GI PERFORMANCE EXAM

PEP I

Upon entering the room...

introduce self: name/title/purpose
Wash or sanitize hands
Clean stethoscope

General survey, observe for:

protective posture
diaphoresis
jaundice
pallor
shallow respirations

how to prepare the patient

supine, knees slightly flexed w/ pillow underneath, arms at side
expose minimum of xiphoid process to pubic symphysis
DRAPE!! lower half of body

after draping/prepping patient, inspect:

skin surface for condition noting any lesions/inflammation
color
scares
visible masses
dilated veins
striae
hernias
contour/fullness (from side and end of table)
umbilicus for contour/hernia/signs of inflammation
evidence of peristalsis
aortic pulsations
cullen sign (explain as periumbilical ecchymosis)
grey-turner sign (explain as flank ecchymosis)

*can use pen light for this part

cullen sign

periumbilical ecchymosis

grey-turner sign

flank ecchymosis

must do ____ before percussion and palpation?

AUSCULTATE!

what to auscultate with diaphragm

bowel sounds in minimum of 4 quadrants (keep diaphragm on patient for at least 5 seconds each time)

what to auscultate with bell

bruits renal arteries bilaterally
bruits iliac arteries bilaterally
bruits femoral arteries bilaterally
bruits area of aorta

how to find renal arteries (for bruits)

use bell of stethoscope
2 fingers UP from belly button, and 2 fingers over bilaterally

how to find iliac arteries

use bell of stethoscope
2 fingers DOWN from belly button, and 2 fingers over bilaterally

how to find femoral arteries

inferior to iliac artery at crease by pelvis/humerus

what can you also exam for while auscultating femoral arteries bilaterally?

inguinal lymph nodes bilaterally

when palpating inguinal lymph nodes:

"below the bone" in the crease
can have patient bend leg to find the crease

how to find aorta

2 fingers UP from belly button

after auscultation:

percuss!

first, percuss...

lightly in all 4 quadrants and over bladder (about 3 in each quadrant)

what to state you would percuss if patient was female?

i would percuss over uterus

after percussing 4 quadrants/bladder...

liver span in right MCL (mark and measure)

how to do liver span

percuss DOWN from 3rd ICS at right MCL
continue DOWN until tone changes to dull (usually around 5th ICS)
once tone changes to dull, MARK.
from there, keep percussing DOWN until tone changes back to resonance/tympanic and MARK
then, measure length of liver
normal= 6-12 cm

after liver span:

percuss splenomegaly

how to percuss splenomegaly

percuss lowest ICS in LAAL (left anterior axillary line) with patient at rest and with deep inspiration

what is the technique called for percussing splenomegaly

castell's technique

after percussing for splenomegaly:

percuss spleen for approx. size (traube's space)

how to percuss spleen for approx. size

borders of traube's space: 6th rib superiorly (nipple line), midclavicular line medially, midaxillary line laterally, and costal margin inferiorly
percuss from midline across this space towards anterior axillary line

*on left side of pt body

after percussion, what next?

palpate!

what to palpate first:

palpate lightly (1 cm deep) across 4 quadrants for tenderness guarding, and masses using rolling technique

then, deeply across 4 quadrants for tenderness, guarding, and masses

while palpating, what are you looking for?

tenderness, guarding, and masses
be sure to look at patient's face!

after palpating quadrants...

liver edge/muprhy's sign

hook method for liver edge

stand to patient's right facing their feet
hook fingertips around right costal margin
press up toward costal margin as patient takes deep breath

*explain murphy's sign HERE

what is murphy's sign?

as patient is taking deep breath, you are placing hand at costal margin of RUQ (done with liver edge)
if gallbladder inflamed, patient will experience pain and stop breath

after liver edge, what next?

spleen tip palpation

how to do spleen tip palpation:

reach across patient w/ left hand and place beneath patient
lift anteriorly on rib cage to lift spleen
palpate up/laterally towards spleen w/ right hand starting below costal margin
patient will take deep breath while palpating

after spleen palpation...

palpate upper margin of bladder and abdominal aorta (estimate size)

how to estimate size of abdominal aorta

palpate deeply above umbilicus and slightly to left of midline
feel for pulsation
normal width 2-3 cm

what to palpate after bladder/abdominal aorta?

kidneys bilaterally

how to palpate kidneys bilaterally

RIGHT: lift upward w/ left hand at 12th rib

place right hand below costal margin (fingers pointing up towards pt shoulder)

have patient take deep breath/hold-> then have patient release breath

LEFT: place left hand at 12th rib

place right hand below costal margin (fingers pointing up towards pt shoulder)

have patient take deep breath/hold -> then have patient release breath

what special testing for peritoneal signs?

rebound tenderness
markle sign (heel jar)

how to perform rebound tenderness

palpate in region of pain
after taking hand away: if it hurts patient more on release, then test is positive for rebound tenderness

how to perform markle sign (heel jar)

tap heel
if localized abdominal pain = positive markle sign test

special testing for appendicitis:

referred tenderness (Rovsing sign)
psoas sign
obturator sign

how to perform referred tenderness (Rovsing sign)

deeply palpate in LLQ
positive if patient finds pain in RLQ

how to perform psoas sign

patient supine and have patient right leg extended and place your hand over right lower thigh
have patient resist you pushing their leg down
positive if patient finds pain in RLQ

how to do obturator sign

patient supine and passively flex right hip to 90 degrees
passively rotate flexed hip internally (toes point outward/laterally)
positive finding is pain in RLQ with passive internal rotation

special testing for ascites

describe technique for shifting dullness

ascites technique for shifting dullness (just explain)

if patient has ascites and is laying supine, the fluid would rush to the sides, so if i percuss the top of the abdomen it would be tympanic but if i percuss the sides it would be dull

if patient then laid on the left side the fluid would rush to the left side and if i percuss the right side it would be tympanic and if i percuss the left side if would be dull

special testing kidneys:

CVA tenderness bilaterally

how to perform CVA tenderness (kidneys)

have patient sit upright and face away from you
indirectly (left palm over CVA area and strike with right fist) fist. then, if not too much pain, can do direct (striking with one fist)

CVA= costovertebral angle area

what to note at the END

need for digital rectal exam if indicated
*special testing may be negative but on digital rectal exam it may be positive

also if there are any positives on history/exam/masses that indicate digital rectal exam

what to also note at the END if patient is female

need for pelvic exam indicated
*special testing may be negative but on pelvic exam it may be positive

also if there are any positives on history/exam/masses that indicate pelvic exam

LAST STEP:

wash or sanitize hands