Gastrointestinal History and Physical Exam

History

 

Chief Concern

A good spot to begin is with "how's your appetite?"

 

 

 

Appetite and Consumption

Ask about diet, referring to Canada's Food Guide.

Ask about dysphagia or odynophagia.

 

Bowel Function and Habit

Start with open-ended questions such as "how are your bowel movements?" "how frequent are they?" have you noticed any changes?"

Nocturnal defecation and urgency are important and should be specifically questioned.

 

Abdominal Pain

Abodominal pain should be described in patient's own words, rated, localized, and described according to timing and aggrevating/relieving factors.

 

Weight Loss

The history is tremendously important when weight loss is occurring. Intake, absorption, and metabolism should all be queried.

 

 

 

 

 

Past Medical History

Previous surgeries should be discussed, as recurrence or complications are possible.

 

Family History

Directly inherited and polygenic disorders are important. Country of origin can also be helpful.

 

 

Social History

Smoking, alcohol, and employment can all be involved in GI disease.

Understanding hopes and expectations, the home situation, and social supports will help with planning the future.

 

Medications

Many drugs affect the GI tract, and drugs taken over the past several months should be identified. NSAIDs can cause hemorrhage, antibiotics can disrupt normal flora, andvarious drugs can cause liver toxicity.

 

Review of Systems

It is quicker to run through all systems the first time a patient is interviewed rather than spend much time on fruitless investigations and find important information later.

 

• liver
• spleen
• assessing for ascites
• the kidneys

 

General Exam

Hands

Clubbing, leuchonychia, kolionychia, Dupuytren's contracture, and palmar erythema can all suggest liver disease, as can asteryxis.

 

Chest

Spider nevi and gynecomastia can suggest liver disease.

 

Abdominal Inspection

Look for the presence of pallor or jaundice.

Observe the contour and symmetry of the abdomen, looking for flank or local bulge.

Note any scars, striae, dilated veins, rashes.

Frequently, the normal aortic pulsation is visible.

 

 

Auscultation

Listen to the abdomen before percussing or palpating, as these can change the frequency of sounds. Normal sounds, such as clicks and gurgles, are normally heard 5-34 times/minute.

Bruits can be sometimes be heard in the epigastrium and upper quadrants due to renal artery stenosis. A bruit during both systole and diastole suggests renal stenosis is the cause of hypertension. Bruits can also be heard over the aorta, the iliac arteries, and the femoral arteries, but can be benign.

 

Percussion

Percussion helps assess the amount and distribution of gas and stool, liver and spleen size, as well as ascites, and masses.

 

Palpation

Gentle palpation is useful for helping relax the patient and identify areas of tenderness, muscular resistance, and some superficial masses. If the patient is frightened or ticklish, start with their hand under yours. Observe the patient's face while examining.

Deep palpation can be used to find abdominal masses.

Rebound tenderness begins with slow, moderately deep pressure and a quick withdrawal. Pain suggests peritoneal inflammation and can be felt at areas other than that of palpation.

 

 

The Liver

Due to its location under the rib cage, the liver can be difficult to assess.

 

 

Percussion

Normal liver spans are 6-12 cm in the midclavicular line and 4-8 cm in the midsternal line. While it is the most accurate method, percussion can often underestimate liver size.

 

Palpation

Ask the patient to take a deep breath in and try to feel the liver edge as it descends. On inspiration, the liver edge is palpable about 3 cm below the right costal margin midclavicularly. Try to trace the liver edge across its span.

 

 

Other systemic signs of liver disease include clubbing, spider nevi, gynecomastia, ascites, and others.

 

The Spleen

An enlarged spleen usually points anteriorly, downward, and medially.

 

Percussion

Percussion raises suspicion of splenomegaly but must be confirmed with palpation. Dullness in Traube's space, above the left midaxillary costal margin, suggests an enlarged spleen, and can occur on inspiration.

 

Palpation

The spleen can be palpated with two hands.

 

 

Assessing for Ascites

A large belly with bulging flanks suggests ascites, as normally, obesity protrudes forwards.This is a sensitive, but not very specific, sign. Fluid-filled flansk will be dull on percussion.

 

shifting dullness

Percuss for air resonance, starting at the middle. make a mark where the resonance becomes dull. Then, have the person roll onto their side and repercuss, noting potential changes in fluid markers. not very sensitive, but specific.

 

fluid wave

have someone push their hand down in the midline. tap one side and feel for a fluid wave across the abdomen. sensitive but not specific.

 

 

The Kidneys

Although kidneys are not normally palpable, detecting an enlarged kidney may be very important.

Additional Resources

abdominal exam video (St George's University Clinical Skills Online)