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Clinical Examination

Clinical Examination

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Published by Marwan M.

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Published by: Marwan M. on Jun 30, 2010
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CLINICAL EXAMINATION y General examination starts with the hands, skin and nutritional status and noting the

presence of anaemia or jaundice. y Detailed examination starts with the mouth and tongue, before examining the abdomen with the patient lying flat. Examination of the abdomen 1. Inspection Abdominal distension, whether due to flatus, fat, fetus, fluid or faeces. Intermittent distension is most commonly a feature of functional bowel disorders. 2. Palpation The organs sometimes palpable in thin subjects. Include (the lower pole of right kidney 15%, left kidney 7%, liver 50%, sigmoid 75%, aorta, spleen normally is not felt) . Reidel's lobe is an anatomical variant consisting of a palpable enlargement of the lateral portion of the right lobe of the liver. Any palpable mass is carefully felt to evaluate its size, shape and consistency and whether it moves with respiration, to decide which organ is involved. A succussion splash suggests gastric outlet obstruction if the patient has not drunk for 2-3 hours. 3. Percussion To detects the areas of dullness caused by the liver and spleen, ascites or over masses. It can also detect a full bladder. Ascites is a term for excess fluid in the peritoneal cavity. It is detected clinically by central abdominal resonance due to gas within small bowel loops with dullness in the flanks which shifts when the patient lies on their side. This 'shifting dullness' is a reliable physical sign, but 1-2 L of fluid must be present. A large ovarian cyst can sometimes produce an enlarged abdomen, but the dullness is more centrally placed than in ascites. 4. Auscultation Not of great value in abdominal disease, except in the acute abdomen. Abdominal bruits are often present in normal subjects and are rarely clinically significant. 5. Examination of the rectum and sigmoid colon y Do digital examination in all patients with  A change in bowel habit.  Rectal bleeding.  Prior to proctoscopy or sigmoidoscopy.



Proctoscopy is performed in all patients with a history of bright red rectal bleeding to look for anorectal pathology such as haemorrhoids; a rigid sigmoidoscope is too narrow and long to enable adequate examination of the anal canal. Sigmoidoscopy is part of the routine in-hospital examination in all cases of diarrhoea and in patients with lower abdominal symptoms such as a change in bowel habit or rectal bleeding. The rigid sigmoidoscope allows inspection of a maximum of 20-25 cm of distal colon. Flexible sigmoidoscopy (FS) (60 cm) reaches usually up to the splenic flexure. It can be performed in the outpatient department after evacuation of the distal colon. FS is useful in patients with: Increased stool frequency or looseness. Rectal bleeding. 

Most rectal bleeding is due to benign ano-rectal disease (haemorrhoids or fissure-in-ano). Up to 60% of colonic neoplasms occur within the range of FS. It can also be used to biopsy or remove lesions in the sigmoid area, and for the follow-up of patients with distal colitis. If the presenting complaint is constipation with hard stools FS has the same rate of abnormality as in a control population. Practical Box 6.1 Sigmoidoscopy and proctoscopy Sigmoidoscopy

y y y

The technique using a 25-cm rigid sigmoidoscope is easy to learn, provides valuable information and is safe in competent hands No bowel preparation is required. Explain to the patient the nature of the procedure, obtain consent The technique is relatively painless. In the IBS, the patient's pain is often reproduced by air insufflation

1. Rectal examination is initially performed 2. The sigmoidoscope is passed into the anus, pointing towards the symphysis pubis. The obturator is removed, and the instrument passed under direct vision to the rectosigmoid junction and beyond if possible (using air insufflation) 3. The mucosa of the anus and rectum is inspected. The normal mucosa is shiny with superficial vessels and no contact bleeding 4. Biopsies can be taken of any lesions that are seen or from apparently normal-looking mucosa, which occasionally shows histological evidence of inflammation Proctoscopy 1. The proctoscope is passed into the anus and the obturator is removed 2. The patient strains down as the proctoscope is removed 3. Haemorrhoids are seen as purplish veins in the left lateral, right posterior or right anterior positions 4. Fissures may also be seen, but pain often prevents the procedure from being performed Stool examination The shape and size may be helpful (e.g. 'rabbit dropping' or ribbon-like stools in the irritable bowel syndrome). Stool charts for recording weight and frequency of defecation are useful in inpatients to follow the progress of diarrhoea.

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