Rahaf Wardeh Internal Medicine 2016-2017
Gastrointestinal Examination – Dr.Hammouri’s Style
*The details and explanation of every step are in the notes after the list. Keep in mind you’re
looking for any signs of GI pathology*
Element Components Details
Introduction Introduce yourself
Consent
Privacy
Confidentiality
Let patient introduce Name, age, nationality, occupation.
themselves
Before Physical Position and Exposure Explain what you’ll do to patient
Examination Position patient supine
Proper exposure is from Chest (above nipples)
till mid-thigh, but till inguinal area is enough for
privacy.
Adjust the height of the bed to your comfort
(student should be comfortable examining)
Stand on RIGHT side of the patient
Wash hands!
Physical Vitals Hear Rate (30 sec x 2) (N: 60-100 bpm) + pulse
Examination *or you can do them later character
after inspection* Resp Rate (N: 12-20 br/min)
Blood Pressure (N: 90-120/60-80)
Temperature: (N: 36.5 – 37.5)
SpO2 (N: 95% + )
+/- Pain Score
Inspection Surrounding of the Patient Comment on any: Identification tag (name band
on wrist), O2 mask, IV lines, CV line (& the
solutions being infused), cannula color, cannula
insertion site, ECG leads, urinary catheter (+
urine bag content), drainage tubes, chest tubes,
NG tubes, walking aids, pathological specimens
(Gallstones, aspirated fluid….) *make sure
belongs to the patient* …
General Appearance Lying supine? Sitting upright? Standing?
Calm? Well? Comfortable? Alert? Ill?
Distressed? Tense? In pain? Confused?
Unconscious?
Hands Koilonychia
Leukonychia
Clubbing
Rahaf Wardeh Internal Medicine 2016-2017
Tendon xanthomas
Dupuytren's contracture
Palmar erythema
Flapping tremor
Arms (both arms) Ecchymosis
Itching scratches
Spider nevi
Face & Neck Face:
o Loss of outer 1/3 of eyebrows
o Exophthalmos
o Xanthelasma
o Pallor
o Jaundice (day light)
o Angles of the mouth (ulcers/fissures)
o Tongue hydrated/dry/bald (use a torch)
o Buccal discoloration (use a torch)
o oral ulcers
Neck:
o JVP/distended veins (use torch)
o Thyroid gland
o Virchow’s LN
Chest Gynecomastia (patient must be sitting)
Chest hair/Axillary hair distribution
Spider nevi
Abdomen Contour of the abdomen
Movement with respiration
Abdominal Distention
Umbilicus shape: inverted/flat/everted?
Comment on any:
o Masses
o Visible pulsation
o Visible peristalsis
o discoloration
o Scars
o Distended veins
Palpation Abdomen be on the same level of patient; wash hands;
warm hands; ask for site of pain and start away
from it; use surface of fingers (don’t poke)
start from Left Lower Quadrant in counter
clockwise pattern; don’t skip any area.
comment on the 4 quadrants/9 regions; look at
patient’s face
Rahaf Wardeh Internal Medicine 2016-2017
Superficial Palpation:
o tenderness?
o Rigidity & guarding?
o masses? Organomegaly?
Deep Palpation:
o Deep tenderness
o Deep masses
Abdominal Organs Liver
o Palpate from RLQ up, lateral to rectus
abdominis muscle, feel on inspiration to
feel edge of liver, move hand on
expiration till costal margin, percuss
from costal margin up till you feel
dullness of liver, mark this point.
Mark angle of Louis and start percussing
from 2nd ICS mid-clavicular line down till
you feel dullness of the liver.
Distance Liver span (N: 6-12 cm)
Comment on liver edge if felt.
Spleen
o Palpate from RLQ toward LUQ passing
over the umbilicus. Ask patient to take
deep breaths once you reach the
midline, feel on inspiration to feel edge
of spleen, move hand on expiration till
costal margin. Still suspicious? Let
patient turn right, palpate left side after
the midline. Try to incenuated your hand
below the costal margin. Still suspicious?
Percuss on Traube’s area. Comment on
border & notch of spleen if felt.
Kidneys
o Place left hand under the patient at the
costovertebral angle lateral to
paravertebral muscles. Place right hand
on the abdomen of the patient in front
of the left hand (as if sandwiching).
Push up with left fingers and try to feel
for any mass hitting the right hand.
Ask the patient to take a deep breath to
feel something slipping between your
hands. Repeat for other kidney.
Percussion *looking for any fluid in the If abdomen is hugely distended transmitted
Rahaf Wardeh Internal Medicine 2016-2017
abdomen* thrill. (if not sure, start with this one)
If intermediate distention shifting dullness
Transmitted thrill: place your left hand on the
left side of the abdomen, and hit the right side
and feel if there is any thrill (wave). If yes, let
patient place his hand in the midline & try again.
Shifting dullness: percuss until umbilicus, then
go to the right and percuss. If any dullness, let
the patient turn and percuss again.
Auscultation Auscultate in 6 sites: Below the umbilicus for bowel sounds
Above the umbilicus by 1 inch, then 1 inch to
the right and left for renal vessels bruit
Epigastric region for aortic bruit
Above the left costal margin for splenic rub
(splenic infarction)
Above right costal margin for Hepatic Hum (liver
hemangiomas)
line ascending between umbilicus and Right
costal margin for Venous Hum (Portal HTN)
Extras Conclude your examination Examination of the hernial orifices, genitalia
by Digital Rectal Examination
Peripheral edema / Sacral Edema – against the
bone both legs.
Summary & Thank + Drape & cover
conclusion the patient
Additional Notes:
Hands & Arms:
- Koilonychia could be due to anemia from chronic GI bleed
- Leukonychia could be due to hypoalbuminemia in Liver disease
- Clubbing is nonspecific but occurs in liver cirrhosis & IBD
- Dupuytren’s contracture: patients with liver cirrhosis will have autoimmune fibrosis of
flexors of ring finger. Check for it by asking patient to place hands against each other
- palmar erythema due to liver cirrhosis
- tendon xanthomas in hypercholesterolemia can cause ischemic enterocholitis
- Asterixis (flapping tremor) in liver cirrhosis. Check for it by asking patients to
extend arms with extended wrists.
- Ecchymosis happens in liver cirrhosis (prolonged PT and PTT)
- Itching in case of primary biliary cirrhosis
Rahaf Wardeh Internal Medicine 2016-2017
- Spider nevi can be found in proximal arms and upper part of the chest, due to liver cirrhosis.
Face & Neck:
- Loss of outer 1/3 of eyebrows happens in myxedema (hypothyroidism) which can cause
constipation.
- Exophthalmus happens in thyrotoxicosis (hyperthyroidism) which can cause diarrhea.
- Buccal discoloration = brown patches, found in Peutz-Jeghers syndrome (intestinal polyps +
brown buccal spots)
- Ulcerations in the mouth can happen in Crohn’s diseases (IBD)
- When checking neck veins and JVP (although this is cardio mainly), use a torch and note any
distended, prominent veins. If not, look for pulsations between the two heads of SCM
muscle. Arterial pulsations are seen and felt; venous pulsations are seen but not felt.
Palpation:
- When spleen enlarges, it enlarges upward first, then starts extending downward when
there’s no longer space up. We can check for this by percussing over 7 th, 8th, 9th intercostal
spaces “Traube’s Area”. If resonant, then there’s NO splenomegaly. If dull
splenomegaly, and confirm by Ultrasound.
Transmitted thrill: when you hit the abdomen, the wave is transmitted to the other side across
the skin. Then place the patient’s hand in the middle for the purpose of stopping the wave. If
the thrill is still felt, this means there is fluid in the abdomen that is transmitting the wave to
other side and this is what you’re feeling. Otherwise, you wouldn’t be feeling the wave because
it will be blocked by the hand of the patient.
Shifting dullness: after you percuss from xiphoid process to the umbilicus, start percussing to
the right, better than left, because most common cause of ascites is liver cirrhosis liver
shrank and the right side is empty, whereas the spleen will be enlarged and will fill the left side;
so percuss to the right side because that is where the fluid will be (if any). If you detected any
dullness, ask the patient to turn to the left while keeping your hand in place, and re-percuss
after waiting for 30 seconds to give chance to the fluid to be shifted. If the dullness became
resonance fluid in the abdomen.
