THEMEDPRACTICALEXAM.COM

Head to Toe Examination (General Physical Examination with GIT Relevance)

A. Head & Face

  1. Eyes:

    • Pallor: Inspect lower palpebral conjunctiva (Hb < 7 g/dL if palmar creases lighter than surrounding skin when hand hyperextended).

    • Icterus (Jaundice): Inspect upper sclera (requires serum bilirubin ≥2.5 mg/dL), under aspect of tongue, palms, nails, skin. Note type (lemon yellow - hemolytic, orange yellow - hepatocellular, greenish yellow - obstructive).

    • Xanthelasma: Yellowish plaques around eyelids (seen in hyperlipidemia, sometimes associated with liver disease).

    • Kayser-Fleischer (KF) Ring: Brownish-green ring at the limbus of the cornea (Wilson's disease).

    • Bitot's spots: Foamy patches on conjunctiva (Vitamin A deficiency, malabsorption).

  2. Mouth & Oral Cavity:

    • Lips: Cheilosis (cracks at angles), fissures, ulcers, circumoral pigmentation (Peutz-Jeghers syndrome).

    • Gums: Gingivitis, bleeding, hypertrophy.

    • Teeth: Caries, maldon teeth (fluorosis), Hutchinson's teeth (syphilis), ridging.

    • Tongue:

      • Size: Macroglossia (e.g., amyloidosis, acromegaly).

      • Color & Surface: Glossitis (atrophic, beefy red - B12 deficiency, iron deficiency), fur (dehydration), papillae (atrophy), geographical tongue.

      • Tremor: Asterixis/Flapping tremor (hepatic encephalopathy) - have patient extend arms, dorsiflex wrists, spread fingers, observe for brief, jerky, asynchronous flapping movements.

    • Buccal Mucosa: Koplik's spots (measles), slate grey/blue pigmentation (Addison's disease), ulcers, leucoplakia, thrush.

    • Palate, Fauces, Tonsils, Pharynx: Ulcers, erythema, swelling, exudates.

    • Breath: Halitosis, characteristic odours (fruity - ketosis, fishy - uremia, mousy - hepatic failure, putrid - suppurative lung diseases).

    • Swallowing Ability: Ask about dysphagia for solids/fluids.

  3. Parotid Gland Enlargement: (Chronic liver disease, alcoholism, malnutrition).

B. Neck

  1. Lymphadenopathy (Cervical): Especially supraclavicular nodes (Virchow's node - gastric malignancy). Palpate submental, submandibular, preauricular, jugulodigastric, supraclavicular, deep cervical, occipital, posterior auricular. Note site, number, size, consistency, tenderness, mobility, matted/discrete, fixity.

C. Hands & Nails

  1. Clubbing: Inspect nail bed angle of index finger. Bulbous enlargement of fingertips/toes (Chronic liver disease, Inflammatory Bowel Disease (IBD), malabsorption, lung disease associated with GI conditions).

  2. Palmar Erythema: Reddening of palms (Chronic Liver Disease).

  3. Dupuytren's Contracture: Flexion contracture of fingers (Chronic Liver Disease, alcoholism).

  4. Nails:

    • Leuconychia: Whitening of nails (hypoalbuminemia - liver failure, malnutrition).

    • Koilonychia: Spoon-shaped nails (iron deficiency anemia - common in GI bleeding/malabsorption).

    • White bands (Muehrcke's lines, Terry's nails): (Hypoalbuminemia, Chronic Liver Disease).

    • Splinter Hemorrhages: Small reddish-brown lines under nails (Infective Endocarditis - consider in septicemia from GI source).

  5. Joints: Arthritis (IBD, Hemochromatosis - 2nd & 3rd MCP joints).

D. Upper Limbs

  1. Muscle Wasting: Especially small muscles of hands (malnutrition, chronic illness).

  2. Skin: Scratch marks (pruritus due to cholestasis), bruises/bleeding (coagulopathy in liver disease).

E. Trunk

  1. Skin:

    • Spider Naevi: Telangiectasias with central arteriole and radiating capillaries (typically upper torso, face, neck, arms; ≥5 suggests liver disease).

    • Loss of Axillary/Pubic Hair: (Chronic Liver Disease, hypogonadism).

    • Striae Atrophicae/Gravidarum/Purple Striae: (Rapid weight changes, Cushing's syndrome, liver disease).

    • Hyperpigmentation: (Hemochromatosis, Addison's disease, malabsorption).

    • Acanthosis Nigricans: Dark, velvety skin patches (insulin resistance, GI malignancy).

    • Skin Tags: (Insulin resistance).

    • Sister Mary Joseph's Nodule: Umbilical nodule (metastatic malignancy, often GI).

  2. Gynaecomastia: Breast enlargement in males (Chronic Liver Disease, malnutrition).

  3. Muscle Wasting: Generalised or specific patterns.

F. Abdomen (Overall General Inspection before detailed Abdominal Exam)

  1. Ascites: Look for generalized fullness, fullness in flanks, stretched/shiny skin, everted umbilicus.

  2. Umbilical Hernia: (Common with ascites/portal hypertension).

  3. Caput Medusae: Dilated periumbilical veins with flow away from umbilicus (Portal Hypertension).

  4. Flank Veins / Veins over Back: (IVC obstruction).

G. Lower Limbs

  1. Pedal Edema: Bilateral pitting edema (Hypoalbuminemia - liver failure, malnutrition, protein-losing enteropathy; also cardiac, renal causes).

  2. Leg Ulcers: (Inflammatory Bowel Disease - Pyoderma Gangrenosum, Crohn's related; Hemolytic disorders).

  3. Arthritis/Deformities: (IBD, Gout, Hemochromatosis).

IV. Specific Stigmata/Associations (Summary relevant to GIT)

  • Signs of Chronic Liver Disease: (As detailed above under various sections: Icterus, Palmar Erythema, Clubbing, Asterixis, Dupuytren's, Leuconychia, Gynaecomastia, Loss of Hair, Spider Naevi, Ascites, Testicular Atrophy, Umbilical Hernia, Caput Medusae, Pedal Edema, Parotid Enlargement, Glossitis).

  • Signs of Hepatic Encephalopathy: (Asterixis/Flapping tremor, constructional apraxia, altered sensorium, bilateral extensor plantar response - though specific CNS exam needed for latter).

  • Signs of Portal Hypertension: (Ascites, Caput Medusae, Splenomegaly - on abdominal exam).

  • Malabsorption: (Muscle wasting, icthyosis, brittle hair/nails, hyperpigmentation, stomatitis/dermatitis, anemia, Bitot's spots).

  • Inflammatory Bowel Disease (IBD): (Erythema Nodosum, Pyoderma Gangrenosum, peripheral arthritis, ocular manifestations like uveitis/episcleritis, perianal skin tags).

  • Hemochromatosis: (Hyperpigmentation of skin, arthritis of 2nd & 3rd MCP joints).

  • Pancreatitis: (Grey Turner's sign - flank ecchymosis; Cullen's sign - periumbilical ecchymosis; rare, severe signs).

  • GI Malignancy: (Sister Mary Joseph's nodule, Acanthosis Nigricans, Sign of Leser-Trélat, migratory thrombophlebitis).

  • Wilson's Disease: (KF Ring, Wing beating tremor, Dystonia - CNS signs).