Transcript History taking and examination of patients with abdominal, groin or

History
&
examination of patients
with abdomen, pelvis or
perineum problems
Prof. M K Alam
 HISTORY
 CLINICAL EXAMINATION
 CLINICAL DIAGNOSIS
 INVESTIGATIONS
 FINAL DIAGNOSIS
 TREATMENT
IMPORTANT POINTS BEFORE
HISTORY-TAKING
 Introduce yourself
 Explain yourself
 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
Different parts of a history
 PERSONAL DETAILS
 PRESENTING COMPLAINT
 HISTORY OF PRESENT ILLNESS
 SYSTEMIC INQUIRY
 PAST MEDICAL/SURGICAL HISTORY
 FAMILY HISTORY
 HISTORY OF MEDICATIONS
 SOCIAL HISTORY
 OTHER HISTORY
PERSONAL DETAILS
 NAME
 AGE
 SEX
 NATIONALITY
 MARITAL STATUS
 OCCUPATION
Record date of history taking and examination
PRESENTING COMPLAINT
 What are you complaining of?
(record in patient’s own words)
 When more than one complain:
(record in order of severity)
HISTORY OF PRESENT ILLNESS
 Full analysis of the complain or complaints.
 Get right back to the beginning of the trouble
COMMON COMPLAINTS
•
•
•
•
•
•
Abdominal pain
Abdominal mass or swelling
Change in bowel habit
Vomiting
Abdominal distension
Discharge (abdomen, perineum)
Analysis of pain
• Site: ask patient to point- finger vs hand
• Onset : Slow- inflammation
Sudden- perforation, ischemia
• Severity: Mild in beginning- inflammation
Severe- perforation, ischemia
Site: Pain locations (Great degree of overlap)
• Right hypochondrium.- gallbladder
• Left hypochondrium.- pancreas
• 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
• Nature: dull (inflammation),
sharp (rupture viscus), colic (intermittent)
throbbing (abscess)
• Progression: steady increase (inflammation),
decreasing, fluctuating (colic)
• Duration: acute or chronic
Analysis of pain
• Aggravating factors: fatty foods increases
pain in gallstone disease
• Relieving factors: Sitting and leaning
forward eases pain in acute pancreatitis.
Eating relieves pain in duodenal ulcer
Analysis of pain
• 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 a longer duration
• Painful or painless? Inflammatory, neoplasm
• Change in size since first noticed? Increaseneoplasms, disappear or reduce in size? -hernias
• Aggravating/relieving factors: Hernias increase
in size with activity
• Any cause? Trauma- hematoma, cough- hernia
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- hemorrhoid
• Any pain? Hemorrhoids- painless, anal fistulapainful
Vomiting
• Non- bilious: Early stage, late- pyloric obstruction
• Bilious: bowel obstruction
• Faeculent: late stage of bowel obstruction
• Blood: Duodenal ulcer, oesophageal varices, neoplasm
• Vomiting relieves pain- gastric ulcer
• Vomiting food taken few days ago: pyloric stenosis
SYSTEMIC INQUIRY
Begin with the involved or affected (chief
complain) system
Example:
If chief complaint is related to gastrointestinal
system(GI)- continue with the GIT inquiry.
SYSTEMIC INQUIRY- GIT
 Weight- amount, duration
 Jaundice
 Appetite
 Abdominal pain
 Dysphagia
 Fat intolerance
 Nausea
 Constipation
 Vomiting
 Diarrhoea
 Heartburn
 Melena
 Haematemesis
 Rectal bleeding
 Flatulence
 Stool
SYSTEMIC INQUIRY
• Respiratory system:
 Cough, sputum, hemoptysis, wheeze, dyspnea,
chest pain
• Cardiovascular system:
 Angina (cardiac pain), dyspnea ( rest/ exercise),
Palpitations, ankle swelling, claudication
SYSTEMIC INQUIRY
Obstetric & Gynecology
Nervous system
 LMP
 Headache
 Vaginal discharge
 Fits
 Vaginal bleeding
 Depression
 Pregnancies
 Facial/limb weakness
SYSTEMIC INQUIRY
MUSCULOSKELETAL
 Muscular pain
 Bone & Joint pain
 Swelling of joints
 Limitation of movements
 Weakness
SYSTEMIC INQUIRY
METABOLIC/ENDOCRINE
 Bruising/ bleeding (nutrients deficiencies)
 Sweating (thyrotoxicosis)
 Thirst (diabetes)
 Pruritus (skin infection, jaundice, uremia, Hodgkin’s)
 Alcohol
 Weight- ?dieting,
amount and duration
PAST MEDICAL/ SURGICAL HISTORY
 Rheumatic Fever
 Tuberculosis/ asthma
 Diabetes
 Jaundice
 Operations/ accident
 Blood transfusion
 Mental illness
FAMILY HISTORY
 Diabetes
 Hypertension
 Heart disease
 Malignancy
 Cause of death
Father/Mother/Siblings/Spouse/Children/Grand parents /
Close relatives
HISTORY OF MEDICATIONS
 Insulin
 Steroids
 NSAID
 Contraceptive pills
 Antibiotics
 Others
SOCIAL HISTORY
 Marital status
 Occupation
 Travel abroad
 Accommodation
 Habits ( smoking, alcohol )
 Dependent relatives
OTHER HISTORY
 Psychiatric/ emotional background
 Allergies
Food
Drugs
 Immunizations
Tetanus
Diphtheria
Tuberculosis
Hepatitis
Others
Review and analyse
 More questions looking for clues?
Clinical Examination
Before starting a clinical
examination, analyze patient’s
history for a possible diagnosis
CLINICAL EXAMINATION
Observe your patient while history taking:
• General health- emaciated (? Malignancy)
• Intelligence
• Attitude
• Mental state (dehydration, encephalopathy)
• Posture ( peritonitis- flexed & still)
• Mobility
CLINICAL EXAMINATION
•
•
•
•
Permission
Privacy
Presence of a nurse
Precautions
CLINICAL EXAMINATION
•
•
•
•
Inspection
Palpation
Percussion
Auscultation
CLINICAL EXAMINATION
• Practice a standard routine every time
• Hand- head to toe
• Head to toe
General Examination
• 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
General Examination
•
•
•
•
•
•
Pulse- rate, rhythm, volume, nature
Nails- koilonychia, clubbing
Skin- dehydration, moist palm, anemia
Anemia- conjunctiva, nail bed
Jaundice- sclera, under surface of tongue
Oral cavity- mucous membrane for
hydration status, tongue for coating
• Scalp
• Ear/ nose
General Examination
• Neck- vein, goitre, lymph nodes, other
swellings
• Chest- asymmetry, expansion, breath
sound, added sound
• Cardiac- rhythm, heart sound, murmur
• Abdomen (local examination)
• Limbs- asymmetry, swelling, movement,
pulses, power
LOCAL EXAMINATION
(ABDOMEN)
• Abdomen-extends from nipple level to the bottom of the pelvis
• Exposure: nipples to knees (ideal)
• Patient lying flat on a pillow
• Arms by the side ( not under the head!)
• Sit or kneel beside the patient
• Adequate light
INSPECTION OF THE ABDOMEN
• Asymmetry (from the foot end of the bed)- mass
• Movement with breathing (restricted- peritonitis)
• Swelling or mass- location
• Distension- central (SIO) or peripheral (LBO, ascites)
• Scar, sinus, wound
• Prominent veins (portal hypertension)
• Shape of the umbilicus
• Cough impulse ( groin, umbilicus, scar)
PUH
PALPATION OF THE ABDOMEN
• Gentle palpation: start away from the area
of pain- for tenderness
• Deep palpation- deep tenderness- acute
pancreatitis, Murphy’s sign, Rovsing’s sign
• Guarding: muscle contracted overlying the
tender area- acute inflammations
Palpation
• Organomegaly: liver , spleen, kidneys
• Other masses- abdominal wall or intra-abdominal
Define all the features of a mass (site, size, surface,
borders, tenderness, pulsation, mobility)
• Cough impulse
Palpable masses
• Mass in RUQ: ca. hepatic flexure, enlarged gallbladder,
enlarged right kidney, hepatomegaly
• Mass in epigastric region: liver, gastric carcinoma,
abdominal aortic aneursym
• Mass in LUQ: splenomegaly, carcinoma descending colon,
swelling in tail of pancreas, enlarged left kidney
• Mass in periumbilical region: PUH, ca. transverse colon,
tumour deposit (Sister Mary Joseph's nodule)
Palpable masses
• Mass in LLQ: faecal scybala, carcinoma descending colon
• Mass in the suprapubic region: distended urinary bladder,
pregnancy, ovarian mass
• Mass in RLQ: appendiceal disease, ca. ascending colon,
Crohn's disease of ileo-caecal area
• Mass in inguinal region: hernia, lymphadenopathy,
aneurysm
Percussion
–
–
–
Organs and masses
Liver span
Ascites: fluid thrill, & shifting dullness
Auscultation
–
Bowel sounds: normal, increased (bowel obst.)
absent (peritonitis, ileus)
–
–
Bruit- vascular lesions
Succussion splash (pyloric stenosis)
Abdominal wall hernias
• Swelling
• Vary in size: Disappear or reduce with rest. Increase
in size with activity- standing, coughing
• Pain- mild to severe
• Irreducibility
Examination of abdominal wall
hernias
• Inspection: (?standing vs lying)
Site ( groin, scars)
Extension to scrotum,
Scar,
Cough impulse
Reducibility
• Palpation:
?Can get above it-inguinoscrotal swellings
Tenderness
Cough impulse
Reducibility
Defect
Control by blocking internal ring
• Percussion- resonant if content is bowel
• Auscultation- bowel sound
EXAMINATION OF THE PERINEUM
• External genitalia
• Perineum examination: left lateral position,
hips flexed to 90º and knees flexed to less than 90°
• Lift uppermost buttock to expose the area
• Inspection: scar of previous surgery,
sinus (one opening blind track),
fistula (track connecting two epithelial surfaces)
fecal soiling, blood/mucous discharge,
mass protruding from anus
• Palpation: tenderness, discharge, mass
• Rectal examination: Tone, tenderness, mass,
prostate, blood, stool
Thank you!