Transcript 7_Examination of the abdomen

History taking in abdominal
diseases
History taking
• Family history
– Colon cancer
– Gallstones
History taking
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Factors, habits and previous
diseases
Diet
Drugs
Alcohol
Smoking
Transfusion
Iv. drug abuse
Lifestyle
History taking - summary
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Abdominal pain
Dysphagia
Nausea and vomiting
Anorexia and unexpected weight loss
Abdominal gas
Abdominal distension
Diarrhea
Constipation
Gastrointestinal bleeding
Jaundice
History taking
Abdominal pain
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Localisation
Type
Severity
Chronology
Aggravating or relieving factors
Associated symptoms
Radiation of pain
Diffuse abdominal pain
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Peritonitis
Intestinal obstruction
Irritable bowel syndrome
Tense ascites
Acute abdomen
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Peritonitis
Appendicitis
Bowel or gastric perforation
Gallbladder perforation
Intestinal obstruction (ileus)
Mesenterial ischaemia
Extrauterine pregnancy (ectopic pregnancy)
Acute necrotising pancreatitis
Biliary colic
Renal colic
History taking
Other causes abdominal pain
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Diabetic ketoacidosis
Hyperthyroidism
Acute intermittent porphyria
Hypercalcemia, hyperkalemia
Vasculitis
Pneumonia
Sickle cell crisis
Herpes zoster
Radiation of pain
• Ulcer disease: to the back
• Biliary pain: to the back, right scapula,
right shoulder
• Pancreatic: band-like, to the back
• Kidney, ureter: to the genitalia, groin
• Splenic: left shoulder
History taking
Substernal pain
Cardiac pain
Esophageal pain
Radiation: left
Type: pressing,
constricting
Aggravating factors:
physical activity,
stress
Relieving factors:
nitrates
Associated symptoms:
dyspnoea, sweating
Radiation : back
Type:burning,
spasmodic
Aggravating factors:
body position, eating
Relieving factors:
antacid
Associated symptoms:
dysphagia,regurgitation
History taking
Dysphagiadifficulty in swallowing
• Where is the food „hanging up”?
oropharyngeal or esophageal
• Difficulty to swallow liquids?
• Odynophagia- painful swallowing
History taking
Weight loss
• Is it associated with anorexia?
• Chronology
• Severity (significant:> 5%
of body weight)
• Underlying diseases
• Causes:
general disorders: diabetes, hyperthyroidism,
chr.infections,malignancy, medications
behavioral disorders: anorexia nervosa, depression
GI disorders: malignancy, malabsorption,
hepatic, biliary, pancreatic diseases
History taking
Nausea and vomiting
• Organic, functional or psychogenic?
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connection with meals
• accompanied by weight loss
• Content of the vomit
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Factors: taste, smell, color, pH
Subtypes: acid : reflux disease, duodenal ulcer
bile: bilio-pancreatic diseases
undigested food: obstruction of the
upper GI
faeces (miserere): bowel obstruction
(ileus)
blood: ie. ulcer, tumor, oes.varix
History taking
Abdominal gas
• Belching, bloating (meteorism),
flatulence
• Causes
– Aerophagia (habitual, poor dentition, inadequate
chewing, rapid eating)
– GI motor dysfunction or obstruction
– Malabsorption, maldigestion
– Bacterial overgrowth
History taking
Bowel movement
Factors: frequency, volume, fluidity, color,
associated sensations, change in bowel habits,
stool calibre
• Diarrhea
> 300 g of stool/day
more than 3 loose or watery
stools/day
• Constipation two or less stools/week
History taking
Bowel movement
• Stool alterations
– Color
– Content
- hypocholic, acholic
- pleiochromic
- bloody
- mucus
- blood
- fat - steatorrhea
- undigested proteins creatorrhea
History taking
Bowel movement
• Constipation
– Chronic or recent onset
• Causes
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Decreased fluid and/or food intake
Functional (irritable bowel syndrome)
Medications
Hypothyroidism
Fecal impaction
Rectal or colon cancer
Chronic debilitating disease
History taking
GI bleeding
• Classification
– Hematemesis
– Melena
– Hematochezia
– Occult bleeding
- fresh blood
- coffee ground
- blood on the stool
- blood mixed with the
stool
History taking
Jaundice
• Observe it in bright, natural light
• First time you can observe on the sclerae
History taking
Jaundice
• Important anamnestic factors
• Color of the skin: overproduction: lemon
obstructive: dark-yellow,
greenish
• Color of the stool: overproduction: dark, greenish
(pleiochromic)
obstructive: hypocholic, acholic
• Color of the urine: overproduction: cherry-red
obstructive: dark, brown
• Associated symptoms: anemia, pain, fever,
hepatomegaly, splenomegaly, ascites
Physical examination of the
abdomen
1.Inspection
2.Auscultation
3.Percussion
4. Palpation
Position of the patient
Physical examination
Inspection
• Configurations of the abdomen
in the level or above or below the chest
apple-type : visceral obesity - cardiovascular
risk
pear-type : gluteal obesity
• Abdominal skin
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striae : white, livid (pink)
hernias
veins : caput Medusae
visible peristalsis
visible pulsations
scars
Physical examination
Abdominal distension
• Generalised
• Localised
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Obesity
Pregnancy
Ascites
Bowel obstruction ileus
• Big ovarian cyst
• Peritonitis
Hepatomegaly
Splenomegaly
Polycystic kidney
Gastric distension
Inflammatory mass
Tumor
Obstructed bladder
Hernia
Physical examination
Auscultation
• Bowel sounds
• above the umbilicus or in the RUQ
• normal: 5-35/min, clicks and gurgles
• altered: absent: paralytic ileus
hyperperistalsis: diarrhea,
mechanical bowel obstruction
• Bruits
• arterial
aortic, renal, iliac arteries
• Friction rubs spleen, liver, peritonitis
• Succussion splash normal: above the
stomach
pathologic: gastric or bowel obstruction
Physical examination
Percussion
• Meteorism
• Liver span midclavicular line: 6-12 cm
midsternal line: 4-8 cm
• Splenic dullness
norm: in the midaxillary
line
pathological:dullness in the ant. axillary line
during inspiration
• Liver or/and splenic dullness absent:
perforation
Ascites
shifting dullness
Physical examination
Palpation
• Position
• Warm hands, short fingernails
• Approach slowly, avoid quick
movements
• Exemine tender areas at last
• Watch the patient’s face
Physical examination
Palpation
1. Light palpation
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muscular resistance - guarding defense musculaire
alterations in the abdominal wall
Physical examination
Palpation
2. Deep palpation
a. assessing abdominal masses
b. assessing abdominal tenderness
Physical examination
Palpation
• Characteristics of an abdominal mass
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location
size
shape
consistency
surface
tenderness
movable or fixed
shifting by respiration
Physical examination
Palpation of the liver and
spleen
• Characteristics:
1. size
2. surface
3. edge
4. consistency
5. tenderness
(6. liver pulsation)
Physical examination
Palpation of the gallbladder
• Hydrops vesicae felleae
Curvoisier’s sign - painless enlargement of
the gallbladder due to cancer of the head of
the pancreas
Murphy’s sign - RUQ pain aggravated by
inspiration - acute cholecystitis
Physical examination
Palpation of the aorta
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to the left of the midline
normal: < 3-4 cm
>6 cm: aortic aneurysm
transmitted pulsations: pancreatic or
gastric tumor, pseudocyst of the
pancreas
Physical examination
Rectal digital examination
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Perianal diseases fistulas, masses
Anal alterations hemorrhoids, fisssuras, masses
Rectal alterations polyp, neoplasm, ulcer
Prostate gland
Douglas’s space
Stool on the glove