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GI Assessment: Palpation, Jaundice & Percussion

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1. Palpation

• Localized masses
• Free peritoneal fluid (ascites)
• Areas of tenderness
• Localized or diffuse peritoneal inflammation

Key principles

• Start with light palpation to identify areas of tenderness, then progress to deep palpation for organ assessment and masses.
• Voluntary vs. involuntary guarding: Cold examiner hands or brusque contact can produce voluntary guarding — warm hands and gentle technique are essential for accurate assessment. True involuntary guarding reflects genuine peritoneal irritation.
• Rebound tenderness (Blumberg's sign): Eliciting it may suggest peritonitis when positive, but it is not always reliable on its own.
• Less reliable for chronic pain: Palpation is less likely to elicit peritoneal signs (rebound tenderness, guarding) in chronic or recurrent abdominal pain compared to acute pain.
• Attention during palpation should also be paid to skin lesions, rashes, pallor, jaundice, and edema.

Organ-specific palpation

Murphy's Sign (Cholecystitis)

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2. Percussion

• Organ size (hepatic and splenic dullness)
• Ascites (shifting dullness, fluid wave)
• Distended bowel (tympany)
• Solid masses or organomegaly (dullness)

Liver percussion

• Normal liver span: ~6–12 cm in the mid-clavicular line.
• Dullness over the liver area; loss of hepatic dullness → pneumoperitoneum (free air under diaphragm — surgical emergency).

Splenic percussion

• Inspection and percussion combined with palpation provide the best chance of identifying an enlarged spleen. The patient should take deep breaths while checking for the tip of the spleen.
• Dullness in Traube's space (left lower anterior chest) suggests splenomegaly.

Ascites

• Shifting dullness: Percuss from midline (tympanic) to flank (dull); roll patient to opposite side and recheck — if dullness shifts, ascites likely.
• Fluid wave / puddle sign: Useful for large-volume ascites.

Bowel / Obstruction

• Infrequent, prolonged rushes of high-pitched "tinkling" peristalsis are heard over distended bowel loops in intestinal obstruction.
• Diffuse tympany suggests obstruction or ileus.
• Absent bowel sounds + diffuse tenderness → peritonitis.

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3. Jaundice

Detection on exam

• Best seen in sclera (icteric sclerae) and mucous membranes — scleral icterus often appears first.
• Also visible in the skin, particularly on the face and trunk in natural light.
• Associated findings to assess simultaneously: pallor, edema, rashes/skin lesions, spider angiomata, palmar erythema, asterixis (hepatic encephalopathy).

Categories of jaundice (clinical approach)

Courvoisier's Sign

Jaundice + Percussion findings

• Dullness to percussion in the lower lung fields may be present with hepatic abscess or empyema.
• Hepatomegaly percussed > 12 cm MCL: suggests hepatitis, congestion, or malignant infiltration.
• Tympany + jaundice: consider proximal bowel obstruction with biliary involvement.

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Clinical Pearls

• Always inspect before palpating/percussing: note scars, distension, visible pulsations or peristalsis.
• Auscultate before palpation to avoid altering bowel sounds.
• A systematic approach (Inspection → Auscultation → Percussion → Palpation) ensures no finding is missed.
• Jaundice, ascites, and splenomegaly together = portal hypertension until proven otherwise.
• RUQ tenderness + fever + jaundice = Charcot's triad → ascending cholangitis (emergency).

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JVP & Murmur Examination

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PART 1: Jugular Venous Pressure (JVP)

Why It Matters

Which Vein to Use

• Internal jugular vein (IJV) — preferred. It is valveless and directly in line with the SVC and right atrium.
• External jugular vein — valved and not directly in line, but can still discriminate high vs. low CVP.

How to Measure

1. Position patient at 30–45° (adjust if needed — elevated JVP may require sitting upright).
2. Identify the highest point of jugular venous pulsation.
3. Measure the vertical distance from this point to the sternal angle (angle of Louis).
4. >4.5 cm above the sternal angle = elevated JVP (abnormal).
5. If pulsations are visible above the clavicle in the sitting position, this is clearly abnormal (distance from clavicle to right atrium is ≥10 cm).

Note: Sternal angle measurement tends to underestimate true CVP; it should be used to distinguish normal from elevated, not for precise quantification.

JVP vs. Carotid Pulse — How to Differentiate

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The JVP Waveform

Abnormal Waveform Patterns

Special Maneuvers

• Apply firm continuous pressure over the RUQ for >15 seconds.
• Positive = sustained rise in JVP by >3 cm.
• Assess after 10 seconds to allow respiratory artifacts to settle. Patient must not hold breath or Valsalva.
• Predicts pulmonary artery wedge pressure >15 mmHg in heart failure.

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PART 2: Murmur Examination

Systematic Approach to Any Murmur

1. Timing — systolic, diastolic, or continuous
2. Duration — early, mid, late, or holo (pan)
3. Intensity — graded I–VI
4. Quality — harsh, blowing, rumbling, musical
5. Frequency — high, medium, low pitched
6. Configuration — crescendo, decrescendo, crescendo-decrescendo (diamond), plateau
7. Location — where it is loudest (aortic, pulmonary, tricuspid, mitral areas)
8. Radiation — where it transmits to

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Grading of Murmur Intensity (Levine Scale)

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Systolic Murmurs

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Diastolic Murmurs

All diastolic murmurs are pathological and warrant further investigation.

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Continuous Murmurs

• Heard throughout systole and diastole.
• Classic cause: Patent ductus arteriosus (PDA) — "machinery" murmur.

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When to Order Echocardiography

• No further workup needed: Asymptomatic, Grade I–II midsystolic murmur, normal ECG and CXR, no other cardiac findings.
• Echo indicated: Grade ≥III/VI, holosystolic or late systolic murmur, any diastolic or continuous murmur, or any systolic murmur with abnormal ECG/CXR or symptoms of heart disease.

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Maneuvers to Characterize Murmurs

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Clinical Pearls

• A prominent JVP + holosystolic murmur at the lower sternal border louder on inspiration = tricuspid regurgitation.
• Elevated JVP + S3 gallop + mitral regurgitation murmur = decompensated heart failure.
• Cannon a waves in the neck during a wide-complex tachycardia → the rhythm is ventricular tachycardia.
• Kussmaul's sign + distant heart sounds + pulsus paradoxus = pericardial tamponade or constrictive pericarditis — do not miss.

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Respiratory Examination: Auscultation & Percussion

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PART 1: Percussion

Technique

• A uniform, free, easy stroke of the striking finger (plexor) striking the finger being struck (pleximeter).
• The ability to sense minor changes in pitch — the note is not just heard but predominantly felt.
• Always compare symmetrically — left vs. right at the same level.
• Percuss from top to bottom, both anteriorly and posteriorly.

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Percussion Notes & Their Meanings

Three Tonal Zones in Large Pleural Effusion

1. Resonant — above the fluid (normal lung)
2. Dull — at the level of the fluid
3. Flat — completely below the fluid level (maximum attenuation)

Pneumothorax vs. Pleural Effusion on Percussion

Diaphragm Excursion

• Percuss down the posterior chest during full inspiration, then full expiration.
• Mark the level of resonance-to-dullness transition each time.
• Normal excursion: ~5–7 cm.
• Reduced excursion: hyperinflation (COPD), pleural effusion, diaphragmatic paralysis.

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PART 2: Auscultation

How to Auscultate

• Use both the diaphragm (high-pitched sounds) and bell (low-pitched sounds).
• Auscultate systematically: compare left vs. right at each level (apex, mid-zones, bases), anteriorly and posteriorly.
• Instruct the patient to breathe deeply through the mouth.

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Normal Breath Sounds

Bronchial breath sounds heard over peripheral lung = pathological → consolidation (fluid-filled alveoli transmit sound well).

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Abnormal Breath Sounds (Added Sounds)

1. Crackles (Rales)

• Discontinuous, non-musical sounds.
• Caused by sudden opening of collapsed or fluid-filled airways/alveoli.

• Crackles in pulmonary oedema: predominantly bibasal.
• Crackles in IPF: described as "Velcro" — dry, fine, end-inspiratory, bibasal.
• Note: "Wet" vs. "dry" crackles distinction has not been shown to reliably differentiate etiologies — do not rely on this alone.

2. Wheeze

• Continuous, musical, high-pitched — generated by turbulent airflow through narrowed airways.
• Predominantly expiratory, but can be biphasic.

Not all wheeze = asthma. Peribronchial oedema in congestive heart failure also causes diffuse wheeze ("cardiac asthma").

3. Rhonchi

• Low-pitched, continuous, snoring/gurgling sounds.
• Caused by secretions in medium-sized airways.
• Acute: viral/bacterial bronchitis.
• Chronic: bronchiectasis, COPD.
• Clear partially or completely with coughing (distinguishes from wheeze).

4. Stridor

• High-pitched, focal, inspiratory wheeze — best heard over the neck.
• Indicates upper airway obstruction (larynx, trachea).
• Causes: croup, epiglottitis, foreign body, laryngeal tumour.
• Stridor is an emergency until proven otherwise.

5. Pleural Rub

• Creaking, grating sound — like leather rubbing on leather.
• Heard in both inspiration and expiration.
• Caused by inflamed pleural surfaces rubbing together.
• Indicates pleuritis (pneumonia, PE, TB, malignancy).
• Disappears when effusion develops (fluid separates the surfaces).

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Vocal Resonance Tests

Egophony (E→A change) = abnormal sound transmission through consolidated parenchyma → present in pneumonia, absent in IPF and effusion. Extremely useful to distinguish causes of crackles.

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Diminished/Absent Breath Sounds

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Clinical Summary Table

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Clinical Pearls

• Always auscultate before percussion is not mandatory in chest exam (unlike abdomen), but systematically cover all zones.
• Pulsus paradoxus — exaggerated fall in systolic BP >10 mmHg on inspiration — is an ominous sign in obstructive lung disease, indicating significant negative intrathoracic pressures and impending respiratory failure.
• JVD + peripheral oedema in a respiratory patient → cor pulmonale from chronic hypoxia.
• A unilateral silent chest in a breathless patient = pneumothorax or massive effusion until proven otherwise — act urgently.

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