Presentation is loading. Please wait.

Presentation is loading. Please wait.

History & examination of patients with abdomen, pelvis or perineum problems Prof. M K Alam.

Similar presentations


Presentation on theme: "History & examination of patients with abdomen, pelvis or perineum problems Prof. M K Alam."— Presentation transcript:

1 History & examination of patients with abdomen, pelvis or perineum problems Prof. M K Alam

2 HISTORY CLINICAL EXAMINATION CLINICAL DIAGNOSIS INVESTIGATIONS FINAL DIAGNOSIS TREATMENT

3 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

4 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

5 PERSONAL DETAILS NAME AGE SEX NATIONALITY MARITAL STATUS OCCUPATION Record date of history taking and examination

6 PRESENTING COMPLAINT What are you complaining of? (record in patient’s own words) When more than one complain: (record in order of severity)

7 HISTORY OF PRESENT ILLNESS Full analysis of the complain or complaints. Get right back to the beginning of the trouble

8 COMMON COMPLAINTS Abdominal pain Abdominal mass or swelling Change in bowel habit Vomiting Abdominal distension Discharge (abdomen, perineum)

9 Analysis of pain Site: ask patient to point- finger vs hand Onset : S low- inflammation Sudden- perforation, ischemia Severity: Mild in beginning- inflammation S evere- perforation, ischemia

10 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

11 Analysis of pain Nature: dull (inflammation), sharp (rupture viscus), colic (intermittent) throbbing (abscess) Progression: steady increase (inflammation), decreasing, fluctuating ( colic) Duration: acute or chronic

12 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

13 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

14 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

15 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)

16 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

17 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

18 SYSTEMIC INQUIRY Begin with the involved or affected (chief complain) system Example: If c hief complaint is related to gastrointestinal system(GI)- continue with the GIT inquiry.

19 SYSTEMIC INQUIRY- GIT Weight- amount, duration Appetite Dysphagia Nausea Vomiting Heartburn Haematemesis Flatulence Jaundice Abdominal pain Fat intolerance Constipation Diarrhoea Melena Rectal bleeding Stool

20 SYSTEMIC INQUIRY Respiratory system: Cough, sputum, hemoptysis, wheeze, dyspnea, chest pain Cardiovascular system: Angina (cardiac pain), dyspnea ( rest/ exercise), Palpitations, ankle swelling, claudication

21 SYSTEMIC INQUIRY Obstetric & Gynecology LMP Vaginal discharge Vaginal bleeding Pregnancies Nervous system Headache Fits Depression Facial/limb weakness

22 SYSTEMIC INQUIRY MUSCULOSKELETAL Muscular pain Bone & Joint pain Swelling of joints Limitation of movements Weakness

23 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

24 PAST MEDICAL/ SURGICAL HISTORY Rheumatic Fever Tuberculosis/ asthma Diabetes Jaundice Operations/ accident Blood transfusion Mental illne ss

25 FAMILY HISTORY Diabetes Hypertension Heart disease Malignancy Cause of death Father/Mother/Siblings/Spouse/Children/Grand parents / Close relatives

26 HISTORY OF MEDICATIONS Insulin Steroids NSAID Contraceptive pills Antibiotics Others

27 SOCIAL HISTORY Marital status Occupation Travel abroad Accommodation Habits ( smoking, alcohol ) Dependent relatives

28 OTHER HISTORY Psychiatric/ emotional background Allergies Food Drugs Immunizations Tetanus Diphtheria Tuberculosis Hepatitis Others

29 Review and analyse More questions looking for clues?

30 Clinical Examination Before starting a clinical examination, analyze patient’s history for a possible diagnosis

31 CLINICAL EXAMINATION Observe your patient while history taking: General health- emaciated (? Malignancy) Intelligence Attitude Mental state (dehydration, encephalopathy) Posture ( peritonitis- flexed & still) Mobility

32 CLINICAL EXAMINATION Permission Privacy Presence of a nurse Precautions

33 CLINICAL EXAMINATION Inspection Palpation Percussion Auscultation

34 CLINICAL EXAMINATION Practice a standard routine every time Hand- head to toe Head to toe

35 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

36 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

37 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

38 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

39

40

41

42 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)

43

44

45 PUH

46 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

47 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

48

49

50 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)

51 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

52 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)

53 Abdominal wall hernias Swelling Vary in size: Disappear or reduce with rest. Increase in size with activity- standing, coughing Pain- mild to severe Irreducibility

54 Examination of abdominal wall hernias Inspection: (?standing vs lying) Site ( groin, scars) Extension to scrotum, Scar, Cough impulse Reducibility

55

56

57

58 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

59

60 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

61

62 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

63

64

65 Thank you!


Download ppt "History & examination of patients with abdomen, pelvis or perineum problems Prof. M K Alam."

Similar presentations


Ads by Google