indicates CO2 retention or liver cirrhosis
Face
- Scleral jaundice – inspect eyeball for yellowing
- Xanthelasma – inspect surrounding face for cholesterol deposits
- Conjunctival pallor – pull lower eyelids down and ask patient to look up: Assoc w/
anaemia
- Mouth Ulcers: Assoc. w/ Crohn’s and Coeliac Disease
- Perioral pigmentation: Bright pigments assoc. w/ multiple intestinal polyps e.g
Putz-Jaeger syndrome
- Telangiectasia (small spider veins, patterning) on lips and nose: Assoc. w/ GI bleeding
Chest
Inspection:
Spider naevi – red dots on chest, face, upper limbs. Pressing on one will cause it to blanch
then when pressure removed, colour will return from centre outwards. >3 indicates liver
cirrhosis however also possible in pregnancy.
Gynaecomastia and Axillary Hair Loss: Assoc. w/ liver cirrhosis
Left Supraclavicular Lymph Node – receives lymph drainage from entire abdomen, therefore
enlargement may occur in malignancy.
Abdomen
Inspection: Scars, stomas, distension, masses, visible veins, abdominal movement.
- Scars:
- Visible veins: Caput medusa is a sign of portal hypertension. Other visible veins may
be due to IVC blockage.
- Abdominal shape should be assessed from the side of the bed, squatting so that
abdomen is at eye-level. Ask patient to take deep breaths.
Abdominal Palpation:
- Superficial, deep, organomegaly. Be sure to cover all 9 areas, leaving any painful
areas till last, and beginning from furthest away.
- Superficial – palpate gently by resting hand and rocking fingers – watch patient’s
face for pain. Rebound Tenderness suggest peritoneal inflammation.
- Deep – repeat areas but press more firmly – feel for masses and organomegaly.
- Abdominal regions:
- Organomegaly – liver spleen and kidneys.
o Liver: enlarges towards the right iliac fossa. Begin by placing hand at umbilicus
parallel to anticipated liver edge. Ask patient to breathe deeply. As they inhale,
the liver will be pushed downwards which may be felt as a light tap against the
index finger. If nothing is felt move your hand towards the costal margin and
repeat. If liver is enlarged then trace it’s position towards the midline to
determine extent.
▪ Percussion is performed to define upper and lower borders of liver.
Helps to differentiate between enlarged liver or liver which is being
pushed down by hyperinflated lungs. Percussion over abdomen should
be resonant but over enlarged liver or spleen will be dull. Percuss from
areas of resonance (above 6th rib superiorly) to areas of dullness.
o Spleen: Repeat exact same process as above but begin from left iliac fossa. If
spleen is not palpable, roll patient on to their right side. Percussion is
performed if splenomegaly is suspected but is not considered standard
practice in a routine exam. Enlarged organs appear below:
o Kidneys: Place hand underneath flank and push down on anterior area with
other hand as you flick briskly with the hand that’s underneath the patient.
- Percussion: Liver, spleen, bladder, shifting dullness (ascites).
o Begin from the midline and move laterally. Once the tone changes from
resonant to dull, keep hand in that position and ask the patient to roll away
from you. Percuss again. If the transition point from resonance to dullness has
moved, then fluid presence is suggested.
▪ If fluid is suspected, then examine for fluid thrill. Ask patient to press
down on their midline with the lateral edge of their hand. Percuss firmly
in one flank by flicking your finger and feel for a transmitted wave in the
other flank.
- Auscultation: bowel sounds, bruits.
o Bowel sounds – heard anywhere – consider frequency and character.
Diminished or absent bowel sounds occur in peritonitis. Frequent high pitched
tinkling sounds indicate intestinal obstruction.
o Bruits – listen over liver. May indicate tumour or alcoholic hepatitis. If one is
heard, then listen to the heart as well to exclude possibility of transmitted
sounds.
Legs
- Inspect.
- Check for peripheral oedema which may indicate liver or kidney disease.