General inspection
Observe the patient from the end of the bed:
Search around the bed for any clues eluding to the diagnosis (IV infusions, drug packets, special feeds, etc.). This is rather like looking at your mirrors in a driving test, so make sure you 'over-dramatise' your observations so that the examinerknows that you are making an effort to make good observations. Key findings now can also help you later - if you, for example, find an infusion of 5-ASA (Pentasa), then you can immediately add a diagnosis of an Inflammatory Bowel Disease to one of your differentials.
Look at the patient:
- colour (jaundice, cachexia, pallor).
Look at the skin:
- bronze pigmentation (haemochromatosis - 'bronze diabetes'), Addisonian pigmentation (darkened palmar skin creases / nipples, etc. with 1o adrenocortical insufficiency), acanthosis nigricans (darkening, usually around axilla - suggestive of GI malignancies).
Look at the hands:
- koilonychia (spoon shaped nails - iron deficiency), leuconychia (white nails - hypo-albuminaemia), clubbing (cirrhosis, inflammatory bowel disease, coeliac disease), palmar erythema (chronic liver disease), pallor (anaemia), Dupuytren's contracture (alcoholism, familial), asterixis ('flap' liver failure, but other causes as well - tell patient to hold arms out and cock wrists back, ideally holding for 3 minutes, but a shorter time will suffice in an exam), choreo-athetosis (Wilson's disease), tremor (alcoholism).
Look at the arms:
- ecchymoses (clotting abnormalities e.g. hepatocellular damage), petechiae (alcohol, splenomegaly), muscle wasting (malnutrition), proximal myopathy (alcohol), scratch marks (jaundice), spider naevi (cirrhosis).
Look at the eyes:
- jaundice, pallor, Kayser-Fleischer rings (Wilson's disease), iritis (inflammatory bowel disease), xanthelasma (lipid deposits).
Look at the mouth:
- dentition, gum hypertrophy (scurvy, gingivitis, leukaemia, phenytoin), pigmentation (Addison's, haemochromatosis, drugs, melanoma), ulcers (aphthous, Crohn's, coeliac, AIDS), angular stomatitis (vitamin B6, B12, folate, iron deficiencies), candidiasis.
(Subtly) smell the breath:
- fetor hepaticus (hepatocellular disease), ketosis (diabetic ketoacidosis), alcohol, uraemia, cigarettes.
Look at the tongue:
- leucoplakia (premalignant white regions), glossitis (nutritional deficiencies - such as vitamin B12, carcinoid syndrome), macroglossia (Down syndrome, acromegaly, tumour infiltration, amyloidosis).
Feel for lymphadenopathy:
- check the axillae, cervical and supraclavicular nodes (especially on the left side - the presence of a left supraclavicular node, Virchow's node, is known as Troisier's sign when associated with a GI malignancy).
Look at the chest:
- spider naevi (central arteriole with thin branches like spiders legs, which blanch on pressure and refill upon release - more than 2-3 is abnormal), gynaecomastia (cirrhosis, chronic active hepatitis, alcohol, drugs - 'DISCO': Digoxin, Isoniazid, Steroids, Cimetidine, Other - eg. Oestrogens, Marijuana)
Other features:
- Short of breath/any respiratory distress (eg. using accessory muscles, pursed lips)?
Inspection (specific to the gastrointestinal system)
Don't forget this, or you may miss vital signs such as scars:
-Expose the patient ? classically this is described as from 'nipple to knee' or 'nipple to pubic symphysis' (usually removing any tops and rolling down trousers to just below groin (can leave underwear on), is sufficient). Make sure you use blankets to preserve the patient's modesty whilst you are not examining the abdomen itself.
- Look at the abdomen: scars, stomas, fistulae, distension ('F's - fat, fluid, fetus, flatus, faeces, filthy big tumour), symmetry, local swellings, hernia, veins (caput Medusae around umbilicus ? sign of portal hypertension seen with alcoholic liver disease; IVC obstruction), visible pulsations (abdominal aortic aneurism), visible peristalsis (intestinal obstruction), Grey-Turner's sign - discoloration in the flanks or Cullen's sign - discoloration peri-umbilically (haemorrhage 2opancreatitis), striae (ascites, pregnancy, recent loss of weight, Cushing's syndrome).
Palpation
Always check if pain-free first!
- If the patient is in pain ask where it is and begin palpation in the non-tender area. If the bed is low, then kneel down by the bedside to palpate. Not only does this look less 'imposing' for the patient, but it also makes it easier to get your hand in the correct position for palpation.
Gentle (superficial) palpation
- Assess the degree of tenderness: guarding occurs with moderate pain, rebound/release tenderness with severe pain (peritonism). You should look at the patients face at all times in order to assess the amount of pain (if any) that palpation is causing them. If they are finding any area particularly painful then be gentle. Before proceeding to deep palpation, it can be a good touch to ask 'I notice that this area seems tender to you - would you mind if I felt a little deeper, or would you prefer that I didn't?'. It is always a difficult balance between a 'real-life' acute situation (where sometimes you have to examine in the presence of some pain in order to quickly find treatable pathology) and an exam (where it is more your examination technique that is being assessed rather than your findings).
- Detect superficial or large masses. The patient must be relaxed or else you will mistakenly think they are guarding! Rebound/release tenderness is assessed by slowly pressing down to depress the abdominal wall, then suddenly releasing (positive if increased pain upon releasing). Percussion tenderness is also considered a useful sign of peritoneal irritation - gently percuss over the tender area to determine this.
Deep palpation
- Detect deeper masses or define character of masses already discovered. Be careful with painful masses.
- Palpate the liver: feel for hepatomegaly ? begin in the right iliac fossa and ask the patient to breathe in and out slowly. Move your hand up slowly towards the right costal margin with each expiration, trying to feel a liver edge during inspiration. Feel the liver edge if it is identified. Record the total liver span: to do this, percuss down the chest along the right mid-clavicular line until the liver dullness appears. Measure from here to the palpable liver edge. If felt, note the character - is it smoothly enlarged (eg. right heart failure), or is it 'knobbly' (malignancy)?
- Palpate the gallbladder: the gallbladder is sometimes palpable below the right costal margin. Murphy's sign: on deep inspiration the patient catches their breath when an inflamed gallbladder presses the examining hand. This section can usually be skipped in exams.
- Palpate the spleen: begin palpation below the umbilicus (or with a very large spleen in the right iliac fossa) and slowly advance your hand towards the left costal margin. If the spleen is impalpable roll the patient onto the right side and repeat palpation.
- Palpate the kidneys: use two hands to 'ballot' - for the left kidney place your right hand posterolaterally, and your left hand over the left upper quadrant. Try to capture the kidney between your hands, then ballot the kidney by pushing upwards with your right hand, attempting to feel the contents with your anterior hand, which must remain still. The opposite hands are used for the right kidney.
- Other things you should routinely feel: abdominal aorta (just above the umbilicus with both hands held still in an upside down 'V' shape - be gentle and feel for an 'expansile' (hands move sideways) and 'pulsatile' (hands move upwards) mass - can move your right hand to estimate the diameter if an aneurism is felt), inguinal lymph nodes, and inguinal hernia (cough reflex - place hands on inguinal canal area and ask patient to cough - feel for a positive cough impulse)
- Other things you may feel: any other organ - stomach, duodenum, pancreas, bowel, bladder.
