history & examination of patients with abdomen, pelvis or perineum problems

History &

examination of patients with abdomen, pelvis or

perineum problems

Prof. M K Alam

HISTORYCLINICAL EXAMINATIONCLINICAL DIAGNOSISINVESTIGATIONSFINAL DIAGNOSISTREATMENT

IMPORTANT POINTS BEFORE HISTORY-TAKING

Introduce yourselfExplain yourselfFull attentionTreat with respectLet patient talkGuide, not dictateNo leading questionNo short-cutsTry not to write and talk at the same time

Different parts of a historyPERSONAL DETAILSPRESENTING COMPLAINTHISTORY OF PRESENT ILLNESSSYSTEMIC INQUIRYPAST MEDICAL/SURGICAL HISTORYFAMILY HISTORYHISTORY OF MEDICATIONSSOCIAL HISTORYOTHER HISTORY

PERSONAL DETAILSNAMEAGESEXNATIONALITYMARITAL STATUSOCCUPATION 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? Increase- neoplasms, 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 fistula-

painful

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

AppetiteDysphagiaNauseaVomitingHeartburnHaematemesisFlatulence

JaundiceAbdominal painFat intoleranceConstipationDiarrhoeaMelenaRectal bleedingStool

SYSTEMIC INQUIRY

• Respiratory system:Cough, sputum, hemoptysis, wheeze,

dyspnea, chest pain

• Cardiovascular system:Angina (cardiac pain), dyspnea ( rest/

exercise), Palpitations, ankle swelling, claudication

SYSTEMIC INQUIRYObstetric &

Gynecology

LMPVaginal dischargeVaginal bleedingPregnancies

Nervous system

Headache FitsDepressionFacial/limb

weakness

SYSTEMIC INQUIRY MUSCULOSKELETAL

Muscular painBone & Joint painSwelling of jointsLimitation of movementsWeakness

SYSTEMIC INQUIRY METABOLIC/ENDOCRINE

Bruising/ bleeding (nutrients deficiencies)

Sweating (thyrotoxicosis)

Thirst (diabetes)

Pruritus (skin infection, jaundice, uremia, Hodgkin’s)

AlcoholWeight- ?dieting, amount and duration

PAST MEDICAL/ SURGICAL HISTORY

Rheumatic FeverTuberculosis/ asthmaDiabetesJaundice Operations/ accidentBlood transfusionMental illness

FAMILY HISTORY

DiabetesHypertensionHeart diseaseMalignancyCause of death

Father/Mother/Siblings/Spouse/Children/Grand parents / Close relatives

HISTORY OF MEDICATIONS

InsulinSteroidsNSAIDContraceptive pillsAntibioticsOthers

SOCIAL HISTORY

Marital statusOccupationTravel abroadAccommodationHabits ( smoking, alcohol )Dependent relatives

OTHER HISTORYPsychiatric/ 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!