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GIT Examination - Clinical Skills with Dr.Fahd

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CLINICAL SKILLS WITH DR.FAHD


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GIT EXAMINATION

[Multimedia object] GIT EXAMINATION


HAND:

NAIL: Clubbing (biliary cirrhosis, IBD, coeliac disease). Leukonychia (hypoalbuminemia esp. in CLD). Koilonychia (iron deficiency anaemia). Muehrckes lines transfers opaque lines (in hypoalbuminaemia &/or chemotherapy, severe illness). - Cyanosis (in CLD). - Blue lanulae (Wilsons disease).

DORSUM: - Muscle wasting.

PALM: - Warmth & moisture (thyrotoxicosis: which may cause diarrhea or abnormal intestinal motility). - Pallor (anaemia: in GI bleeding, malabsorption folate,B1 2 , hemolysis hypersplenism). - Palmar erythema (CLD, thyrotoxicosis).

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GIT Examination - Clinical Skills with Dr.Fahd

- Dupuytrens contracture (in alcoholism, pancreatitis) due to xanthine

TREMOR: - Fine tremor (Wilsons disease, alcoholism). - Flapping tremor flappinf of hepatic encephalopathy- (liver failure, alcoholism, Wilsons disease).

VITAL SIGNS:
RADIAL PULSE. BLOOD PRESSURE. TEMPERATURE. RESPIRATORY RATE.

ARM & FORARM:


- Scratch marks pruritis (primary biliary cirhosis, obstructive or cholestatic jaundice patient). - Bruising (in CLD: clotting factor except factor VIII). - Muscle wasting (malnutrition in alcoholic patient, in pancreatitis). - Spider naevi if >2 (alcoholic cirrhosis, viral hepatitis). - Epitrochlear L.N & axillary L.N. - Petechiae (chronic alcohol consumption, portal HTN).

HEAD:

EYES: Conjunctival pallor (anaemia). Scleral icterus jaundice. Iritis (IBD). Xanthelasma (cholestasis, hypercholestrolaemia in primary biliary cirrhosis). Kayser-Fleisher ring slit-lamp examination (Wilsons disease). Periorbital purpura (Black-Eye Syndrome). Following sigmoidoscopy, amyloidosis, and factor X deficiency. MOUTH:

Hygiene: Poor, average or good. Teeth: Real or false (if false; you should remove it). Decay or caries (responsible for fetor). Sore. Breakage or rotten tooth stump (cause ulcers).
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GIT Examination - Clinical Skills with Dr.Fahd

Gums: Bleeding. Hypertrophy (phenytoin, pregnancy, scurvy, gingivitis, leukaemia). Gingivitis. Pigmentation.

Tongue: - Central cyanosis (the floor of the tongue). - Glossitis smoothness of the surface (malnutriton, alcoholism, rare in carcinoid syndrom). - Coating (esp. in smokers). - Lingua nigra ( due to Bismuth compounds). - Geographical tongue (Vit. B2 deficiency). - Macroglossia (Down syndrome, acromegally, tumor or amyloidosis infilteration). Lips: - Angular stomatitis (deficiency of Vit.B6 , B1 2 , folate, iron). - Peripheral cyanosis. - Pallor (anaemia). Oropharynx & tonsils: - Signs of inflammation & suppuration. Anywhere in the mouth: - Oral thrush candidiasis (may cause dysphagia or odynophagia). - Leukoplakia(sore teeth, smoking, spiritis, sepsis, syphilis). - Aphthous ulcer (crohns disease, coeliac disease, AIDS).

PAROTIDS: - Enlargement (parotidomegaly). BILATERAL Mumps may be unilateral also, sarcoidosis, lymphoma, alcohol consumption, malnutrition, severe dehydration. - Tenderness (parotitis).

UNILATERAL Mixed parotid tumor occasionally bilateral , tumor infilteration, duct blockage.

LYMPH NODES: S ubmental. S ubmandibular. Preauricular. Postauricular.


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GIT Examination - Clinical Skills with Dr.Fahd

- Occipital.

NECK:

LYMPH NODES: - Anterior cervical. - Posterior cervical. - S upraclavicular (Troisiers sign: enlarged L.supraclavicular L.N, Vircows L.N in gastric carcinoma). - S calenes L.N.

THYROID:

enlargement (goitre).

CHEST:
- Gynecomastia (CLD, alcoholic cirrhosis, chronic active hepatitis, alcohol consumption, digoxine, cimetidine). - Spider naevi.

ABDOMEN:
INSPECTION:from nipple to pubic symphysis. - Movement of abdominal wall with respiration: absent or shallow in generalized peritonitis (still silent abdomen). - S hape : Flat. Distended. Scaphoid. - S ymmetry. - S cars: - S triae: Ascitis. Pregnancy. Recent loss of weight. Cushings syndrome. - S kin lesions: Herpes Zoster vesicles (may cause abdominal pain). The Sister Joseph nodule metastatic tumor deposits in umbilicus & area of peritonium closed to the skin. Cullens sign black eye umbilicus (in extensive haemoperitonium, in acute pancreatitis). Grey-Turners sign (acute pancreatitis). - Local S wellings: splenomegaly or hepatomegaly. - Abdominal distension: Fat (gross obesity). Fluid (as ascitis).
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GIT Examination - Clinical Skills with Dr.Fahd

Flatus (intestinal obstruction). Feces (constipation).

Fetus (pregnancy). Phantom pregnancy. Filthy tumour (ovarian tumor, hydatid cyst). Prominent veins: Thin veins over the costal margin: not of clinical significance. Caput Medusae: portal hypertension. Inferior vena caval obstruction (usually due to tumor or thrombosis or tense ascitis). Visible Pulsations: aortic aneurysm. Visible Peristalsis: Pyloric stenosis (from left to right). Distal small bowel obstruction. Normal finding in very thin elderly patients. Umbilicus: Slightly everted normally. Buried in fat in obese. Everted & shallow in ascitis. Directed upwards in pregnancy or ovarian tumour. Directed downwards in ascitis. Presence of omphalolith in elderly obese woman. Hair distribution. Herniae.

Normal, symmetrical, flat abdomen that moves freely with respiration; No scars, striae or other skin lesions; No local swellings or generalized abdominal distension; No prominent veins, visible peristalsis or pulsation; The umbilicus is centrally located & slightly inverted; Normal male hair distribution & there is no hernia. PALPATION: SUPERFICIAL PALPATION: Superficial masses. Tenderness (rebound tenderness used to confirm peritonitis). Guarding. Rigidity.

DEEP PALPATION: - Deep masses or tenderness. ORGANOPALPATION:(if yes, you should determine: edge & surface, consistency,
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GIT Examination - Clinical Skills with Dr.Fahd

tenderness, pulsation) How to distinguish between Left kidney & spleen ? 1- Upper boarder of spleen is not palpable. 2- Spleen has a notch. 3- With inspiration: spleen moves inferiomedially while LT kidney moves inferiorly. 4- Percussion notes for kidney: resonant (bowel gas), for spleen: dull. 5- Spleen usually not ballotable (unless in ascitis). 6- Friction rub may heared over spleen but not over kidney. Liver. Spleen. Kidney. Ascitis (fluid thrill). Urinary Bladder. Gallbladder. Testes. Inguinal L.N.

PERCUSSION: Liver (for liver span). Spleen (over the L. costal margin). Kidney (over a R. or L. subcostal mass). Ascitis (shifting dullness).

AUSCULTATION: - Bowel sounds : Present: intermittant soft gurgling sounds. Absent: paralytic ileus (over 3 minutes). Obstructed bowel sounds: louder & more high-pitched with tinkling quality. Borborygmi (intestinal hurry or rush): loud gurgling sounds occur in diarrheal states & often audible without the stethoscope. - Friction rubs : Hepatic rub: Tumor (HCC or metastases). Abscess. Recent liver biopsy. Infarction. Fitz-Hugh-Curtis syndrome: gonococcal or chlamydial perihepatitis. Splenic rub: infarction. - Venous hum: Between the xiphisternum & umbilicus in portal hypertension (due to large volumes of blood flowing in the umbilical & para-umbilical veins in the falciform ligament channeling the blood from the L. portal vein to the
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GIT Examination - Clinical Skills with Dr.Fahd

epigastric or internal mammary veins in the abdoninal wall). At the umbilicus & associated with dilated superficial abdominal veins, called Cruveilhier-Baumgarten syndrome & due to liver cirrhosis (due to patent umbilical vein that allows a portal-to-systemic shunting). Over the inferior mesentric vein. After portocaval shunting. - Bruits: Over the liver: HCC. Alcoholic liver disease. AVM. Transiently after a liver biopsy. In the epigastrium (chronic intestinal ischemia from MAS). Over the spleen (AVM). One inch above the umbilicus & one inch on either sides of the midline (renal artery stenosis).

RECTAL EXAMINATION:

INSPECTION:
T hrombosed external haemorroid. Skin T ags (in hemorrhoids, crohns disease). Fissure-in-ano. Fistula-in-ano. Faeccal soiling, blood, mucus. Condylomata accuminata. Carcinoma of the anus. Pruritus ani. Rectal Prolapse. Prolapsed internal haemorroids. Polyps. Papillomata. Excoriation from diarrhoea.

PALPATION:
ANUS: - External sphincter tone. - Thickening or mass. - Pain. RECTUM :
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GIT Examination - Clinical Skills with Dr.Fahd

- Wall: Carcinoma. Polyp. Hypertrophied anal papilla. Amoebic granuloma. Foreign body. Endometriosis. - Contents: Full of faeces (indentable). Empty & collapsed. Empty but ballooned out. PROSTATE GLAND: - Normal: Smooth, symmetrical, rubbery with median groove & mobile rectal mucosa above it. - BPH: Smooth, asymmetrically enlarged, rubbery with obliterated median groove & mobile rectal mucosa above it. - Carcinoma: Irregular, asymmetrically enlarged, hard with obliterated median groove & fixed rectal mucosa above it. - Prostatitis: Smooth, symmetrically enlarged, boggy, tender with median groove & mobile rectal mucosa above it. POUCH OF DOUGLAS: Metastatic deposits (Blumer shelf). Sigmoid colon carcinoma. Ovarian tumour. Pelvic abscess or sarcoma.

CERVIX: - Carcinoma.

LOWER LIMBS:
- Oedema. - Bruising. - Scratch marks.

Dr.Fahd .... new intern


Cr ea t e a Fr ee W ebsit e

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