Gastrointestinal Examination Josh Exley

introduction Wash hands Introduce self Explain procedure, gain consent Positioning 45 degrees until examining abdomen Exposure ‘For this examination, I’ll need you to undress from the waist up. Would you like a chaperone for this?’ ‘Are you in any pain or discomfort at all?’

Initial inspection TALK AS YOU GO ALONG Surroundings Fluids Oxygen Stoma/Catheter bags From the end of the bed Unwell/in pain Visibly jaundiced Cachexia

Hands Look for: Feel for: Clubbing, leukonychia, koilonychia Palmar erythema Asterixis – ‘liver flap’ Feel for: Dupuytren’s contracture Capillary refill Radial pulse

Head and neck Look for: Sclera – jaundice Conjunctival pallor Angular stomatitis Glossitis Apthous ulcers Feel for: Lymph nodes of neck – particularly left supraclavicular (Virchow’s) Eyes Mouth

Inspection of chest/abdomen Gynaecomastia Spider naevi Abdominal distension – 6 Fs Faeces, Fat, Flatus, Foetus, Fluid, F*cking huge masses Caput medusa Scars/Stoma

Palpation Bed now flat Get down to patient’s level Double check no pain – Start furthest away from any tender region General palpation, first superficial then deep, all 9 areas KEEP WATCHING PATIENT’S FACE

Organ specific palpation ‘Take deep breaths in and out’ Press down on inspiration, don’t take your hand off Liver – start in RIF and work towards right costal margin Spleen – start in RIF and work towards left costal margin Kidneys – two-handed balloting

Shifting dullness Percuss from midline to left flank, listening for a change in percussion note Leave finger at first point of note change (resonant to dull) Roll patient towards you and percuss again Test is positive if percussion note is now resonant

Auscultation Bowel sounds Renal bruits Just below umbilicus, should hear within 1 minute Renal bruits Superior and lateral to umbilicus

if you have time Examine legs Peripheral oedema Erythema nodosum Pyoderma gangrenosum ‘I would like to conclude by examining the hernial orifices, the external genitalia and performing a PR exam.’

Finishing up Thank patient and offer to help them get dressed Wash your hands Report to the examiner, if you haven’t done so already Systematic & Concise Always state negative findings