Leicester Medical School

Transcription

1 Leicester Medical School Overview THE GASTROINTESTINAL SYSTEM PHYSICAL EXAMINATION The abdominal examination should include the following: - General inspection from the end of the bed. - General examination of: o Hands / pulse o Face o Lymph nodes - Examination of the abdomen. o Inspection o Palpation o Percussion o Auscultation Preparation - Introduce yourself to the patient if you have not already done so and check the identity of the patient - Wash your hands - Ask the patients permission to carry out the examination - Give a brief explanation to the patient before you start. Further explanation/instructions can be given as you proceed. - Equipment o Stethoscope - Patient position o Ideally the patient should be lying flat with the head propped on a single pillow and the arms at the sides. o When you are ready to examine the abdomen it should be exposed from above the costal margins to the level of the symphysis pubis. General Observations - Check visually from the end of the bed. Note: o Obvious discomfort/pain, breathlessness, distension o Colour o Items around the bed (e.g. catheter bag, IV fluids) Hands

2 Eyes - Inspect both hands; nails, back and then palms. o You should be able to recognise, and know the significance of, the following: anaemia, dehydration, clubbing, leukonychia, koilonychia, palmar erythema, Dupuytren's contracture, spider-naevi. - Feel the radial pulse. Note the rate, rhythm and volume - Check for hepatic flap of liver failure (if appropriate) o Ask patient to stretch arms out in front of them with the wrists dorsiflexed and fingers extended. o Look for irregular, jerky flexion/extension at the wrists and MCP joints - Gently pull down lower eyelids and ask the patient to look up. Inspect for: o pale conjunctiva of anaemia o yellow sclera of jaundice ideally in natural light Mouth - Ask patient to open their mouth. Inspect the teeth, tongue, gums and inner surface of the cheeks o You should be able to recognise, and know the significance of, the following: ulcers, candidiasis, changes to the tongue e.g. glossitis, macroglossia, - Note any obvious odour of the patients breath e.g. Fetor hepaticus, ketosis, uraemia Neck Virchow s Node An enlarged supraclavicular lymph node on the left-hand side. Suggestive of gastric malignancy. - Palpate for enlarged lymph nodes, first from the front, then back/right. o Occipital o Post-auricular o Pre-auricular o Submandibular o Submental o Anterior and posterior cervical o Supraclavicular (check for Virchow s Node) The Abdomen INSPECTION With the abdomen exposed, look carefully for - Scars, abdominal distension, focal swelling, asymmetry - You should be able to recognise, and know the significance of, the following: dilated/prominent veins, visible peristalsis, obvious pulsation, skin discolouration. - Note the location and nature of any surgical stomas PALPATION You should be at the same level as the patient to palpate the abdomen, looking at the patients face for any signs of discomfort.

3 The abdomen should be examined by light (superficial) and deep palpation in all 9 areas before examining specific organs. The order they are examined in does not matter. Remember to examine any areas of tenderness last. Ask the patient if they have any pain before commencing. Light Palpation - Gently palpate all nine areas - Start away from known pain. - Hold your hand flat, and gently press in by extending at the MCP joints to palpate with the palmar surface of your finger - not digging in with your finger tips. - If there is pain on light palpation, try and determine if this is rebound tenderness Deep Palpation - Re-examine using the same technique but now using more pressure - Note any masses or structural abnormality - Masses should be described in terms of site, size, shape, surface, consistency, mobility, movement with respiration, tenderness and pulsatility The Liver - The liver is not normally palpable. - Start palpation from the right iliac fossa using the same technique as before but angle your hand so that the index finger is aligned with the costal margin - Ask the patient to take breaths in and out as you proceed, and feel for the descending liver edge on inspiration - If the liver is not felt move your hand 1-2cm superiorly toward the right hypochondrium during expiration, ready to apply gentle pressure again during inspiration - Repeat this process until the liver edge is palpated or you reach the costal margin. - Describe your findings o o o Note how far beyond the costal margin the liver extends in centimetres Is the surface smooth or irregular? Is there any tenderness? The Spleen - Start palpation from the right iliac fossa moving diagonally toward the left hypochondrium - Ask the patient to take breaths in and out as you proceed and use the same technique as for the liver - Describe your findings as for the liver. - In healthy individuals the spleen is not palpable. It enlarges along the line of the 9 th rib and moves downwards and inwards on inspiration. - The spleen has a distinctive notch which can help to differentiate it from other structures in splenomegaly The Kidneys Practice Tip! The liver edge is sometimes palpable just below the costal margin at the height of inspiration in normal healthy individuals. Practice your technique on your colleagues Practice Tip! The right kidney lies a little lower than the left. The lower pole of the right kidney may be palpable in normal, thin individuals. Rebound Tenderness pain is worse when you release pressure on the abdomen than when you press down this is a sign of peritoneal irritation

4 - The kidneys are not normally palpable; however, you may feel the lower pole of the right kidney in a thin person. - Place your left hand behind the patients back just below the ribs at the right hand side - Place your right hand on the abdomen below the right costal margin just lateral to the rectus abdominis. - Ask the patient to breathe out and push your hands together firmly (but gently) - Ask the patient to breathe in. You may feel the lower pole of the kidney moving down between the hands - If this happens try to Ballot or push the kidney back and forward between your hands - Repeat for the left kidney by leaning over and placing the left hand under the left loin. Bladder - Palpable suprapubically if full - Start palpation from umbilicus with index finger horizontal and proceed inferiorly toward symphysis pubis Aorta - Palpate in the vertical midline of abdomen above the umbilicus. - Place the fingers on either side of the outer margins, feeling for pulsation - Normal diameter is 2-3cm - Palpable in most healthy people. Percussion may reveal enlargement of the spleen that is not detectable on palpation. This is because the spleen would have to be 2-3 times its normal size to be palpable on abdominal examination PERCUSSION - You should percuss any lumps or masses identified on palpation to determine their size and nature - Percuss individual organs to help determine their size (you may see some clinicians percuss the 9 regions) - If the abdomen appears distended and you suspect the presence of ascites test for shifting dullness and fluid thrill The Liver - Percuss from right iliac fossa upwards - Identify both the lower and upper borders of the liver - Note the length in centimetres at the midclavicular line The Spleen - Percuss from the right iliac fossa diagonally toward the left hypochondrium - Continue percussing over the ribs toward the midaxillary line and lower left ribs for dullness. Bladder - Begin percussing from just above the umbilicus with the finger positioned horizontally on the abdomen - Percuss inferiorly toward the symphysis pubis. Ballotting the Kidney This demonstrates the mobility of the kidney - helping to confirm what the structure is.

5 Shifting Dullness - Percuss from the centre of the abdomen laterally with the fingers positioned longitudinally until dullness is detected. - Keep your finger pressed there (or mark the spot with a pen) as you - Ask the patient to roll on to the opposite side to where you have marked - Wait at least 30 seconds - Repeat percussion moving from this point back toward centre - If the dullness was an air/fluid level, the previously dull area will now be resonant as fluid is moved away by gravity. Practice Tip! Practise listening to as many abdomens as possible to recognise the range of sounds produced by normal peristalsis Fluid Thrill - Place your left hand flat against the left side of the patients abdomen - Ask the patient to place the edge of one hand longitudinally on midline of abdomen to prevent transmission of the impulse via the skin - Tap on the right side of the abdomen with the right hand - Feel for a ripple of fluid against the left hand AUSCULTATION Bowel Sounds - Listen with the diaphragm of the stethoscope just below the umbilicus - Describe findings you should be able to recognise and understand the significance of: o Normal, tinkling and absent bowel sounds. You may have to listen for a while if the sounds are quiet Bruits - Listen with the diaphragm of the stethoscope for turbulent blood flow o Over the aorta, just above the umbilicus o Over the renal arteries just above and to either side of the umbilicus o Over the liver Completing the Examination - Cover patient /assist to redress if necessary - Thank the patient - For completion you should also consider: o Examination of hernial orifices o Digital Rectal Examination o Examination of external genitalia - Bed side tests o Blood Pressure and Temperature o Urine dipstick Ascites and Shifting Dullness Ascites is free fluid within the peritoneum. With the patient lying on their back, gravity will cause the fluid to move toward the patients back and the bowel will float centrally. When the patient is rolled to onto their side, the fluid will be moved by gravity to the side they are lying on. On percussion any dullness caused by the presence of fluid will also move.

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