1. Methods of Physical Examination for GIT
Taking History &
Methods of Physical Examination for GIT
Koray Topgül
Department of Surgery, MD, Prof.

2. ALL PATIENTS HAVE A PROBLEM!
HOW TO SOLVE IT?
We can, we should….
HISTORY ……70%
CLINICAL EXAMINATION (history+physical exam..80%)
CLINICAL DIAGNOSIS
INVESTIGATIONS
FINAL DIAGNOSIS
TREATMENT

3. IMPORTANT POINTS BEFORE HISTORY-TAKING
Introduce yourself
Explain yourself
Full attention (eye contact)
Treat with respect
Let patient talk
Guide, not dictate
No leading question
No short-cuts
Try not to write and talk to the patient at the same time

4. Different parts of a history
PERSONAL DETAILS
PRESENTING COMPLAINT
HISTORY OF PRESENT ILLNESS
SYSTEMIC INQUIRY
PAST MEDICAL/SURGICAL HISTORY
FAMILY HISTORY
HISTORY OF MEDICATIONS
SOCIAL HISTORY
OTHER HISTORY

5. PERSONAL DETAILS NAME AGE SEX NATIONALITY MARITAL STATUS OCCUPATION
Record date of history taking and examination

6. PRESENTING COMPLAINT What are you complaining of?
(record in patient’s own words)
When more than one complain:
(record in order of severity)

7. HISTORY OF PRESENT ILLNESS
Full details of the complaint or complaints.
Get right back to the beginning of the trouble.
Each complain- fully analyzed e.g., pain
Site
Time and mode of onset ( sudden, gradual)
Severity
Nature (aching, burning, stabbing, constricting, throbbing)
Progression
Duration
Aggravating/ relieving factors
Radiation
Cause

8. SYSTEMIC INQUIRY of the involved or affected system
Example:
Chief complaint related to gastrointestinal system(GI)-
continue with the GIT inquiry.

9. SYSTEMIC INQUIRY GASTRINTESTINAL SYSTEM
Weight
Appetite
Dysphagia
Nausea
Vomiting
Heartburn
Haematemesis
Flatulence
Jaundice
Abdominal pain
Fat intolerance
Constipation
Diarrhoea
Melaena
Rectal bleeding
Stool

10. SYSTEMIC INQUIRY RESPIRATORY SYSTEM
Cough
Sputum
Hemoptysis Hemoptysis[a] or haemoptysis is the act of coughing up blood or blood-stained mucus from the bronchi, larynx, trachea, or lungs.
Wheeze
Dyspnoea
Chest pain
Smoking

11. SYSTEMIC INQUIRY UROGENITAL SYSTEM
Loin pain
Dysuria
Nocturia
Frequency
Haematuria
Urinary stream
Incontinence
Urethral discharge

12. SYSTEMIC INQUIRY CARDIOVASCULAR SYSTEM
Angina (cardiac pain)
Dyspnoea ( rest/ exercise)
Palpitations
Ankle swelling
Claudication
Varicose veins

13. SYSTEMIC INQUIRY Obstetric & Gynecology Vaginal discharge
Vaginal bleeding
Pregnancies
Nervous system
Headache
Fits
Depression
Facial/limb weakness

14. SYSTEMIC INQUIRY MUSCULOSKELETAL
Muscular pain
Bone & Joint pain
Swelling of joints
Limitation of movements
Weakness

15. SYSTEMIC INQUIRY METABOLIC/ENDOCRINE
Bruising/ bleeding
Sweating
Thirst
Pruritus
Alcohol
Weight

16. PAST MEDICAL/SURGICAL HISTORY
Rheumatic Fever
Tuberculosis/ Asthma
Diabetes
Jaundice
Operations/ Accident
Blood transfusion
Mental illness

17. FAMILY HISTORY Diabetes Hypertension Heart disease Malignancy
Cause of death
Father/Mother/Siblings/Spouse/Children/Close relatives

18. HISTORY OF MEDICATIONS
Insulin
Steroids
NSAID
Contraceptive pills
Antibiotics
Others

19. SOCIAL HISTORY Marital status Occupation Travel abroad Accommodation
Habits ( smoking, alcohol )
Dependent relatives

20. OTHER HISTORY Food Drugs Tetanus Diphtheria Tuberculosis Hepatitis
Psychiatric/ Emotional background
Allergies
Food
Drugs
Immunizations
Tetanus
Diphtheria
Tuberculosis
Hepatitis
Others

21. Review and analyse
More questions looking for clues?
Questions

22. ABDOMINAL EXAMINATION

23. GASTROINTESTINAL EXAMINATION
General examination
General inspection
Hands and arms
Face, eyes and mouth
Neck
Abdominal examination
Inspection
Palpation
Percussion
Auscultation

24. GENERAL INSPECTION Nutritional state (wasting) Pallor
Jaundice (liver disease)
Pigmentation (hemochromatosis)
Mental state (encephalopathy)
Nutritional state – record weight, height, waist circumference
May indicate
haemochromatosis
iron overload indicates accumulation of iron in the body

25. FACE, EYES … Conjuctival pallor (anaemia) Sclera: jaundice, iritis
Cornea: Kaiser Fleischer’s rings (Wilson’s disease)
Xanthelasma (primary biliary cirrhosis)
Parotid enlargement (alcohol)
Uveitis, Iritis
Uveitis is swelling and irritation of the uvea, the middle layer of the eye. The uvea provides most of the blood supply to the retina.
Kayser-Fleischer rings
are dark rings that appear to encircle the iris of the eye. They are due to copper deposition as a result of particular liver diseases.

26. ABDOMINAL EXAMINATION POSITIONING
Abdomen can be divided in four quadrants
Patient should be lying on supine position
In order to accurately localize the findings on physical examination, one usually divides the abdomen into four quadrants:
Upper right and left
Lower right and left
The dividing lines are:
Vertically, a connecting line between the xiphoid process and the pubic symphysis;
Horizontally, a line across the umbilicus.
Examine the patient in good light and warm surroundings.
Position the patient comfortably supine with the head resting on one pillow in order to relax the muscles of the abdominal wall.

27. ABDOMINAL EXAMINATION INSPECTION
Shape and movements
Scars
Distension
Localised: mass, organomegaly
Generalized: 5 F’s
Prominent veins (caput medusae)
Striae
Bruises
Pigmentation
Visible peristalsis
Shape and movements with respiration – flat or slightly scaphoid (shaped like a boat)
Scars from previous surgical procedures
Distension
Localised: malignancy, hepatopathy, splenomegaly
Generalized: Fat (obesity), fluid (ascites), flatus (obstruction), faeces (constipation), fetus (pregnancy)
Prominent veins (caput medusae) in portal hypertension blood flows trough portocaval anastomoses. Image: end stage liver disease
Striae
Visible peristalsis

28. Pigmentation: Cherry angiomas "Campbell De Morgan spots," cherry red papules on the skin containing an abnormal proliferation of blood vessels. They are the most common kind of angioma.
Ascites – bulging flanks
Ascitic abdomen

29. ABDOMINAL EXAMINATION PALPATION
Ensure that your hands are warm
Stand on the patient’s right side
Help to position the patient
Ask whether the patient feels any pain before you start
Begin with superficial examination
Move in a systematic manner through the abdominal quadrants
Repeat palpation deeply.
Leave the painful area for last. Move in a systematic manner through the nine regions of the abdomen in the direction of the painful area.
Make sure you use the pads of your fingers and not the finger tips as this might hurt the patient.

30. ABDOMINAL EXAMINATION PALPATION
Tenderness: discomfort and resistance to palpation
Involuntary guarding: reflex contraction of the abdominal muscles
Rebound tenderness: patient feels pain when the hand is released
Tenderness + rigidity: perforated viscus
Palpable mass (enlarged organ, faeces, tumour)
Aortic pulsation
ABNORMAL FINDINGS

31. ABDOMINAL EXAMINATION MURPHY’S SIGN
Pain in RUQ
Inflammation of gallbladder (cholecystitis)
Courvoisier's law
Murphy's sign
sign of gallbladder disease consisting of pain on taking a deep breath when the examiner's fingers are on the approximate location of the gallbladder.
Pain on inspiration during gentle palpation below the right subcostal arch. As the patient breathes in, the liver moves down exposing the gallbladder to pressure from the examiners hand. Murpy’s sign may also be present with hepatitis.
The gallbladder (GB) is filled with echogenic sludge (Sl) and a gallstone (red arrow) is impacted in the gallbladder neck.  The gallbladder wall (red arrowheads) is markedly thickened indicative of wall edema and there are pericholecystic fluid (blue arrows) pockets surrounding the gallbladder.
Courvoisier's law
states that in the presence of an enlarged gall bladder which is nontender and accompanied with jaundice, the cause is unlikely to be gallstones.

32. ABDOMINAL EXAMINATION BLUMBERG’S SIGN
a.k.a. rebound tenderness
Pain upon removal of pressure rather than application of pressure to the abdomen
Peritonitis and/ or appendicitis

33. ABDOMINAL EXAMINATION MCBURNEY’S POINT
1/3 ASIS to umbilicus
Location of AV in retrocecal position
Deep tenderness (= acute appendicitis)
From ASIS (anterior superior iliac spine) to the umbilicus.
Determines:
- location of appendix (varies)
- deep point = acute appendicitis

34. ABDOMINAL EXAMINATION FLUID THRILL
Place the palm of your left hand against the left side of the abdomen
Flick a finger against the right side of the abdomen
Ask the patient to put the edge of a hand on the midline of the abdomen
If a ripple is felt upon flicking we call it a fluid thrill = ascites
IF IT IS NOT CLEAR

35. ABDOMINAL EXAMINATION PALPATION OF THE LIVER
Start palpating in the right iliac fossa
Ask the patient to take a deep breath in
Move your hand progressively further up the abdomen
Try to feel the liver edge
Try to feel the liver edge and work out if it is enlarged or displaced downwards.

36. ABDOMINAL EXAMINATION PALPATION OF THE SPLEEN
Roll the patient towards you
Palpate with your left hand while using your left hand to press forward on the patient’s lower ribs from behind
Feel along the costal margin
Try to feel the liver edge and work out if it is enlarged or displaced downwards.

37. ABDOMINAL EXAMINATION PERCUSSION
Dull sounds: solid or fluid-filled structures
Resonant sounds: structures containing air or gas

38. ABDOMINAL EXAMINATION AUSCULTATION
Place the diaphragm of the stethoscope to the right of the umbilicus
Bowel sounds (borborygmi) are caused by peristaltic movements
Occur every 5-10 sec.
Absence of b.s.: paralytic ileus or peritonitis
Bruits over aorta and renal a. could be a sign of an aneurysm and stenosis