summary of GI system

summary of GI system.

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summery of events

GIEP

1. wash hands
   
2. General physical examination
   hands
   tremours
   arm
   hair
   eyes
   mouth
   chest
3. inspection of abdomen
   
4. general palpation of abdomen
   Superficial
   Deep
5. organ palpation and percussion
   Liver
   Spleen
   (no kidney)
6. general percussion
7. shifting dullness
8. fluid thrill
9. auscultation
   Abdominal sounds
   Bruits
10. thank, wash hands, leave

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Things we usually forget;

• positioning of patient - you're in deep shit when you complete the P.E just to realize your patient is propped up 45deg. GG.
• patient's legs - are they straight? SP's can be bastards.
• flapping tremour
• gynacomastia
• fetor hepaticus
• axilliary hair loss
• to divide the abdomen into 9 parts - we're expected to regurgitate the 2 horizontal and 2 vertical lines, and name the 9 quadrants before we even touch the patient.
• Warn, Warm and touch patient prior to palpation.
• to LOOK AT THE FACE of patient as we palpate
• whenever eliciting shifting dullness, remember that there are 2 steps to it.
• to expose the patient properly (at least till the ASIS level, by right it is down till the mid-thigh)
• to turn the patient over 90deg (or more, not less) when we attempt to palpate a spleen
• washing hands as we leave - common to all PE station.

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things you should practice

• naming the 9 quadrants of the abdomen.

the abdomen can be divided into 9 regions by using 2 horizontal and 2 vertical planes.
the 2 vertical planes being 2 imaginary planes connecting the left and right mid-clavicular line and mid-inguinal point.
the 2 horizontal planes are the subcostal and transtubercular line, where subcostal being the line connecting the two lowest point of coastal margin, or the 10th rib, and transtubercular line being the line connecting the two illiac tubercules.

• organ palpation - different lecturers will stress on different ponits, but ALL LECTURERS stress on organ palpation technique.
• percussion.

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things we should know (Viva Material)

yellow discolouration of skin is not necessarily due to jaundice.

could also be;

• carotenoderma - from eating too much carotene - spares sclera
• quinacrine (drug) - ask drug history
• exposure to phenols

difference between kidney and spleen

• kidney is BALOTTABLE, spleen is NOT
• NOTCH ON ANTERIOR BORDER - palpable in spleen, not in kidney
• spleen enlarges diagonally towards RLQ, while the kidney enlarges inferiorly
• kidney can be resonant to percussion (d/t overlying bowel), spleen should be DULL
• UPPER EDGE of spleen NOT palpable, upper edge of kidney is
• SPLENIC RUB on auscultation (have patient breath in and out)

Traube’s Space

• triangular area demarcated by xiphisternal line, lower costal margin, Mid Axiliary Line
• tympanic due to the gastric bubble - in splenomegaly, stomach is displaced and region sounds dull (not a specific test)
• False Positives: full stomach, pleural effusion and pneumonia

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extra stuff (if you're interested)

Jaundice can be seen most prominently at the sclera of the eye due to the high elastin content of the sclera (Harrison's pg 261)

long-standing jaundice may cause a Green discolouration of the skin (bilirubin ->biliverdin) (Harrison pg261)

Clinical presentation of chronic renal failure

Mnemonic: RESIN & 8 Pʼs

R Retinopathy
E Excoriations (scratch marks)
S Skin is yellow
I Increased blood pressure
N Nails are brown
P Pallor
P Purpura and bruises
P Pericarditis and cardiomegaly
P Pleural effusions
P Pulmonary oedema
P Peripheral oedema
P Proximal myopathy
P Peripheral neuropathy

Common conditions producing acute abdominal pain

condition	Usual pain characteristics	Possible associated S/S
Appendicitis / meckel’s diverticulitis	Initially periumbilical or epigastric, colicky, later becomes localized to RLQ, often at Mcburney’s. - more medial pain may be meckel’s.	Guarding, tenderness + iliopsoas +obturator sign, RLQ skin hyperesthesia, anorexia, nausea, vomiting - after onset of pain. Low-grade fever + Aaron, Rovsing, Markle and Mcburney signs.
peritonitis	Onset sudden / gradual. Pain generalized / localized, dull / severe and unrelenting. Guarding, pain on inspiration.	shallow respiration with Blumberg, Markle and Balance signs, reduced or absent bowel sounds, nausea and vomit.
Cholecystitis	Severe, unrelenting RUQ or epigastric pain - may be referred to right subscapular area.	RUQ tenderness and rigidity, +Murphy sign, palpable gallbladder, anorexia, vomiting, fever, possible jaundice
pancreatitis	Dramatic, sudden, excruciating LUQ / epigastric / umbilical pain. May be radiating to back / left shoulder.	Epigastric tenderness, vomiting, fever, shock +grey turner’s sign +Cullen sign - both + after 2-3d.
Salpingitis	LQ pain, worse on left	Nausea vomiting, fever, suprapubic tenderness, rigid abdomen, pain on pelvic exam.
PID (Pelvic Inflammatory Disease)	LQ, increase with activity (PID shuffle)	Tender adnexa and cervix, cervical discharge, dyspareuria
Diverticulitis	Epigastric, radiating down left side of abdomen especially after eating - may be referred to back	Flatulence, borborygmus, diarrhea, dysuria, tenderness on palpation.
Perforated Gastric / Duodenal Ulcer	Abrupt, RUQ, may be referred to shoulders	Abdominal free air and distension with increased resonance over liver, tenderness over epigastrium / RUP
Intestinal obstruction	Abrupt, Severe, colicky, spasmodic, referred to epigastrium, umbilicus	Distension, minimal rebound tenderness, vomiting, visible peristalsis, bowel sounds may be absent (paralytic) / hyperactive (mechanical obstruction)
Volvulus	Referred to hypogastrium and umbilicus	Distension, nausea, vomiting, guarding, sigmoid loop volvulus may be palpable
Bile stone colic	Episodic, severe, RUQ / epigastric lasting 15 min - several hours	RUQ tenderness, soft abdominal wall, anorexia, vomiting, jaundice, subnormal temperature
Renal calculi	Intense, Lumber, loin to groin pain, may be episodic	Fever, hematruria, +Kehr sign
Ectopic pregnancy	Lower quadrant, referred to shoulder, with rupture - agonizing	Hypogastric tenderness, symptoms of pregnancy, spotting, irregular menses. If ruptured - shock, rigid abd.wall, +Kehr and Cullen signs
Splenic rupture	Intence, LUQ, radiating to Left shoulder, may worsen with foot elevated	Shock, pallor, lowered temperature
IBS (Irritable Bowel Syndrome)	Hypogastric, crampy, variable, infrequent.	May relieve by passage of flatus.

Abdominal signs associated with common abnormalities

Aaron	Pain / distress in area of heart / stomack on palpation of mcburney’s  point.	Appendicitis
Ballance	Fixed dullness to percussion in left flank, and dullness in right flank which disappear on change of position	Peritoneal irritation
Blumberg	Rebound tenderness	Peritoneal irritation, appendicitis
cullen	Ecchymosis around umbilicus	Hemoperitoneum, pancreatitis
Kehr	Abd. Pain radiating to left shoulder	Splenic rupture, Renal calculi, Ectopic pregnancy
Markle (heel jar)	Patient stand with straight knees, then tip-toe - relax to hit heel on floor. - abd. Pain = positive	Peritoneal irritation, appendicitis
mcburney	Rebound tenderness and sharp pain when Mcburney’s point is palpated	Appendicitis
Murphy	Abrupt cessation of inspiration on palpation of gall bladder	Cholecystitis
Romberg-Howship	Pain down the medial aspect of thigh to knees	Strangulated obturator hernia
Rovsing	RLQ pain intensified with LLQ abdominal palpation	Peritoneal irritation; appendicitis.