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

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

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

4. Hand
Nail Palm Dorsum Wrist

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

6. Hand
Palm
Pallor
Palmer erythema
Dupuytren contracture

7. Hand
Dorsum
Muscle Wasting
Tendonous xanthemata

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

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. Neck Lymph Node Examination
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. (4P) Scar.
Striae.
Stoma.
Shape of the umbilicus (inverted, flat, exerted).
Shape of the flank (full, straight, empty).
Skin lesions.
Inspection
(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. 2nd 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 6th 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 Kidney percussion
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 ….