Gastroenterology

You are seeing Mr. Jamison, a 45 year old known alcoholic, in the ER because he states that his skin color has recently changed. Please perform a focused physical examination.

Physical Examination

Inspection

• Comments on overall appearance
• Comments on proximal and temporal muscle wasting
• Examines sclera, frenulum, and skin for icterus
• Examines upper thorax, neck, and head for spider nevi
• Examines abdomen for caput medusa
• Examines for asterixis

Examination of the hands

• Examines for nail changes
• Examines for flexion contractures
• Comments on palmar erythema
• Examines for thenar muscle wasting

Examination of the Abdomen

• Estimates liver span using palpation and percussion
• Comments on size and texture of the liver
• Palpates for splenomegaly
• Percusses in Traube’s Space
• Percusses for Castell’s Sign

Examination for Ascites

• Comments on presence of bulging flanks from the foot of the bed
• Percusses abdomen for presence of ascites
• Examines for Shifting Dullness (positive)
• Performs Fluid Wave Test (positive)

You are seeing Mrs. Park, a 62 year old female, in the ER for recurring abdominal pain that has recently worsened. She would like to know what’s been causing this pain and comes to you for investigations. Please take a focused history and perform a focused physical examination.

History

• Onset and duration of pain
• Location of pain (right upper quadrant)
• Alleviating and aggravating factors
• Quality of pain
• Radiation of pain
• Frequency of pain
• Association of pain with specific food (worse with greasy/fatty foods)
• Associated nausea/vomiting and fever
• Change in appearance of stools (pale)
• Presence of blood in stools
• Change in bowel habit
• Recent weight loss
• Change in urine color (tea colored)
• Decreased appetite
• Previous abdominal surgery
• Past history of similar symptoms
• Personal history of gastrointestinal disease
• Alcohol history
• Effect on daily activities

Physical Examination

Inspection

• Inspects abdomen for masses, scars
• Comments on presence of scleral icterus
• Comments on absence of extra-hepatic stigmata of liver disease
• Percussion/Palpation/Auscultation
• Percusses abdomen and estimates liver span by percussion
• Palpates for tenderness (patient has tenderness in right upper quadrant)
• Monitors patient’s reaction to palpation, commenting on guarding
• Assesses for rebound tenderness
• Palpates for splenomegaly
• States that they would perform a digital rectal examination as part of the abdominal examination
• Assesses for Murphy’s Sign (positive)
• Auscultates in all four quadrants of the abdomen

You are seeing Mrs. Park, a 62 year old female, in the ER for recurring abdominal pain that has recently worsened. She would like to know what’s been causing this pain and comes to you for investigations. Please take a focused history and perform a focused physical examination.

History

• Onset and duration of pain
• Location of pain (right upper quadrant)
• Alleviating and aggravating factors
• Quality of pain
• Radiation of pain
• Frequency of pain
• Association of pain with specific food (worse with greasy/fatty foods)
• Associated nausea/vomiting and fever
• Change in appearance of stools (pale)
• Presence of blood in stools
• Change in bowel habit
• Recent weight loss
• Change in urine color (tea colored)
• Decreased appetite
• Previous abdominal surgery
• Past history of similar symptoms
• Personal history of gastrointestinal disease
• Alcohol history
• Effect on daily activities

Physical Examination

Inspection

• Inspects abdomen for masses, scars
• Comments on presence of scleral icterus
• Comments on absence of extra-hepatic stigmata of liver disease
• Percussion/Palpation/Auscultation
• Percusses abdomen and estimates liver span by percussion
• Palpates for tenderness (patient has tenderness in right upper quadrant)
• Monitors patient’s reaction to palpation, commenting on guarding
• Assesses for rebound tenderness
• Palpates for splenomegaly
• States that they would perform a digital rectal examination as part of the abdominal examination
• Assesses for Murphy’s Sign (positive)
• Auscultates in all four quadrants of the abdomen

You are seeing Frank, a 27 year old homeless male, who was brought into the ER by police because he was found vomiting in a nearby alleyway. Take a history of his complaint. Then, perform a focused physical examination.

History

• Onset of vomiting
• Contents/ appearance of vomitus
• Blood in vomit
• Recent alcohol intake
• Change in bowel habit
• Association with abdominal pain
• Severity of abdominal pain
• Radiation of abdominal pain
• Association of abdominal pain with position (worse when supine)
• Fever
• Relevant social history, including current housing state
• Alcohol history
• Assessment for alcohol abuse (CAGE)
• Drug history
• Hepatitis status, past vaccination

Physical examination

Inspection/Auscultation

• Comments on patient’s overall appearance, including jaundice and muscle wasting
• Notes any stigmata of chronic liver disease
• Inspects for masses and bulging flanks
• Inspects for Cullen’s and Grey Turner’s signs
• Auscultates in all four quadrants of the abdomen

Percussion/Palpation

• Uses light and deep palpation to examine for tenderness
• Monitors patient’s reaction to palpation in epigastrum, commenting on guarding
• Assesses for peritoneal findings, including rebound and shake tenderness
• Estimates liver span using percussion
• Palpates for splenomegaly
• States that they would perform digital rectal examination as part of the abdominal examination

Special Maneuvers

• Assesses if pain varies with position (comments that pain associated with pancreatitis is somewhat alleviated when patient leans forward)
• Assesses for asterixis and ascites

You are seeing Mr. Martin, a 58 year old male, in the ER for a one-week history of dark stools. Take a focused history of his complaint.

History

• Onset of symptom
• Change in bowel habit
• Appearance of stool – distinguishes melena from bright red blood per rectum
• Association with bowel movements
• Tenesmus
• Incomplete voiding
• Pain on defecation
• Abdominal pain
• Dyspepsia
• Symptoms of reflux
• Nausea and vomiting
• Systemic symptoms, especially weight loss
• Personal history of constipation and/or hemorrhoids
• Personal history of gastrointestinal ulcers
• Country of origin (risk factor for H. Pylori infection)
• NSAID use
• Smoking history (quantity in pack-years)
• Alcohol use
• Hepatitis status
• Past colonoscopy and upper endoscopy
• Family history of gastrointestinal cancers

History

• Onset and duration of abdominal pain
• Location of pain
• Alleviating factors
• Aggravating factors
• Progression of pain
• Quality of pain
• Radiation of pain
• Severity of pain
• Associated nausea and vomiting
• Fever
• Changes in bowel habit
• Blood in stools
• Menstruation history
• Urinary symptoms
• Sexual history and use of contraception
• Previous pregnancies
• Previous abdominal surgery
• Recent changes in diet
• Travel history
• Infectious contacts

Physical Examination

Inspection/Auscultation

• Comments on patient’s position on the examination table and drapes patient appropriately
• Inspects the abdomen for masses, scars
• Auscultates in all four quadrants of the abdomen

Percussion/Palpation

• Uses light and deep palpation to examine for tenderness
• Monitors patient’s reaction to palpation, comments on guarding
• Assesses for rebound tenderness in the right lower quadrant
• Notes tenderness at McBurney’s point
• States that they would perform a digital rectal examination as part of the abdominal examination

Special Maneuvers

• Assesses for Murphy’s Sign
• Assesses for Rosving’s sign
• Assesses for Psoas sign