GI Examination
PREPARATION OF THE PATIENT
1. Greet the patient respectfully and with kindness.
2. Introduce yourself
3. Take a permission
4. Insure privacy
5. Wash your hands
• Exposure: you should say to examiner that ideally I should expose form nipple to mid thigh but for
social reasons I will expose from the xiphisternum to the symphysis pubis
• position: ensure the patient is comfortable, centralized, ask the patient to lying flat Arms at side
(behind head tightens abdomen) & legs straight, You may also ask the patient to flex the hips to 45°
and the knees to 90° in order to relax the abdominal muscles.
General examination (ABCDE)
General inspection: from the END OF THE BED
Comment on ABCDE:
1. Appearance: looks well/ Unwell? Comfortable/ uncomfortable? Mental state> conscious, oriented to
time, place & person
2. Body built (cachectic, average, underweight, Overweight, obese)
3. Color (pallor, jaundice, pigmentation...)
4. Distress (dyspnic tachypnic)
5. Environment (IV lines, NG tube, stoma, drains, oxygen O2 mask , urine catheter)
Take a vital signs of the patient ( HR, RR, BP, Temp)
From the right side
1. Hands: Palmar erythema, Dupuytren’s Contracture, pallor crease, flapping tremor (asterixis) ,muscle
wasting.
2. Nails: koilonychia, leuconychia, clubbing.
3. Arms: scratch marks, spider naevi, ecchymoses, Tattoo, Needles marks, muscle wasting, examine
radial pulse, Water Hammer Pulse
4. Face:
❖ eye: Jaundice, pallor, Iritis, Kayser Fleisher rings(Wilson), corneal arcus(lipid), Xanthelasma
❖ mouth: central cyanosis, ulcers, angular stomatitis, candidiasis, smell: fetor hepaticus, oral hygiene
5. Neck: JVP if elevated or not, cervical lymph nodes, left supraclavicular node” Virchow's node"
6. Chest: Spider naevi - >5 is significant, Gynaecomastia (apparent or not and feel it), loss of hair
Local abdominal exam
INSPECTION:
Look from both ends of the bed
1. Contour (flat, scaphoid, distendend, protuberant)
2. Symmetry
3. Type of breathing: men abdominthoracic, women thoracoabdominal
Look from RT side
Comment upon:
1. Distension: 5Fs ( fat, fluid, feces, flatus, fetus)
2. Scars (describe: name, site, length, old or new,healed by1or 2 )
❖ if new >discoloration, discharge, signs of inflammation
❖ if old>> keloid, hypertrophoid
3. Stria, Scratch marks, Skin pigmentation, Bruising, stoma
4. Umbilicus: Position (centralized or shifted), Shape (inverted, everted ) inflamed or not discharge or not
5. Distended veins : do filling test
6. Visible Pulsations, Visible peristalsis, visible Mass (describe it ), Bulging flanks, Hair distribution
Active inspection
to asses:
1. Hernia orifices (Ask the PT to cough while inspecting the hernia orifices)
2. Divarication of recti (raising test)
PALPATION:
Rules :
❖ Inform the patient what you are going to do
❖ Make sure that your hand is warm
❖ Ask the patient whether there is a painful area
❖ In palpation kneel down to be at the level of abdomen
❖ Maintain eye contact with palpation
❖ Always start palpation in the region diagonally opposite to any lesion or pain, and proceed
systematically to other regions approaching the affected area last of all.
❖ Proceed with palpation in a predetermined sequence (S or G sequence); so as not to miss any of the
nine abdominal quadrants.
❖ Keep the palmar surface of the hand flat in contact with the abdominal wall. All the movements of
the hand should occur at the metacarpophalangeal joints and the hand should take the shape of the
abdominal wall.
A. Superficial PALPATION
1. to Gain confidence
2. Superficial Tenderness:
3. Superficial mass:
4. Rigidity & guarding ( involuntary and voluntary)
5. Direction of flow if dilated veins:
Determine the direction of the flow by placing two fingers on the vein, sliding one finger along the vein to
empty it and then releasing one finger and watching to see which way the empty segment fills.
B. DEEP PALPATION
Deeply palpate all quadrants in a systemic way to comment on deep tenderness, deep masses.
Note: two hands, one on top of the other, may be required if obesity or muscular resistance occurs.
The Organs:
The Liver
1. Palpation
• Place your right hand on the right iliac fossa (MCL), resting transversely parallel to the costal
margin (Index parallel to right costal margin)
• Compress deep and Keep your hand stationary at this position.
• Ask patient to take deep breath and try to feel the liver edge as it descend with inspiration.
• As the patient to expire, slide the hand a little nearer to the right costal margin till you palpate lower
border of the right lobe of the liver
• If the liver is enlarged, put one hand on the liver anteriorly and the other hand at the back. Ask the
patient to hold his breath and feel for pulsation
If the liver is enlarged I would like to comment upon:
• The size of enlargement (fingerbreadths below the costal margin in MCL)
• The character of the edge (sharp or rounded).
• The surface (smooth or nodular)
• The consistency (soft, firm, hard or heterogeneous)
• The presence of pulsations
• The presence of tenderness
Normal liver edge: soft, sharp, regular with smooth surface.
2. Percussion of the liver (span of the liver):
• Determine the lower border of the liver by percussion starting from RIF
• Determine the upper border of the liver by heavy percussion starting from the 2nd intercostals
space opposite the sternocostal junction
• Percuss down along each inter-costal space in the MCL and when you reach the dullness ask the
patient to take a deep breath and hold it
• Percuss again, (tidal percussion)
• Measure the distance between the upper border and lower border in the right midclavicular line, this
is the span of the liver.
The spleen:
1) Palpation:
The standard method (one hand ) or bimanual examination(recommended):
• Start palpation from the right iliac fossa with the tips of the examining hand directed towards
the Lt costal margin
• The left hand is placed over the lateral aspect of the left costal margin, exerting a certain amount of
compression.
• Follow the rules of palpation moving toward the left hypochondrium until you feel the spleen.
The right lateral position method: If the spleen is not palpable when the patient is flat
• Ask the patient to turn to the right side
• Insinuate the hand below the costal margin
• Ask the patient to take a deep breath
• Press till you feel the lower edge of the spleen
2) Percussion
Percussion of the Traube's area:
• Area defined by left sixth rib superiorly, the left anterior axillary line laterally, and the left costal
margin inferiorly.
• If Traube's space is dull, the spleen is enlarged.
Splenic percussion sign (Castell’s method):
• Percuss the lowest intercostals space in the left anterior axillary line
• Then ask the patient to take a deep breath, and percuss again.
• When spleen size is normal, the percussion note usually remains tympanic
The kidney:
To feel the right kidney: (ballotment)
• Put your left hand behind the patient's right loin in the renal angle (between the last rib and the iliac
crest)
• Put the right hand on the right lumbar region (RUQ)
• press Lt hand forwards and Rt hand backward
• ask the patient to take a deep breath
• During expiration push your right hand deeply but gently and keep it still during inspiration
• Repeat as the patient takes his breath.
To feel the left kidney:
• Repeat the same procedure by leaning across the patient from RT side
• If difficult or your arms are short go to the patient's left side and do it
Ascites examination
FLUID THRILL: severe ascites
• Instruct the patient to lie in the supine position
• Place one hand flat over the lumbar region on one side
• Get the patient to put the hand in the midline of the abdomen
• Tap or flick the opposite lumbar region
• A thrill will be felt in the other hand
Shifting dullness: moderate ascites
• Instruct the patient to lie in the supine position
• start percussion form epigastrium with your hand horizontally until reach the umbilicus
• Then percuss the region of the umbilicus with the finger pointing towards the feet;
• Move laterally towards the flank, the percussion note is tested out towards the flanks.
• When dullness is reached, ask the patient to turn to the opposite side, while keeping the examining
hand over the exact site of dullness
• Ideally 30 seconds to 1 minute should then pass so that fluid can move inside the abdominal cavity
and then percussion is repeated over the marked point.
• Shifting dullness is present if the area of dullness has changed to become resonant >>indicates the
presence of moderate free ascites.
AUSCULTAION:
Some prefer to perform before percussion or palpation as they may disturb the intestines, altering their
activity and thus bowel sounds.
1-Bowel sounds ( normal 5-35/min)
• For small intestine: put the diaphragm of the stethoscope below &RT to umbilicus, below < to
umbilicus, above umbilicus
• For large intestine: laterally: listening in one spot, such as the right lower quadrant, is usually
sufficient.
• When bowel sounds are not present, one should listen for a full 3 minutes before determining that
bowel sounds are, in fact, absent.
2-Bruits Aorta at midline just above umbilicus, renal arteries 2 cm superior and lateral to umbilicus, iliac
1cm inferior and lateral to umbilicus
Say finally I should complete my examination by
• Perform a digital rectal examination
• Examine the external genitalia
• Examine Inguinal Nodes
• Examine Lower limb
• Examine Back
