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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!
