2.4 Examination of Gastrointestinal System 2.4.1 Examination of the Abdomen Note: non-routine parts are denoted by a (small font) but they should be noted if you observe them. Setting: □ Positioning: supine with head resting on a pillow46 □ Exposure: nipple to pubic symphysis ± mid-thigh (if it is a surgical case, need to look for hernias) Approach: □ General examination → General appearance: - Bedside: equipment, treatment devices - Body habitus: weight loss, cachexia, obesity, (↑muscle bulk) - Mental state: orientation - (Skin changes) → Face: - Eyes: jaundice, pallor, (Bitot’s spot, Kayser-Fleischer rings, xanthelasma, periorbital purpura) - Salivary glands: parotid gland, submandibular gland - Mouth: hydration status, (fetor, tongue (coating, lingua nigra, geographic tongue, leukoplakia, glossitis, macroglossia), mucosa (gum hypertrophy, pigmentation, ulcers)) → Neck and chest: spider naevus, gynaecomastia, cervical lymphadenopathy → Upper limb: - Arms: spider naevus, (bruising, scratch marks) - Axilla: lymphadenopathy, (acanthosis nigricans) - Hands: clubbing, leukonychia, palmar erythaema, Dupuytren’s contracture, asterixis, (blue lununae) → Legs: ankle oedema, (ankle pigmentation, bruising) □ Inspection of abdomen: → Shape: normal, scaphoid, distended (5S) → Umbilicus: buried, everted, inverted → Skin lesions: striae, scars, stomas, fistulae, (Cullen’s sign, Grey-Turner’s sign, pigmentation) → Dilated veins: caput medusa vs IVC obstruction → Movement: asymmetrical movement with respiration, epigastric pulsation, visible peristalsis → Cough impulse (in surgical examination) □ Palpation of abdomen: superficial, deep for any mass, tenderness ± peritoneal signs □ Liver: → Palpation: lower border → Percussion: upper and lower border □ Spleen: → Palpation: along Gardner’s line, hooking at Rt lateral position → Percussion: along Gardner’s line □ Kidneys: → Palpation: bimanual, ballottement
46 This helps relax the abdomen and facilitates abdominal palpation.
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□ Go back to any mass previously detected: site, size, shape, surface, edge, consistency, tenderness, pulsatility □ Ascites: → Inspection: distension with bulging flanks, ankle oedema → Shifting dullness (if ≥1L fluid) → Fluid thrill (if fluid under tension) □ Auscultation: → Bowel sounds at four quadrants → Bruits: liver, renal, aortic → Succussion splash □ Other examination: examination of hernia orifices, PR examination
A. General Examination 1. General Appearance Bedside:
□ Equipment: ventilator, O2 therapy, cardiac monitor □ Tubes and drains: IV access, chest drain, Foley’s catheter, central venous catheter, NG tube, PTBD tube, PEG tube □ Others: specimen bottles