malignancy

Appetite & weight change

depression malnutrition thyrotoxicosis reflux esophagitis with stricture carcinoma intrinsic Mechanical esophageal web pharyngeal pouch Schatzki ring extrinsic achalasia neuromuscular esophageal spasm scleroderma goitre tumor

colon cancer or IBD jaundice anemia splenectomy cholecystectomy NSAIDs halothane, phenytoin phenothiazines anabolic steroids, contraceptive pills (dose-related) paracetamol toxicity cholestasis bleeding in GIT acute hepatitis

Family Hx
causes

dysphagia Treatment

odynophagia

painful swallowing

difficulty initiating swallowing >>pharyngeal dysphagia intermittent >>esophageal spasm or lower ring progressive >>stricture, carcinoma, achalasia solid & liquid >>motor disorder

acute liver cell necrosis

in liver dis.

pruritus & lethargy

timing obstructive or cholestatic >>pale stool & dark urine contents GI infection pregnancy causes source is proxiaml to or at deudenum commonly due to peptic ulcer Mallory-Weiss tears occur with repeated vomitting bright red blood per rectum not mixed with stools hematochezia hematemesis drugs Causes peptic ulcer gastric outlet obstruction hepatobiliary disease

jaundice

nausea & vomitting

bleeding

alcoholism psychogenic retrosternal move upward to throat after meals

hemorrhoids & anorectal dis.

Melena solitary rectal ulcer fistula or villous adenoma IBS infrequent stools (<3 times/week) hard stools difficult evacuation codeine, antidepressant, Ca antacids) hypothyroidism DM hypercalcemia hypokalemia Hirschsprung dis. aganglionosis multiple sclerosis alternating diarrhea & constipation with abdominal pain and no other abnormalities irritable bowel syndrome (IBS) neurological agg./reliev. factors endocrine dis. Causes drugs presentation

Mucus

heartburn & acid regurgitation

agg. by bending or supine & reliev. by antacid sour or bitter taste in mouth >>gastro-esophageal reflux excessive secretion of saliva into mouth waterbrash don't confuse with regurgitation in peptic ulcer & esophagitis frequency & duration site back >>pancreatic dis., peptic ulcer shoulder >>diaphragmatic irritation neck >>esophageal reflux acute or chronic

constipation

radiation character

meals Antacid

vomiting defecation
dull or burning in epigastrium

frequent stools (>3/day) loose or watery consistency high volume persist with fasting diminish with fasting volume related to food excessive solute drag

peptic ulcer presentation

relieved by food or antacid episodic steady, epigastric

secretory

abdominal pain

pancreatic pain

relieved by sitting & leaning forward radiate to back associated with vomiting

osmotic

abnormal intestinal motility inflammation of colon small frequent stools associated blood or mucus steatorrhea fatty, pale, foul stools malabsorption exudative

Types

diarrhea

pattern

biliary pain

epigastric,sever,constant in Rt hypochondrium with cholecytitis colicky superimposed on constant pain in renal angle radiate to groin colicky

renal colic

bowel obstruction

vomiting constipation distension

anorexia+weight loss >>malignancy, depression Written by: Mohammad Al-Marhoon Dr.Marhoon@Gmail.com Reference: Clinical Examination (Talley) WWW.SMSO.NET

appetite or weight change

increased apetite+weight loss >>malabsorption, thyrotoxicosis

Legs (bruising, edema) cardiac failure >>hepatomegaly

Others

Rectal Examination
scars lumps, swellings visible cough impulse relation to pubic tubercle palpable impulse cough reduce it Palpation define type (Read the other map) cervical lymph nodes GI malignancy especially on Lt side large Lt supraclav. LN +carcinoma of stomach Troisier's sign chronic liver dis. cirrhosis (tender) alcoholics spironolactone, digoxin, cimetidine drugs jaundice anemia brownish green rings at periphery of cornea deposition of excess copper (Wilson's dis.) Slit-lamp exam. IBD amyloidosis iritis Kayser-Fleischer rings Eyes gynecomastia supraclavicular nodes Inspection

Hernia Position
lying flat & head on 1 pillow expose: nipples to midthigh (pubic symphysis) Jaundice natural day light malabsorption, malignancy, alcoholic cirrhosis generalized >>chronic liver dis. (hemochromatosis) malabsorption spots around mouth & buccal mucosa Peutz-Jeghers synd. Hamartoma in bowel autosomal dominant risk of adenocarcinoma Acanthosis nigricans Hereditary hemorrhagic telangectasia Porphyria cutanea tarda Systemic sclerosis mental state (hepatic encephalopathy) confluent papilloma >>velvety elevations axilla, nape of neck lips, tongue autosomal dominant fragile vesicles heal by scarring

Abdomen

weight & wasting

Pigmentation

Spider nevi

Neck & Chest General appearance

skin

hepatocellular damage portosystemic shunting

Xanthelasma periorbital purpura (rare) Nails leuconychia <<hypoalbuminemia clubbing <<cirrhosis, IBD -chronic liver dis. -pregnancy -thyrotoxicosis -rheumatoid arthritis -polycethemia thickening & contraction of palmar fascia causing permanent flextion (mostly in ring finger) alcoholism manual workers Astrexis (flapping tremor) -liver failure -cardiac, resp., renal failure -hypoglycemia, hypokalemia

normal in impalpable parotititis facial nerve palsy parotid tumor mumps sarcoidosis, lymphoma Mikulicz synd. opposite upper 2nd molar calculus in parotid duct submandibular gland enlargement gum hypertrophy pigmentation sweet smell severe hepatocellular dis. elongation of papillae in pos. part no symptoms slowly changing red rings & lines vit. B2 deficiency white thickening of mucosa Sore teeth Smoking Spirits Sepsis Syphilis smooth erythematous tongue atrophy of papillae, ulceration nutritional deficiency (iron, folate, vit. B12) -Down's synd. -acromegaly -tumor -amyloidosis -Crohn's dis. -Celiac dis. glossitis leukoplakia Tongue Mouth fetor hepaticus parotid enlargement Salivary glands

GI General Examination
Hands
palms

palmar erythema anemia

calculus (mostly)

Dupuytren's contracture

lingua nigra (black tongue) Geographical tongue

Face

ecchymoses & petechia wasting scratch marks pruritus

-cirrhosis -viral hepatitis - 2nd-5th month pregnancy arm, neck, chest blanch by pressure (flow from center to periphery) spider naevi DDx Campbell de Morgan spot Hereditary hermorrhagic telangectasia abdomen, chest not blanch by pressure

Arms

lips, tongue not blanch by pressure feet, legs blanch by pressure (flow from periphery to center)

venous stars macroglossia aphthous ulcer angular stomatitis Ulcers Candidiasis (moniliasis)

deficiency of vit. B6 & B12, folate, iron Candida albicans -immunosuppression -broad-spectrum antibiotics -faulty oral hygiene -DM

Written by: Mohammad Al-Marhoon Dr.Marhoon@gmail.com Reference: Clinical Examination (Talley)

distension scars, stoma umbilicus

Fat Fluid Fetus Flatus Feces Filthy big tumor Phantom pregnancy

ascites >>everted & point downward pregnancy or big tumor >>upward check blood flow above & below umbilicus

external hemorrhoids skin tags rectal prolapse anal fissure anal fistula anal warts carcinoma of anus pruritus ani palpate prostate in male & cervix in female pt. strain to assess anal tone below umbilicus complete absence over 3 min. >>paralytic ilues in obstruction >>loud & high pitch non-specific continuous low pitched soft murmur between xiphisternum & umbilicus in portal hypertension Cruveilhier-Baumgarten synd. (venous hums +dilated veins) almost always due to cirrhosis not continuous -hepatocellular cancer -alcoholic hepatitis arterial systolic bruit over liver renal bruit epigastruim hepatomegaly liver span massive hepatic necrosis free gas in peritoneal cavity lowest intercostal space in Lt ant. axillary line dull in expiration >>spleenomegaly resonant (overlying bowel) Kidneys Bladder fluid first accumulate in flanks >>dull detected when >2L of fluid start in midline toward flanks & finger pointing downward good sensitivity & specificity mark point of dullness pt. rolled to side & wait 30 sec. repeat percussion >>resonant in massive ascites pt. put medial aspect of hand on center of abdomen flick one side & feel pulsations (thrill) on other side palpate organs or masses in ascites flex the flat hand at metacarpophalangeal joint rapidly to displace fluid cirrhosis alcoholic hepatitis fulminant hepatic failure congestive heart failure Budd-Chiari synd. myxedema peritoneal carcinomatosis TB pancreatic ascites nephrotic synd. Low gradient (<1g/dL) causes Kidneys High gradient (>1g/dL) Dipping Fluid thrill shifting dullness Gallbladder Spleen loss of liver dullness Liver Venous hums friction rub Bowel sounds skin lesion striae veins below umbilicus

flow toward legs >>caput medusae (portal hypertension) flow toward head >>inf. vena caval obstruction

Inspection
Rectal Examination

-ascites -pregnancy -loss of weight -Cushing's synd.

Hernia, local swelling visible peristalsis pulsations pyloric obstruction small bowel obstruction in epigastrium >>abdominal aortic aneurysm normal in thin people Cullen's sign Grey-Turner's sign Sister Joseph nodule (metastatic tumor deposit in umbilicus) symmetry with breathing

Auscultation

pt. breath through mouth bend knees to relax more ask about pain or tenderness Superficial palpation Guarding Rigidity peritoneal irritation peritonitis

Bruits Deep palpation

rebound tenderness

renal a. stenosis mesenteric arterial stenosis

start in Rt iliac fossa move hand with expiration total liver span normal is <13 cm causes Edge -emphysema -asthma -subdiaphragmatic collection -Riedel's lobe hand perpendicular to costal margin from medial to lateral with jaundice causes of enlargement Ca head of pancreas Ca ampulla of Vater choledocholithiasis without jaundice acute cholecystitis Mucocele or empyema Ca gallbladder

Examining Abdomen

Liver

ptosis

Percussion

Palpation

Murphy's sign

pt. catches breath if inflamed gallbladder is touched if gallbladder is enlarged & pt. jaundiced, the cause is unlikely to be gallstons.

Courvoiser's law Ascites Spleen

enlarge inferiorly & medially bimanual plapation with right lateral decubitus position palpable if enlarged 2 times Causes of splenomegaly bimanual method (ballotting) causes of enlargement upper border of spleen not palpable distinguish large Lt kidney with splenomegaly notch in medial border of spleen spleen move inferiomedially kidney move inferiorly spleen is not ballottable percussion dull over spleen resonant over kidney friction rub heard over spleen Pancreatic pseudocyst epigastric doesn't descend with inspiration empty bladder is impalpable check if lesion in the wall or intra-abdominal pt. fold arm across chest & sit halfway up Lt hand underneath back (renal angle) to push contents ant. Rt hand over Rt hypochondrium

Written by: Mohammad Al-Marhoon Dr.Marhoon@Gmail.com Reference: Clinical Examination (Talley) WWW.SMSO.NET

Pancreas Bladder

Ant. abdominal wall (Carnett's test)