Gastrointentinal Assessment

 

Emergency

 

Hx

Ex

Ix

Mx

 

Index

 

 

  

 

Gastrointestinal History

 

HPI

PMH

 

Social

 

Family

 

 

  

Gastrointestinal History of Presenting Illness (HPI)

 

-  Diarrhoea: IBS, gastroenteritis, malabsorption

-  Steatorrhoea: pancreatic insufficiency

-  Others effected: infectious

-  Constipation: opiates, bowel obstruction

-  Melena: PUD, gastric cancer

-  Haematochezia: haemorrhoids, bowel ca, IBD, diverticulitis, polyps, anal fissure, dysentry

-  Nausea

-  Vomiting

-  Haematemesis: PUD, gastric cancer

-  Projectile

-  Dyspepsia: GORD

-  Dysphagia

-  Abdominal pain

-  Abdoinaml mass

-  Jaundice

-  Distension (6 Fs)

-  Foetus

-  Fat

-  Fluid

-  Filthy big tumour

-  Flatus

-  Phantom pregnancy

          

 

 

  

Gastrointestinal Past Medical History (PMH)

 

-  Bowel Cancer, polyps, haemmorhoids

-  Hernia

-  Gall stones, diverticulitis, CF

-  Surgery

-  Scars: laparascopic port sites

-  Cholecysectomy (laparascopic), appendectomy, hernia repair

-  Bowel resection

-  Infections: Hepatitis

-  Medications

-  NSAIDs: PUD

-  Abx: hepatitis, gastroenteritis, pseudomembranous colitis

-  Immunosuppressants: liver transplant

          

 

 

  

Gastrointestinal Social & Personal History

 

-  Alcohol Hx

-  Chronic liver disease, cirrhosis

-  Illicit drugs: IVDU (Hep B,C)

-  Diet & nutrition: vegetarian, intolerances

-  Travel: Hep A/B/C, gastroenteritis

 

 

 

  

Gastrointestinal Family History

 

- CF, atopy

- COPD: alpha 1 antitrypsin def.

- Smokers: COPD, lung Ca

- Occupation: silicosis, asbestos: restrictive lung disease

 

 

 

 

Gastrointestinal Examination

 

General

 

Head

 

Arm

 

Chest

Abdo

Leg

 

 

 

  

General Gastrointestinal Examination

 

-  Jaundice

-  Weight

-  Ideal body weight (IBW)

-  Wasting or weight loss: stretch marks, loose skin, sunken cheecks

-  Obesity: BMI

-  Petechiae (thrombocytopaenia): liver disease, hypersplenism

-  Echymosis (coagulopahty): liver disease, obstructive jaundice

-  Confusion: Wernickes encephalopathy (EtOH)

-  Memory loss: Korsakovs psychosis (EtOH)

-  Scratch marks (pruritis): jaundice

-  Hyperpigmentation

-  Generalised: Haemochromatosis

-  Pressure areas, mouth, nipples, palmar creases, sun kissed: malabsorption

-  Haemorrhoids

-  Chronic liver disease

-  Constipation

 

 

 

  

Gastrointestinal Upper Limb Exam

 

-  Arthropathy: IBD

-  Palmar erythema: liver disease

-  Kolinychia: IDA

-  Leuconychia (Terrys nails) or Muehrckes lines: hypoalbuminaemia

-  Clubbing: liver disease, IBD, coeliac disease

-  Russels sign

-  Red knuckles from inducing vomiting

-  Bulaemia (purging)

-  Blue lanulae &/or choreathetoss: Wilsons disease

-  Asterixis: hepatic encephalopathy

-  Resting tremor: EtOH withdrawal

-  Dupuytrens contracture: genetic, alcohol dependance

 

Dupuytrens

 

 

 

  

Gastrointestinal Head & Neck Exam

 

-  Icteric sclera: jaundice

-  Hepatic fetor

-  Angular stomatitis/chelosis: vitamin def.

-  Glossitis: vitamin def., pernicious anaemia

-  Mouth ulcers: Crohns disease, apthous ulcers

-  Telangiectasia of lips or tongue: hereditary haemorrhagic telagiectasia (blanchable)

-  Xanthalasma: bilairy cirrhosis

-  Facial nerve palsy: parotid tumour

-  Iritis/Uveitis: IBD

-  Kieser fleischer rings: Wilsons disease

 

Keiser 1

 

Keiser 2

 

Neck

-  Lymph nodes

-  Troisiers/Virchows node (L supraclavicular lymph node): gastric cancer (DDx: lung, breast..)

 

Virchows Node

 

 

 

  

Gastrointestinal Chest Exam

 

-  Rosary

- Richitic rosary: Vit D def.

- Scorbitic rosary: Vit C def.

-  Spider naevi: chronic liver disease

 

Spider Naevi

 

-  Gynaecomastia: liver disease

 

Gynaecomastia

 

 

 

  

Gastrointestinal Abdominal Exam

 

Patient

-  Supine, nipples to pubic symphysis/testicles exposed

-  Knees bend slightly if abdomen tight

 

Inspection

-  Masses

-  Visible peristalsis, movement w resp., distension, umbilicus, stomata, fistula, wasting, jaundice

-  Obesity: BMI, central (DM)

-  Ascities: chronic liver disease, malignancy

-  Striae: weight gain/loss, Cushings syndrome

-  Scars

 

Abdo Surgical Scars 2

 

-  Hernias

-  Grey Turner Sign: pancreatitis, AAA

 

Grey Turner

 

-  Cullens Sign: haemoperitoneum

 

Cullens

 

-  Veins

-  IVC

-  Caput medusa: portal hypertension

 

Caput Medusa

 

Palpation (supine) & Percussion

-  Quadrants --> light then deep

 

Abdo Quadrants

 

Abdo Organs

 

-  Guarding = patients contracts abdo m. to prevent palpation

-  Acute abdomen: peritonitis, perforation, infection, rupture

-  Voluntary &/or involuntary

-  Rigidity = more severe, board like

-  Masses

-  Abdominal Pain/Tenderness

-  Rebound tenderness

-  Epigastric pain

-  RUQ

-  Murphys Sign: cholecystitis

-Upward pressure on right hypochondric region in midclavicular line

-Pressure causes pain: cholecystitis

-  RLQ

-  Femoral hernia

-  McBurneys Point: Appendicitis

-  1/3 distance between ASIS & pubic tubercule

-  Location of appendix

-  Pain on pressure may indicate appendicitis

-  LLQ

-  Rosvings Sign: cholecystitis

-  Rebound tenderness felt in RLQ when tested at LLQ

-  RIF --> R Hypochondric for liver edge

-  Hepatomegaly: cirrhosis, hepatitis

-  Ptosis: COPD

-  RIF --> L Hypochondric for spleen

-   Typically not felt

-   Turn on side to ballot

-   Splenomegaly

 

Percussion

-  Liver span

-  Midclavicular

-  N: < 12cm

-  Spleen

-  Usually not palpable

-  Splenomegaly

-  Shifting Dullness: ascities

-  Pt lying supine allowing fluid to settle

-  Percuss laterally from umbilicus to flanks

-  Mark level of change from tympanic --> dull

-  Roll patient to same side

-  Percuss from opposite flank to bed

-  Mark level of change from tympanic --> dull

-  Measure difference between two levels

-  Positive: difference in levels

 

Ascities

 

Auscultate

-  Bowel sounds (epigastric, L lumbar)

 

Continued

-  Inguinal lymph nodes

-  Hernias: femoral, inguinal, direct, indirect

-  Testicular exam

-  Scrotal oedema: liver disease

-  Scrotal swelling: hernias

-  PR

-  Perianal fistula: Crohns disease

-  Skin tags: haemorrhoids

-  Haemorrhoids: constipation, portal hypertension

-  Thrombosed

-  Rectal prolapse

 

Rectal Prolapse 

 

 

 

  

Gastrointestinal Lower Limb Exam

   

-  Peripheral oedema, ankle swelling: chronic liver disease

 

 

 

 

Gastrointestinal Investigations

 

Path

Imaging

Proc

Micro

 

 

 

 

Gastrointestinal Management

 

General

Meds

Surgery

Proc