history & examination of patients with abdomen, pelvis or perineum problems
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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!