Question

GI CASE STUDY Choose one of the following prompts: 1. Imagine you find that your client’s abdomen is distended, pale, and taught. Described the tests you might perform, differentiating between a fluid wave test and a test for shifting dullness 2. A patient arrived in the emergency room with nausea, and localized severe steady pain in the right lower quadrant. You suspect that the client may have appendicitis. Describe physical assessment techniques that can be used to detect appendicitis. 3. A patient presents with tenderness over the liver, right-sided guarding, and reports nausea and sharp pain in the right upper quadrant particularly after eating fried foods. You suspect the client may have cholecystitis. Described the physical assessment techniques used to detect cholecystitis

Answer 1

Here there are 3 different questions which are clubbed together in a single case study. So let us discuss all the three different scenarios one by one.

• 1. Suppose a client is presenting distension in the abdominal region with pale coloration and taught abdomen it is a suggestive feature of Ascites (free fluid accumulation in abdominal cavity).

For the confirmation of ascites further more examinations are required.

Liver examination : An approach should be  made for the liver examination from the right side of the patient by keeping the patient lying to supine position. Patient’s privacy should be preserved by draping the top of their body with the gown and below the waist with a thin sheet. In order to get better compliance and the better examine, make sure the patient is warm and comfortable. In addition to that our hand temperature should be equally warm with patient body temperature, so as to not startle the patient.

Inspection: A through observation is done to look for gross asymmetries across the abdomen.

The skin is observed very precautiously in order to find signs of liver disease, such as caput medusa, or spider angiomata.

Auscultation : The liver inspection is to be followed, along with the rest of the abdominal exam, with auscultation. Listen over the area of the liver for bruits or venous hums.

Percussion: Percuss for the upper and lower margins of the liver. Place the non-dominant hand palm down flat on the abdomen with the fingers parallel to the lower costal margin pointed toward the midline. Percuss with the middle finger of your dominant hand on the middle finger of your non-dominant one.

Begin percussion over the lungs and move from the area of resonant lung sounds to the areas of dullness.

Mark the area of change. Repeat the same process from below, moving again from resonance over the bowel to dullness and again mark the area of change.

Start in the lower right quadrant so as to not miss a great hepatomegaly. Measure the vertical distance from the top to the bottom. We can also use palpation to determine the lower border.

Palpation: Palpation begins over the right lower quadrant, near the anterior illiac spine. Palpate for the liver with one or two hands palm down moving upward 2-3 cm at a time towards the lower costal margin.

Let the patient to have a deep breath. The liver will move downward due to the downward movement of the diaphragm.

Feel for the liver to hit the caudal aspect of our palpating hand. Palpate the bottom margin of the liver for the texture of the liver, i.e. soft/ firm/ hard/ tender/ nodular.

Scratch Test: Several different techniques have been described for this examination. One is to place the diaphragm over the area of the liver and then scratch parallel to the costal margin until the sound intensity drops off marking the edge of the liver. Other techniques involve different patterns of the scratching, for example as in spokes of a wheel and other places for placing the stethoscope such as over the abdomen.

There are several physical examination maneuvers described for detection of ascites described below that are at least moderately sensitive and specific. No single maneuver is both highly sensitive and specific; therefore at least two maneuvers are necessary to increase the accuracy of physical exam for ascites.

Bulging Flanks                                   

1. With the patient supine, the examiner visually observes whether the flanks are pushed outward (presumably by large amounts of ascitic fluid)
2. Positive test: simply the presence of bulging flanks

Note: A patient with an obese abdomen may also have flanks that bulge, although the fat of obesity extends further posterior than fluid in the peritoneum.

Flank Dullness

1. The patient is examined in the supine position.
2. Direct percussion is done over the abdomen, from the umbilicus to the flanks.
3. The location of the transition from tympany to dullness is noted.
4. Positive test: Percussion note is tympanitic over the umbilicus and dull over the lateral abdomen and flank areas

Note: The tympany over the umbilicus occurs in ascites because bowel floats to the top of the abdominal fluid at the level of the fluid meniscus.

The fluid wave test also called the fluid thrill test is a test for ascites (free fluid in the abdominal cavity). It is performed by having the patient (or a colleague) push their hands down on the midline of the abdomen. The examiner then taps one flank, while feeling on the other flank for the tap. The pressure on the midline prevents vibrations through the abdominal wall while the fluid allows the tap to be felt on the other side. The result is considered positive if tap can be felt on the other side. However, even with the midline pressure, transmission through the skin must be excluded. A positive fluid wave test indicates that there is a free fluid (ascites) in the abdomen. When one side of the abdomen is pressed, the other side may also be painful due to the transfer of the fluid in it.

Fluid Wave:

1. Have the patient lying supine.
2. The patient or an assistant places one or both hands (ulnar surface of hand downward) in a wedge-like position into the patient's mid abdomen, applying with slight pressure.
3. The examiner places the fingertips of one hand along one flank, and with the other hand firmly gives a sharp tap along the opposite flank.

Positive test: The examiner is able to detect "a shock wave" of fluid moving against the fingertips pressed along the flank, as the fluid is pushed from one side of the abdomen to the other by the force of the tap along the opposite flank.

Shifting Dullness:

1. This maneuver is performed with the patient supine.
2. Percuss across the abdomen as for flank dullness, with the point of transition from tympany to dullness noted.
3. The patient then is rolled on his/her side away from the examiner, and percussion from the umbilicus to flank area is repeated.
4. Positive test: When ascites is present, the area of dullness will shift to the dependent site. The area of tympany will shift toward the top.
5. It can be detected more easily if the fluid volume is more than 1500 ml

Note: The shift in zone of tympany with position change will usually be at least 3 cm when ascites is present.

• 2. While looking to the second scenario for the detection of appendicitis the following physical assessments are to be done:

Physical examination:

• A. Body temperature: The body temperature may be slightly increased (by an average of 1°C; 1.8°F). In patients presenting with a high-grade fever, another diagnosis should be considered.
• B. Heart Beat and heart rate: Tachycardia and fetor may also be present.
• C. McBurney's sign:  A classic sign is right lower quadrant abdominal tenderness (McBurney's sign) and localised rebound tenderness, if appendix is anterior.
• D. Rovsing's sign: There may also be pain in the right lower quadrant after compressing the left lower quadrant (Rovsing's sign).
• E. Psoas Sign & Obturator sign:  Pain may be elicited with the patient lying on their left side and slowly extending the right thigh to cause a stretch in the iliopsoas muscle (psoas sign) or by internal rotation of the flexed right thigh (obturator sign).
• F. Bowel Sounds: Bowel sounds may be reduced, particularly on the right side compared with on the left.
• G. Classical abdominal findings: Classical abdominal findings may not be present if the appendix is in an atypical position.
• H. Palpable mass & Peri-appendiceal abscess: A Palpable mass may be felt if the appendiceal perforation has been contained by the omentum, resulting in a peri-appendiceal abscess.

(Note:- Patients with perforation may present acutely unwell with hypotension, tachycardia, and a tense, distended abdomen with generalised guarding and absent bowel sounds).

here so many times the similar condition is often confused in the case of early trimester of pregnancies. So for the female patient the information on pregnancies is also to be considered and not get confused with the vomiting due to appendicitis and/or pregnancy.

• 3. Here in the third scenario the case is reflecting and giving an indication towards the Cholicystitis

• The most common presenting symptom of acute cholecystitis is upper abdominal pain.

• Signs of peritoneal irritation may be present, and in some patients, the pain may radiate to the right shoulder or scapula.

• Frequently, the pain begins in the epigastric region and then localizes to the right upper quadrant (RUQ). Although the pain may initially be described as colicky, it becomes constant in virtually all cases.

• Nausea and vomiting are generally present, and patients may report fever.

• Most patients with acute cholecystitis describe a history of biliary pain. Some times it become suggestive of gallstones.

• Radiation of the pain.

  Severity of the pain . local examinnation for the location and migration of the pain

  Lung sounds examination

  Chest sound examinations

  Pain intensity increases with the spicy and fatty intake.

  Pale coloration of skin urine and stools due to biliary obstruction.

  It often resembles with the conditions like jaundice.

  Thank you