abdominal history taking clincal skills_history taking

Clincal skills abdomen

1. بسم الله الرحمن الرحيم History Taking I n A bdominal S ystem D r - Mohamed Sidahmed MBBS(UOK)-MD(SMSB)-MRCP(UK) SEMESTER 3-Nov 2014 - SIU 1

2. HISTORY COMPONENTS Personal data. Main complains. History of presenting illness HPI. Systemic review SR. Past medical history PHx . Family history FHx . Drug history DHx . Social history. Address and answer any patient Concerns 2

3. PERSONAL DATA; Name. gender age residence occupation origin. marital status. 3

4. Main complain ; In patient words including duration eg abdominal pain for 4 weeks & admission period. History of presenting illness (HPI); Analysis of the patient complaints including systemic review of the system affected. Systemic review ; ask about other system relevant symptoms. -Nervous system: Fits, faints, funny turns, coma, weakness, Headaches, sphincter disturbance etc... 4

5. -Cardiovascular system: chest pain, dyspnoea, palpitations, ankle swelling. -Respiratory system: shortness of breath (SOB), cough, wheezes, haemoptysis etc.. - Genitourinary system: change in urine amount, colour and frequency. -Blood in urine, loin or suprapubic pain, burning micturition etc... -Musculoskeletal system: joint or muscle pain, skin rashes or ulcers etc… 5

6. Past medical history ; H istory of similar condition. chronic diseases ( Hypertention , Diabetes mellitus, Asthma, and other relevant conditions). Hospitalization and surgical operations. Blood transfusions. History of contact with patient with chronic cough or jaundice . 6

7. Family History ; History of similar condition . History of chronic diseases (Hypertension, Diabetes mellitus, Asthma, and other relevant conditions ). History of chronic cough or jaundice . Drug History ; Current medications: prescribed or over-the-counter ( n ame, dose & frequency). Long term medications; anti hypertensive , oral hypoglycemic drugs etc… Known drugs Allergy. Recreational drugs Relevant drugs 7

8. Social history ; Occupation. H ome condition ( eg water and electrical supply, animals, stairs at home,rooms and family size etc…) Who lives at home with the patient (partner, Children ?). Who looks after the patient socially and who support him financially?. Did he need help with housework, shopping, cooking. 8

9. Social habit ; *History of smoking: - (current smoker, past smoker X smoker) - duration (how many years ?) -type (Cigarettes / roll-ups / cigars ?) -How many per day ? (Packs\year). *history of alcohol consumption: -Do you drink alcohol? -What (Wine, Beer, Traditional etc…) -How frequent ( dailly , social occassions ) - A nd how much? (calculate units/week). 9

10. *I.V drug abuse (risk of HBV, HCV, HIV, infective endocarditis. History of travelling to endemic areas (risk of HIV, HBV, HCV, TB and viral hemorrhagic fevers… etc ). Sexual history (HBV, HCV, HIV). Address patient concern and let him to ask questions if he want. End the conversation by thanking the patient. 10

11. The GIT is a complex system form of many organs 8 m in length 11

12. COMMON ABDOMINAL SYMPTOMS Abdominal pain Dysphagia Nausea and vomiting Yellowish discolouration of the sclera (Jaundice) Anorexia and unexpected weight loss Heartburn Abdominal distension Diarrhoea Constipation Gastrointestinal bleeding (hematemesis?, melena ?). 12

13. Mouth  – Pain / Ulcers. Dysphagia – Onset / Progression / Solids and/or  liquids. Odynophagia –  pain on swallowing – oesophageal candidiasis. 13

14. Common causes of abdominal distension: Fat – obesity  Flatus – paralytic ileus/obstruction Faeces – constipation Fluid – ascites  Fetus – pregnancy 14

15. Hematemesis : vomiting of blood Melena : dark black, tarry feces that’s associated with upper GI bleeding. 15

16. Hematemesis Colour : Fresh red blood – undigested – acute bleed – Mallory Weiss tear / oesophageal variceal rupture Coffee ground – digested – bleeding peptic/ duodenal ulcer Preceded by forceful retching? – Mallory Weiss tear 16

17. ABDOMINAL PAIN Site Onset and progression character Intensity & Severity Aggravating or relieving factors ( food,fasting , posture, strees etc…) Associated symptoms Radiation of pain 17

18. SURFACE ANATOMY OF THE ABDOMEN 18

19. 19

20. Rt hypochondrial pain Liver (hepatitis, liver abscess, Rt heart failure) Gall bladder tree (stone, cholecystitis ) May radiate to back, epigastrium Pancreatitis Cardiac Pleural/pulmonary 20

21. Epigastric Pain Acute pancreatitis Peptic ulcer disease PUD Gastro-esophageal reflex disease GERD Cardiac Pleural/pulmonary 21

22. Esophageal origin Cardiac origin Radiation : back Type: burning, spasmodic Aggravating factors: body position, eating Relieving factors: antacid Associated symptoms: dysphagia, regurgitation Radiation: left Type: pressing, constricting Aggravating factors: physical activity, stress Relieving factors: nitrates Associated symptoms: dyspnea, sweating 22

23. vomiting It’s important to address the amount of vomiting using a familiar measures. How many times per day, the content of vomiting (undigested materials?, gastric content?), is there’s any blood 23

24. Nausea and vomiting Frequency and volume –  high frequency and volume increases risk of dehydration Projectile vomiting – obstruction? What does the vomit look like?  Undigested food – pharyngeal pouch / achalasia / oesophageal stricture Bilious vomit/ faecal matter – lower GI obstruction (i.e. severe constipation) 24

25. Jaundice (icterus) Is defined as yellow or greenish pigmentation of the skin and the white of the eye (sclera), due to high bilirubin levels. Ask about the duration. Pattern: constantly increasing? Intermittent? Association with Rt hypochondrail pain? Any change in urine or stool colore ? 25

26. Altered bowel habit Diarrhoea : Consistency – how formed is it? Mucous – Inflammatory bowel disease (IBD) / Irritable bowel syndrome (IBS) Blood – Fresh red blood (anal fissure/ haemorrhoids /IBD). Melaena (upper gastrointestinal bleed) Urgency – IBD/IBS/gastroenteritis 26

27. Constipation Duration of constipation Absolute constipation? – not passing flatus – obstruction Colour of the stool Black ( Melaena ) – peptic ulcer / duodenal ulcer / malignancy Fresh red blood   – anal fissure / haemorrhoids / IBD /  polyp / lower GI malignancy Pale   ( steatorrhoea ) 27