3. Digestive system

(systema apparatus digestorii)

Mouth cavity: mucus coat of the inner surface of lips and cheeks, hard and soft palate; color, pigmentation, erosion, leukoplacia, aphthaes; breath, teeth (dental formula, tooth decay, looseness, false teeth); gums (color pattern, tenderness, angiostaxis, gray stripe etc.); tongue (size, color pattern, moisture, mammillar layer evidence, fur – localization, color, thickness), crimson, varnished, scalloped tongue; tonsils (size, color, tenderness, fur, lacunes).

Stomach examination: examination in the patient’s upright and lying position; shape (configuration) – normal, retracted, enlarged, protruding (proportional, disproportional, symmetric, asymmetric), sunken, diastalsis visible through abdominal layers; scarring, pigmentation, pronounced collaterals on the front and the side walls of stomach (“jellyfish head”), herniae ; participation of the frontal abdominal wall in the breathing (regular, irregular breathing, does not participate).

Stomach percussion: percutory sound in different areas of stomach; free or incapsulated fluid in the abdominal cavity (differentiate by changing the patient’s position appropriately); fluctuation symptoms (check if the stomach is strongly enlarged).

Surface (light-touch) palpation: pain, tension of muscles in the frontal abdominal wall, presence of hypodermal tumor-like growth, exploration of weak areas (umbilical and abdominal ring and the white line); Shchotkin-Blumberg and Mengele symptoms.

Deep methodical sliding palpation according to Obraztsov: characteristics of the palpated intestinal tract sections (sigmoid colon, blind intestine, appendicitis, final section of the ileum, ascending and descending large bowel and transverse colon); absence or presence of pain, displaceability, texture (firm, elastic), diameter, surface (smooth and shiny, bumpy), borborygmus.

Determination of the stomach’s lower border: palpation of the greater curvature of the stomach and its pyloric section; pathologic symptoms, splashing sounds on an empty stomach.

Liver: determination of the upper and lower border by percussion and palpation; size according to Kurlov; by how many centimeters it bulges over liver, what shape it is (even, pointy, round); texture, pain, surface type (smooth and shiny, bumpy); throbbing (true, annexal), peritoneal murmur.

Gall bladder: protruding, fixation during respiration; pain in the projection area (unconditional, during breathing, during palpation); shape, size, displaceability, texture, symptoms according to: Kehr, Murphy, Mussy-Georgiyevskiy, Zakharyin, Obraztsov, Ortner.

Pancreas: pain in the upper left stomach section, its pattern, irradiation; pain during palpation in the pancreas projection area and indicative areas (Schofer area, Mayo-Robson area etc.) induration and growth (tumors, cysts).

Spleen: palpation with the patient lying on the back and on the right side (according to Sally); degree of enlargement, pain, border, texture (firm, soft), surface, displaceability; percussion (size in centimeters).

Stomach Auscultation: murmuring in intestines and blood vessels, borborygmus (rubbling); peritoneal murmur.