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GIT Physical Examination Hadeel Khadawardi, teaching assistant at Internal Medicine Department, Faculty of Medicine, Umm Al-Qura University.

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Presentation on theme: "GIT Physical Examination Hadeel Khadawardi, teaching assistant at Internal Medicine Department, Faculty of Medicine, Umm Al-Qura University."— Presentation transcript:

1 GIT Physical Examination Hadeel Khadawardi, teaching assistant at Internal Medicine Department, Faculty of Medicine, Umm Al-Qura University

2 General Approach Vital Signs Position  Flat  On one pillow Introduction  Cachectic  Jaundiced

3 Peripheral Exam Abdominal Exam  Hand  Arms  Face  Neck: LN  Chest  Inspection  Palpation  Percussion (Ascites)  Auscultation GIT Exam

4 Hand Nail Palm Dorsum Wrist

5 Nail  Clubbing  Peripheral Cyanosis  Leuconychia  Koilonychia What are the causes of clubbing? Hand

6 Palm  Pallor  Palmer erythema  Dupuytren contracture Hand

7 Dorsum  Muscle Wasting  Tendonous xanthemata Hand

8 Wrist Flapping tremor(Asterixis) What are the causes of flapping tremor? Hand

9 Arms  Bruising  Petechiae  Muscle wasting  Scratch marks  Spider nevi How to differentiate between Spider nevi, Venous star & Campbell de Morgan spot?

10 Face Eyes Salivary Glands Mouth

11 Face Eye  Jaundice  Pallor  Xanthelasma  Kayser-Fleischer Ring  Arcus Sini  Iritis  Periorbital Purpura

12 Face Parotid gland enlargement What are the causes of unilateral and bilateral parotid gland enlargement?

13 Face Mouth  Jaundice  Central cyanosis  Glossitis  Gum hypertophy & pigmentation  Fetor hepaticus ( methylmerccaptans )  Mouth ulcers

14 Lymph Node Examination Neck What is the difference between Troisier’s sign & Trousseau’s sign?

15 Chest  Gynaecomastia.  Spider Nevi.  Hair Distribution.

16 Abdominal Exam

17 Exposure From the nipple to symphysis pubis.

18 Inspection (7S)  Symmetrical & movement with respiration.  Scar.  Striae.  Stoma.  Shape of the umbilicus (inverted, flat, exerted).  Shape of the flank (full, straight, empty).  Skin lesions. (4P)  Prominent veins (caput medusa, SVC obstruction)  Visible Pulsation (aortic aneurysm).  Visible Peristalsis (NL in thin, intestinal obstruction).  Pigmentation (Cullen’s sign, Gery-Turner’s sign) (1D)  Abdominal Distension (fat, fluid, fetus, flatus, faeces).

19 Palpation Before starting palpation, remember:  Relax the abdominal muscles.  If necessary, ask the patient to bend the knee to relax the muscle.  Ask if any particular area is tender and palpate that area last.  Look into patient facial expression while palpating the abdomen.

20 Palpation Regions of the abdomen

21 Palpation Superficial Palpation  Begin with light pressure in each 9 areas.  Start from the Rt. iliac fossa (anti clock wise).  Note the presence of any tenderness or lump.

22 Palpation Deep Palpation  Apply more pressure in each 9 areas.  Start from the Rt. iliac fossa (anti clock wise).  Note the presence of any deep tenderness or lump. What is the difference between Guarding and Rigidity?

23 Palpation Liver Palpation  Align your hand parallel to the Rt. costal margin, begin in the Rt. Iliac fossa and ask the patient to breath in & out through the mouth.  With each expiration, the hand is moved by 1 or 2 cm closer to the Rt. costal margin.  During inspiration, the hand is kept still waiting for liver edge to strike it.

24 Palpation Liver Span  Upper liver border is defined by percussing down at Rt. 2 nd IC space in MCL, until dullness is encountered.  Lower liver border is defined by percussing up at Rt. Iliac fossa in MCL, until dullness is encountered.  Measure the distance between the two dull areas.  Normal liver span is 10+/-2.

25 What are the causes if hepatomegaly?

26 Palpation Spleen Palpation  One-hand technique: start from Rt. iliac fossa toward Lt. costal margin and ask the patient to breath in & out through the mouth. With each expiration, the hand is moved by 1 or 2 cm closer to the Lt. costal margin.  Two-hand technique: Lt. hand is placed posterolaterally over Lt. lower ribs and Rt. hand is placed below umbilicus toward Lt. costal margin.  If spleen is not palpable, roll the patient to Rt. Side and palpate again.

27 Palpation Spleen percussion  Castell’s Method: percuss on last Lt. IC space & Lt. ant. axillary line. Normally is resonant and dull if splenomegaly.  Traube’s Space: triangle bordered by 6 th rib superiorly, Lt. midaxillary line laterally and Lt. costal margin inferiorly. Normally is resonant and dull if splenomegaly.  Nixon’s Method: place the patient on Rt. Lateral decubitus position, percuss at midpoint of Lt costal margin and proceed perpendicularly toward Lt. posterior axillary line. Splenomegaly if there is dullness > 8 cm.

28  Mild splenomegaly: 1-2 cm below Lt. costal margin.  Moderate splenomegaly: 3-7 cm below Lt. costal margin.  Massive splenomegaly: > 7cm below Lt. costal margin.

29 What are the causes if splenomegaly?

30 Palpation Kidney palpation Bimanual palpation (Balloting)  Lt. hand is slide underneath the renal angle.  Flex the fingers at MCP joints to push the content of the abdomen anteriorly.  Place Rt. hand on the top of abdomen at renal angle to palpate for kidney. Kidney percussion  Kidney is a resonant organ below costal margin.

31 How to differentiate between splenomegaly & Lt. kidney enlargement ?

32 Anterior Abdominal Wall Mass Ask the patient to fold the arms across the upper chest and sit halfway up. If the mass:  Disappear or decrease in size … intra-abdominal mass.  Unchanged … mass is within the abdominal wall.

33 Percussion Ascites Shifting Dullness:  Percuss from the midline out to Lt. flank until dullness is reached.  Mark this point and ask the patient to roll toward you.  Wait for 30 sec. then repeat percuss again.  If the dull area become resonant is indication of ascites.  This maneuver is used to detect mild to moderate ascites.

34 Percussion Ascites Fluid Thrill:  Ask the patient to place the medial edge of his palm firmly on the center of abdomen with fingers directed downward.  Flick the side of abdominal wall and feel the thrill by the other hand on the opposite abdominal wall.  This maneuver is used to detect massive ascites.

35 Percussion Ascites Dipping Maneuver:  To palpate for organomegaly with ascites.  Both hands are placed flat on abdomen and fingers are flexed at MCPs rapidly to displace the underlying fluid.

36 What is SAAG? What is the DDx of portal HTN & non-portal HTN related ascites?

37 Auscultation Bowel Sounds:  Place the diaphragm of stethoscope any where around umbilicus (around iliocecal valve).Percuss from the midline out to Lt. flank until dullness is reached.  Describe it as present or absent. Mark this point and ask the patient to roll toward you.  Absent bowel sounds for 3 min. means paralytic ileus.  Exaggerated bowel sounds mean intestinal obstruction.

38 Auscultation Friction rib  Place the diaphragm of stethoscope over liver and spleen.  Hepatic causes: liver tumor, liver abscess, and liver infarction.  Splenic causes: splenic infarction as in SCA, IE.

39 Auscultation Venous Hum  Place the bell of stethoscope between xiphisternum & umbilicus.  In portal HTN.

40 Auscultation Bruits ( use bell of stethoscope)  Arterial systolic bruit … over liver … HCC.  Renal bruit … on either side of midline above umbilicus … RAS.  Epigastric bruit … epigastric area … mesenteric artery stenosis.

41 To complete your GIT exam, exam:  PR  Back  Legs  Genitalia

42 What are the stigmata of CLD? What are the signs of CLD caused by elevated estrogen level?

43 Optimize, Your Future is Going to be Better ….


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