ydy git (execution) · git examination execution document last updated: feb 2018 by aaron ho (dem...

GIT EXAMINATION Execution Document Last updated: Feb 2018 By Aaron Ho (DEM 3, Class of 2020) 1 WIPE General Inspection - Well and comfortable, no respiratory distress, no jaundice, not dehydrated, no cachexia - No IV drip, O2 lines, NG tube, Stoma bag, Vomit buckets, Total Parenteral nutrition (TPN) - No pyoderma gangrenosum Hands - Leukonychia, Koilonychia, Clubbing - Pallor in the crease, Palmar Xanthomata, Palmar erythema, Dupuytren’s contracture - Hepatic Flap Arms - Petechiae, Scratch marks, Spider Naevi, Bruising, Muscle wasting - Dermatitis herpatiformis, Acanthosis Nigricans Eyes - Conjunctiva Pallor, Jaundice, Xantholasmata, Iritis - Kayser-Fleischer ring (Using wood lamp) Cheek - Flushing, Enlarged Parotid gland (Palpate) Mouth - Fetor hepaticus - Angular stomatitis, Black lip pigmentation (Peutz Jegher’s) - Ulceration, Leucoplakia, Erythroplakia - Thrush, glossitis, macroglossia Neck - Lymph nodes (Left supraclavicular node = Virchow’s node) Chest Inspection - Scars, Gynaecomastia, Spider Naevi, Loss of body hair Abdomen Inspection - Good abdominal movement with respiration - No abdominal mass or distension or scars - No visible pulsation or peristalsis - Sister Joseph’s node, Caput medusa, Shingles, Striae - Cullen’s and Grey turner’s sign Abdomen Palpation and Percussion (Look at patient for pain) - Superficial 9 quadrants - Deep 9 quadrants - Liver (Palpation below, Percussion top) - Spleen (Palpation below, Percussion same; Normal impalpable) - Kidneys (Balloting like playing basketball; Normal not to feel) - Ascites (Percuss umbilicus out. Offer Shifting dullness and Fluid thrill if fluid present) Abdomen Auscultation - Bowel sounds (Below umbilicus) - AAA (2cm above umbilicus)

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GIT EXAMINATION Execution Document

Last updated: Feb 2018

By Aaron Ho (DEM 3, Class of 2020) 1

WIPE General Inspection

- Well and comfortable, no respiratory distress, no jaundice, not dehydrated, no cachexia - No IV drip, O2 lines, NG tube, Stoma bag, Vomit buckets, Total Parenteral nutrition (TPN) - No pyoderma gangrenosum

Hands

- Leukonychia, Koilonychia, Clubbing - Pallor in the crease, Palmar Xanthomata, Palmar erythema, Dupuytren’s contracture - Hepatic Flap

Arms

- Petechiae, Scratch marks, Spider Naevi, Bruising, Muscle wasting - Dermatitis herpatiformis, Acanthosis Nigricans

Eyes

- Conjunctiva Pallor, Jaundice, Xantholasmata, Iritis - Kayser-Fleischer ring (Using wood lamp)

Cheek

- Flushing, Enlarged Parotid gland (Palpate) Mouth

- Fetor hepaticus - Angular stomatitis, Black lip pigmentation (Peutz Jegher’s) - Ulceration, Leucoplakia, Erythroplakia - Thrush, glossitis, macroglossia

Neck

- Lymph nodes (Left supraclavicular node = Virchow’s node) Chest Inspection

- Scars, Gynaecomastia, Spider Naevi, Loss of body hair Abdomen Inspection

- Good abdominal movement with respiration - No abdominal mass or distension or scars - No visible pulsation or peristalsis

- Sister Joseph’s node, Caput medusa, Shingles, Striae - Cullen’s and Grey turner’s sign

Abdomen Palpation and Percussion (Look at patient for pain)

- Superficial 9 quadrants - Deep 9 quadrants - Liver (Palpation below, Percussion top) - Spleen (Palpation below, Percussion same; Normal impalpable) - Kidneys (Balloting like playing basketball; Normal not to feel) - Ascites (Percuss umbilicus out. Offer Shifting dullness and Fluid thrill if fluid present)

Abdomen Auscultation

- Bowel sounds (Below umbilicus) - AAA (2cm above umbilicus)

GIT EXAMINATION Execution Document

Last updated: Feb 2018

By Aaron Ho (DEM 3, Class of 2020) 2

- Renal Bruits (2cm above umbilicus, either side) Summary

- The patient is Connor O’Brien, an 86-year-old man who presented with abdominal pain. I have performed an abdominal examination of which the findings are normal and there’s no peripheral stigmata of abdominal diseases. On palpation, the abdomen is soft and non-tender with no organomegaly. There is no ascites, and auscultation reveals normal bowel sounds with no abdominal aortic or renal bruits

- To follow up with the patient, I would perform a DRE (Digital Rectal Exam) and check for hernias.

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