Examination

Info:

Perform an examination

Your history should guide your examination of all patients. Your examination of this patient should be focused as indicated by the history.

End of the bed

Stand back and look at your patient.

Comment on their general appearance and the presence of any monitors, oxygen or IV lines.

From the observations chart note:

Temperature (T)

Pulse (P)

Blood Pressure (BP)

Oxygen Saturation (SpO2) - always record whether patient 'on air' or 'on 2L nasal prongs' etc.

Respiratory Rate (RR)

The examination of any system should begin at the hands and include the face.

Hands and Nails

Clubbing, leuconycia, koilonychia, palmar erythema, Dupuytren's contracture, flapping tremor.

Finger Clubbing

Neck

JVP - patient at 45 degrees, neck muscles relaxed, use abdominojugular reflex if necessary.

Eyes

Pallor of conjunctiva, yellow sclera.

Mouth

Ulcers, dentition, dry furred tongue, angular stomatitis, glossitis.

Examination of the Abdomen

Inspection

Expose patient adequately and position them supine on the bed.

Look for scars, swellings, distended veins (portal hypertension), distention, intestinal peristalsis, pulsations, movement with respiration.

Palpation

Have you any pain? If yes point to where it hurts most.

Superficial palpation starting away from the site of maximum pain.

Assess presence of:

Voluntary guarding

Involuntary guarding

Board like rigidity

Rebound tenderness

Deep palpation assessing presence of organomegaly, masses and deep tenderness.

Palpate specifically for liver and spleen (both move downwards on inspiration) starting in the RIF.

Ballot the kidneys.

Percussion

May help localise tenderness, especially rebound tenderness.

Assess organomegaly.

Loss of liver dullness may suggest free intraperitoneal gas.

Elicit presence of fluid in peritoneal cavity, ie shifting dullness (>1litre of fluid required).

Auscultation

Bowel sounds:

Normal - low pitched, every few seconds

High pitched - loud and frequent, caused by increased peristalisis e.g. in mechanical obstruction.

Absent (>30sec) - cessation of peristalsis, e.g. in generalised peritonitis

Bruits:

Aortic

Iliac

Renal

Liver

 

PR examination

This should be part of the normal GI system examination.

Examine for the presence of masses, tenderness and blood.

In addition to the focused examination it is sensible to have a quick listen to the patient's heart and lungs and to examine for ankle and sacral oedema.