Abdomen History & Exam

Dr. M. Almadani

How to solve it?

• HISTORY
• CLINICAL EXAMINATION
• CLINICAL DIAGNOSIS
• INVESTIGATIONS
• FINAL DIAGNOSIS
• TREATMENT

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History

• Record date ozf history taking and examination

• Introduce yourself
• Explain & seek permission
• Full attention
• Treat with respect
• Let patient talk
• Guide, not dictate
• No leading question
• No short-cuts
• Try not to write and talk at the same time

• PERSONAL DETAILS

• PRESENTING COMPLAINT
• HISTORY OF PRESENT ILLNESS
• SYSTEMIC INQUIRY
• PAST MEDICAL/SURGICAL HISTORY
• HISTORY OF MEDICATIONS
• FAMILY HISTORY
• SOCIAL HISTORY
• OTHER HISTORY (Gyn.)

PERSONAL

• NAME
• AGE
• SEX
• NATIONALITY
• MARITAL STATUS
• OCCUPATION

PRESENTING COMPLAINT

What are you complaining of? (record in patient’s own words)

When more than one complain: Record in order of:

• Severity
• Chronicity

HISTORY OF PRESENT ILLNESS

• Full analysis of the complain or complaints
• Get right back to the beginning of the trouble
• Analysis of the possible related systems

COMMON COMPLAINTS

• Abdominal pain
• Abdominal mass/ swelling
• Abdominal distension
• Changes in bowel habit
• Vomiting
• Discharge (abdomen, perineum)
• Bleeding
• Weight loss

Analysis of pain

Site: where is the pain?

• Patients point with- finger vs hand
• Locations (Great degree of overlap)
  • Right hypochondrium.- Hepatobiliary, gallbladder
  • Left hypochondrium.- Spleen
  • Epigastrium.- Stomach and duodenum
  • Lumber- kidney
  • Umbilical- small bowel, caecum, retroperitoneal
  • Right iliac fossa- Appendix, caecum
  • Left iliac fossa- Sigmoid colon
  • Hypogastrium- Colon, urinary bladder, adenexae

Analysis of pain

Onset:

• Slow: inflammation
• Sudden: perforation, ischemia

Duration: acute or chronic

Severity: Numeric Pain Rating Scale (1-10)

• 4-6 – moderate pain
• Mild beginning- inflammation
• Severe- perforation, ischemia

Nature:

• Dull (inflammation),
• Sharp (rupture viscus),
• Colic (intermittent)
• Throbbing (abscess)

Progression:

• Steady increase (inflammation),
• Fluctuating (colic)

Aggravating factors:

• Fatty foods increases pain in gallstone disease
• Eating
• Fasting

Relieving factors:

• Sitting & leaning forward eases pain- acute pancreatitis.
• Eating relieves pain- duodenal ulcer

Radiation or referred pain:

• Shoulder- cholecystitis,
• Groin- ureteric colic
• Shifting or migration:
  • periumbilical to RIF in acute appendicitis

Cause:

• Trauma,
• Food from outside- gastroenteritis
• Medication (NSAID)- perforation, bleeding

Swelling or mass

• When noticed?

  • Acute (hematoma, abscess)
  • chronic- neoplasm, organomegaly

• How noticed?

  • Incidentally noticed swelling may be present for longer duration

• Painful or painless?

  • Inflammatory, neoplasm

• Change in size

  • since first noticed? Increase- neoplasms,
  • disappear or reduce in size-?hernias/ improved inflammation

• Aggravating/relieving factors:

  • Hernias increase in size with activity/cough

• Any cause?

  • Trauma- hematoma, cough- hernia

B Symptoms

Weight loss, loss apetite, Night sweats

Vomiting

• Non- bilious: Early stage, late- pyloric obstruction
• Bilious: bowel obstruction
• Faeculent: late stage of bowel obstruction
• Blood: Duodenal ulcer, oesophageal varices, tumor
• Vomiting relieves pain- gastric ulcer
• Vomiting food taken few days ago: pyloric stenosis

Bowel habit

Constipation:

• habitual, recent (neoplasm)
• Absolute constipation (obstipation):
  • Intestinal obstruction

Diarrhoea:

• Duration (acute, chronic)
• Number of stool
• Any blood or mucous (IBD)

Color of stool:

• Bright red (anal, rectum),
• maroon (colon) black-
• melena (upper GI)

History of discharge

• Site: anal, perineum, wound

• Duration

• Nature:

  • purulent (anal fistula),
  • bloody (hemorrhoid),
  • fecal from wound ( int. fistula)

• Relationship to defecation/stool

  • mixed with stool- IBD,
  • independent of stool- hemorrhoids

• Any pain?

  • Hemorrhoids
  • Anal fistula

SYSTEMIC INQUIRY

Begin with the involved or affected (chief complain) system

Example: If the chief complaint is related to gastrointestinal system(GI)- continue with the GIT inquiry.

Respiratory system:

• Cough, sputum, hemoptysis, wheeze, dyspnea, chest pain

Cardiovascular system:

• Angina (cardiac pain), dyspnea ( rest/ exercise),
• Palpitations, ankle swelling, claudication

Obstetric & Gynecology

• LMP
• Vaginal discharge
• Vaginal bleeding
• Pregnancies

Nervous system

• Headache
• Fits
• Depression
• Facial/limb weakness

METABOLIC/ENDOCRINE

• Muscular pain
• Bone & Joint pain
• Swelling of joints
• Limitation of movements
• Weakness
• Bruising/ bleeding (nutrients deficiencies)
• Sweating (thyrotoxicosis)
• Thirst (diabetes)
• Pruritus (skin infection, jaundice, uremia, Hodgkin’s)
• Alcohol
• Weight loss- ?dieting, amount and duration

PAST HISTORY

• Rheumatic Fever
• Tuberculosis/ asthma
• Diabetes
• Jaundice
• Blood transfusion
• Mental illness
• Operations/ accident

FAMILY HISTORY

• Diabetes
• Hypertension
• Heart disease
• Malignancy
• Cause of death
• Father/Mother/Siblings/Spouse/Children/Grand parents / Close relatives - Anybody with Sudden death - not clear/severe disease/died from…Z

HISTORY OF MEDICATIONS

• Insulin
• Steroids
• NSAID
• Contraceptive pills
• Antibiotics
• Others

SOCIAL HISTORY

• Marital status
• Occupation
• Travel abroad
• Accommodation
• Habits ( smoking, alcohol )
• Dependent relatives

• Psychiatric/ emotional background

Immunization & Allergies

• Allergies
  • Food
  • Drugs
• Immunizations
  • Tetanus
  • Diphtheria
  • Tuberculosis
  • Hepatitis
  • Others

Before starting clinical examination:

• Analyze patient’s history.
• Probable diagnostic possibilities
• Think of the common diseases
• Determine physical findings consistent with these entities.
• Permission
• Privacy
• Presence of a nurse
• Precautions (hand hygiene)

Exposure:

• Exposure: nipples to knees (ideal)
• Cover genitalia
• Patient lying flat on a pillow
• Arms by the side (not under the head!)
• Sit or kneel beside the patient
• Adequate light

Observe your patient while history taking for:

• General health - emaciated (? Malignancy)
• Intelligence
• Attitude
• Mental state (dehydration, encephalopathy)
• Posture:
  • Peritonitis - flexed & still
  • Intestinal, biliary or renal colic - rolling around in agony
• Mobility

4 parts

1. Inspection

2. Palpation

3. Percussion

4. Auscultation

   • Practice a standard routine every time
   • Hand - head to toe
   • Head to toe

General

Vitals

• Weight - loss (malignancy), gain (DU)
• Pulse (Tachycardia - infection, fluid/blood loss)
• Blood pressure (low - fluid loss, bleeding)
• Temperature (Fever - infection)
• Respiration rate - raised in infections
• Pulse - rate, rhythm, volume, nature

Hands

• Nails - koilonychia, clubbing, leukonychia
• Skin - dehydration, moist palm, anemia
• Anemia - conjunctiva, nail bed
• Jaundice - sclera, under the surface of the tongue
• Oral cavity - mucous membrane for hydration, tongue for coating
• Scalp
• Ear/nose

Head, Neck, chest, Abdomen extremities

• Neck - vein, goiter, lymph nodes, other swellings
• Chest - asymmetry, expansion, breath sound, added sound
• Cardiac - rhythm, heart sound, murmur
• Limbs - asymmetry, swelling, movement, pulses, power
• Abdomen (local examination)

Inspection

• Asymmetry - from the foot end of the bed - mass
• Movement with breathing (restricted in peritonitis)
• Swelling/mass - location
• Distension - central (SIO) or peripheral (LBO, ascites)
• Scar, sinus, wounds
• Prominent veins - portal hypertension
• Umbilicus - shape, discharge, swelling
• Cough impulse - groin, umbilicus, scar

Grey-Turner sign & Cullen sign

1- abcess 2- periumbilical hernia 3- inisional hernia ascites / caput medusa

Palpation

• Gentle/superficial palpation:

  • Start away from the area of pain

• Deep palpation:

  • Deep tenderness
  • Guarding: muscle contracted overlying the tender area (acute inflammation)
  • McBurney’s point

• Abdominal signs:

  • Rebound/Rovsing’s
  • Murphy’s
  • Obturator
  • Psoas

• Organomegaly: liver, spleen, kidneys

• Other masses - abdominal wall or intra-abdominal

• Define all features of a mass: site, size, surface, borders, tenderness, pulsation, mobility

• Cough impulse

Abdomen Mass Sites & Signs

Mass Region	Possible Causes
RUQ	Ca. hepatic flexure, enlarged gallbladder, enlarged right kidney, hepatomegaly
epigastric region	Liver, gastric carcinoma, abdominal aortic aneurysm
LUQ	Splenomegaly, carcinoma descending colon, swelling in tail of pancreas, enlarged left kidney
periumbilical region	PUH, ca. transverse colon, tumour deposit (Sister Mary Joseph’s nodule)
LLQ	Descending colon (Benign, malignant Carcinoma), Sigmorectal - appendicitis could be transmitted from LLQ to RLQ
suprapubic region	Distended urinary bladder, pregnancy, ovarian mass
RLQ	Appendiceal disease, ca. ascending colon, Crohn’s disease of ileo-caecal area
inguinal region	Hernia, lymphadenopathy, aneurysm

Mcburny pooint

Psoas sign & Obturator sign

CC #Video

Percussion

• Organs and masses

• Liver span
• Ascites:
  • Fluid thrill (large amount)
  • Shifting dullness

Auscultation

• Bowel sounds
• Bruits

check inguinal hernia afterwards mention per rectal/vago examination