Abdominal Examination OSCE PDF

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Gastrointestinal Examination 1. Setting up examination = Wash hands, Introduce yourself, identify patient, Permission, Position = initially at 45 degrees, totally flat later, Pain = check if in any pain, Exposure = shirt open 2. General examination = are they well, in pain, nauseous, vital signs, BMI, jaundiced or pale, are they NBM, vomit bowls, IV infusion, nasogastric tubes, surgical drains etc 3. Hands and nails a. Clubbing = GI lymphoma, IBS, coeliac disease b. Koilonychia (spoon nails) = anaemia c. Leukonychia (opacification/whitening of nail bed) = hypoalbuminaemia d. Palmar erythema = CLD e. Dupuytren’s contracture = alcoholism f. Hepatic flap (asterixis) = occurs in liver failure 4. Arms a. Excessive bruising = clotting abnormality (could be due to liver disease) b. Scratch marks = pruritis (cholestatic jaundice) c. Track marks = IVDU d. Radial pulse = tachycardia could be infection/hypovolaemia (e.g. acute GI bleed) 5. Neck a. Examine cervical and supraclavicular lymph nodes (stand behind patient) b. Check Virchow’s nodes (left sided supraclavicular lymph node) in PTs presenting with dysphagia, is also suggestive of gastric malignancy 6. Face/mouth a. Eyes: i. Jaundice = retract upper eyelid, sclerae ii. Conjunctival pallor = anaemia iii. Kayser-Fleischer rings = brownish green rings due to copper deposits, occurring in Wilson’s disease, which causes cirrhosis iv. Xanthelasma = raised yellow lesions caused by a buildup of lipids beneath the skin due to hypercholesterolaemia b. Mouth: i. Angular stomatitis = reddish brown cracks radiating from corners of the mouth seen in iron, B6, B12, and folate deficiencies ii. Glossitis = red, swollen tongue seen in B12 and folate deficiencies (painful) and iron deficiency (painless) iii. Ulcers = Crohn’s and IBD 7. Inspect the abdomen (lifting the head will tense abdo muscles and highlight any muscular weakness or defect and hernias) a. Contour = flat, rounded or scaphoid

b. Symmetry = should be noted and any visible peristalsis (pyloric obstruction, obstruction of distal small bowel) observed (asymmetrical movement with breathing indicates presence of a mass) c. Distended abdomen = fat, flatus, foetus, faeces or fluid d. Local swelling = enlargement of one of the abdo/pelvic organs e. Visible veins = abnormally prominent veins suggest portal HTN or vena cava obstruction i. Caput medusae = veins radiating out from umbilicus f. Scars = if recent will be pink and vascular, older will be white and indurated i. Look carefully for small laparoscopic scales, including infra-umbilical g. Presence of >5 spider naevi on upper chest/abdo is abnormal = cirrhosis h. Gynaecomastia = excessive development of breast tissue in males, due to alcoholic liver disease, drugs i. Loss of chest hair in main = chronic liver disease j. Stomas = where is it, is there any exposed mucosa, is there a bag, what is in the bag, is there any blood, pus, mucous (large/small bowel, renal tract) k. Striae = pink/white stretch marks caused by weight gain or rapid weight loss (pink/purple in Cushing’s) l. Expansile central pulsation in epigastrium = abdominal aortic aneurysm 8. Ask if the PT has any pain in the abdomen and palpate the 9 regions a. Superficial = masses, tenderness, guarding b. Deeper = allows detection of deeper masses c. Feel for liver (RIF – up the right side) i. Hepatomegaly = HF, acute viral hepatitis, metastases, primary tumours d. Feel for spleen (RIF – to the left side) i. Splenomegaly = portal HTN, leukaemia, lymphoma, haemolytic anaemia e. Ballot the kidneys at the flanks f. Feel for abdominal aortic aneurysm just above the umbilicus g. Say that you would feel for hernias 9. Percuss a. Produces a hollow resonance b. Dull thud without resonance over fluid/solid masses c. Liver/spleen percussion same as palpation d. Shifting dullness (free fluid in abdo?) = start at umbilicus, percuss towards flank until becomes dull, keep fingers on that point and ask PT to roll away from the flank you have your fingers on, then percuss back to the umbilicus (if dull point is now resonant there is shifting dullness = fluid in peritoneal cavity) 10. Auscultation a. Listen for bowel sounds with diaphragm to the right of the umbilicus

b. c. d. e.

Absent = bowel peristalsis has stopped Tinkling = distended bowel in obstruction Gurgling is normal Listen 2-3 cm above and lateral to umbilicus for renal artery stenosis bruits 11. Check lower limb for pitting oedema, bruising, erythema nodosum 12. State that you would finish the exam by carrying out a digital rectal exam 13. Other investigations = urine dip, beta HCG if PT is female...