GI: Head-Toe P/E Cheat Sheet (DRAFT) by med_panda

- Wash/S­anitize hands
- Greet patient in a warm, welcoming tone
- introduce yourself to the patient and clarify their identity and also purpose for visit
- Explain what you would like to do and obtaim consent
- If female student + male patient, (or vise versa) introduce chaperone

- Patient should be laying down (if they are comfor­table that way).
- Exposed from the waist up
- If liver is enlarged or suspected cirrhosis, patient should be propped up at a 45 degree angle to assess the jugular venous pressure ( in order to rule out right heart failure as a cause of liver disease

From foot of bed
- Are they comfor­table at rest?
- Do they appear to be tachyp­neic?
- Are there any obvious medical appliances around the bed?
- Are there any medica­tions around the bed
- Any wasting? (malab­sor­ption, anorexia, malign­ancy), obesity, jaundice, or rashes
Exposed areas of skin
- Fragile vesicles appear on exposed areas of the skin and heal with scarring in patients with porphyria cutanea tarda, a genetic disease that causes cirrhosis and is more common in those with hepatitis C.
- Tense tethering of the skin in systemic sclerosis may be associated with heart burn and dysphagia from gastro­-es­oph­ageal reflux and diarrhea from gastro­int­estinal motility disorders.

- Check sclerae for signs of jaundice
- Red eye from iritis may be seen in inflam­matory bowel disease
- Conjun­ctive pallor suggests anemia, more reliable than nail beds or palmar creases

- Normal parotid gland is impalp­able; enlarg­ement leads to a swelling in the cheek behind the angle of the jaw and in the upper neck
- Examine for signs of inflam­mation (warmth, tender­ness, redness and swelling) and decide whether the fascial swelling is lumpy or not
-> Alcoholic liver disease can cause bilateral parotid swelling
-> A mixed tumor (pleom­orphic adenoma) is the most common cause of a lump. Parotid carcinoma may cause a fascial nerve palsy

- While patient is sitting up, palpate in the suprac­lav­icular fossae for lymph nodes and feel over lower back for sacral edema
- Palpate cervical nodes one at a time from the front
- Palpate the suprac­lav­icular nodes from behind: "­Shrug your shoulders for me"

- In males: Gyneco­mastia or enlarg­ement of the breasts maybe a sign of chronic liver disease. Tender gyneco­mastia is common when patients take the druge spiron­ola­ctone
- Upper chest: Spider naevi
Spider naevi: consist of a central arteriole which radiate numerous small vessels that look like spiders legs. Can range in size from .5cm in diameter. Usual distri­bution in the area drained by the SVC, so they are found on the arm, neck or chest. Pressure applied with a pointed object to the contra­lateral causes blanching of the whole lesion, rapid refilling on release of pressure. Finding of more than 2 on the body is likely to be abnormal except during pregnancy. -> cirrhosis, most common alcohol.
Cherry angioma: Flat, slightly elevated circular spots that occur on the abdomen. They do not blanch on pressure, common and harmless

- At the wrist and forearms, inspect for scars
-Inspect the upper limbs for bruising . Large bruises (ecchy­moses) may be due to clotting abnorm­alities (e.g. in chronic liver disease).
- Look for muscle wasting , which is often a late manife­station of malnut­rition in alcoholic patients. Alcohol can also cause a proximal myopathy.
- Scratch marks due to severe itch (pruritus) are often prominent in patients with obstru­ctive or choles­tatic jaundice.

Pick up the patient's hands.
- Look for any rash.: Note any changes of arthritis . Arthro­pathy of the second and third metaca­rpo­pha­langeal joints may be present in the hands of patients with the iron-s­torage disease haemoc­hro­matosis .
- Look for purpura , which is really any sort of bruising. The lesions can vary in size from pinheads called petechiae to large bruises called ecchymoses , as occurs in liver disease. If the petechiae are raised ( palpable purpura ), this suggests an underlying systemic vasculitis or bacter­emia.
- Palmar erythema (‘liver palms’) is reddening of the palms of the hands affecting the thenar and hypothenar eminences. Often the soles of the feet are also affected. This can be a feature of chronic liver disease.
- Inspect the palmar creases for pallor suggesting anemia, which may result from gastro­int­estinal blood loss, malabs­orption (folate, vitamin B 12 ), hemolysis (e.g. hypers­ple­nism) or chronic systemic disease.
- Dupuyt­ren's contra­cture is a visible and palpable thickening and contra­ction of the palmar fascia causing permanent flexion, most often of the ring finger. It is often bilateral and occasi­onally may affect the feet. It is associated with alcoholism (not liver disease), but is also found in some manual workers and may be familial.
- Note clubbing too
Hepatic flap
Ask the patient to stretch out the arms in front, separate the fingers and extend the wrists for 15 seconds. Jerky, irregular flexio­n–e­xte­nsion movement at the wrist and metaca­rpo­pha­langeal joints, often accomp­anied by lateral movements of the fingers, consti­tutes the flapping of hepatic enceph­alo­pathy in liver failure.