Abdominal Histories Syed Owais 4th Year

1. Abdominal HistoriesSyed Owais (4th Year)

2. Learning Objectives How to take Hx – 30 secs overview How to present Hx! Abdo history – top to bottom (cheeky!) Abdominal presenting complaints Acute Abdo Pain Jaundice General tips for slick-ness in OSCEs Abdo Hx Role-play

3. Intro and CONSENT -> Patient details Name Age Race* Occupation * Not unless necessary

4. The rest of the Hx PC – one sentence = pt’s OWN WORDS HPC – SOCRATES + medical jargon PMH/PSH – MJTHREADS, by which point you should definitely have your differentials Drug Hx + **Allergies** Family Hx Social Hx – smoking, alcohol, drugs, **occupation**, **travel**, contact (sexual or with sick) Systems Review – think WAFFN first (wgt loss, appetite, fever, fatigue, night sweats)

5. How to present (successfully!) This was… (pt name, age, occupation) With known… (significant PMH) Admitted via… (route + when) Presented with… (pt own words! Inc. onset/ severity) The Hx of presenting complaint started with… (chronological : first symptom -> present, include SOCRATES + treat./invest.) List +ve/-ve RISK FACTORS (if known) Then very brief: PMH, DH, FH, Social On direct questioning… (relevant info/systems review) ONE LINE Summary My impression of the pt is that they have… (diff diag)

6. Abdo history – top to bottom (cheeky!) (jaundice, appetite/anorexia, wgt loss, n+v+haematemesis, dysphagia/ordynophagia, dyspepsia, abdo pain, bowel habits/rectal bleeding)(jaundice, appetite/anorexia, wgt loss, n+v+haematemesis, dysphagia/ordynophagia, dyspepsia, abdo pain, bowel habits/rectal bleeding)

7. Presenting Complaint Acute Abdo Pain Jaundice Upper and Lower GI Bleed Constipation/ Diarrhoea Dyspepsia Vomiting/ Nausea Weight Loss

8. S - site O - onset C - character R - radiation A - associated symptoms T - time course/duration E - exacerbating/relieving factors S - severity (1-10) Presenting Complaint

9. History of Presenting Complaint Acute Abdo Pain Site – point with finger to location Onset When did it start? How quickly? What were you doing at the time? Character Where is it worse? Aching, sharp/stabbing/burning? Constant or variable? Colicky?

10. Acute Abdo Pain Radiate? (to back – AAA, pancreatitis, down – renal/ureteric colic, shoulders – gallbladder, chest – MI) Associated symptoms (use GI top to bottom!) Jaundice, Appetite/Anorexia, Wgt loss, N+V+Haematemesis, Dysphagia/Odynophagia, Dyspepsia, Abdo pain, Bowel habits/Rectal bleeding) MUST ask WAFFN (general to all hx): W eight loss..? A ppetite..? F ever..? F atigue..? N ight sweats..? History of Presenting Complaint

11. History of Presenting Complaint Acute Abdo Pain Exacerbating/relieving factors Triggers? Breathing deeply Coughing, moving, hot drinks -> gastritis, pancreatitis Food (fatty -> gallbladder, pancreatitis, PUD, GORD) Contact Relieving factors? Rest, Analgesia, Antacids, Milk, Defecation

12. History of Presenting Complaint Acute Abdo Pain Severity Worse? Staying same? Time off work? Disturbed sleep?

13. History of Presenting Complaint Acute Abdo Pain Risk Factors – Pancreatitis = GETSMASHED, Gallstones, ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion bite, Hypothermia, Hyper –cal./trigly., ECRP/Emboli, Drugs

14. History of Presenting Complaint Make sure it is haemoptysis! Haematemesis/pseudohaemoptysisMake sure it is haemoptysis! Haematemesis/pseudohaemoptysis

15. History of Presenting Complaint Jaundice Associated symptoms Think IBD Bowel changes, back pain, painful eyes/skin Think malignancy Bowel changes, weight loss, back pain (mets), leg swelling Think CLD Ascites, easy bruising, ithy skin, spider naevi Always: WAFFN (prev slide)

16. History of Presenting Complaint Jaundice Exacerbating/precipitating factors Travel (malaria, hepatits)? Food (seafood)? Contact? Infection?

17. History of Presenting Complaint Jaundice Differentials Pre – Hepatic Haemolysis Hepatic Infectious hepatitis, carcinoma Post – Hepatic Gallstones, carcinoma head pancreas

18. Past medical history Active/inactive medical conditions? Past hx of surgery MJTHREADS

19. Drug history What medications are you currently taking/dose? Compliance to medications OTC medications **Allergies**

20. Family history Are there any diseases that run in the family? Draw family tree if you can* * Though NOT necessary

21. Social history Do you smoke? – quantify! Do you drink alcohol? – quantify! Have you ever used recreational drugs? **Travel** hx Pets Who do you live with? What type of home do you live in? What floor? Do you receive help at home?

22. Systems review Cardiology Gastroenterology Neurology Genitourinary Rheumatology Skin General: WAFFN (if not asked earlier)

23. General tips for slick-ness in OSCEs Signpost Change Of Topic Summarise after HPC, if not, ALWAYS after PMH (after this point you should have your diff diagnosis) At the end must ask for q’s and concerns – SHOW EMPATHY Then… Ask for any more concerns! (Easy marks lost) When answering pt q’s… DON’T! Simply say: “I cannot comment on that, but I will forward your concern onto the doctor”

24. Role Play - Jaundice

25. Abdo Hx - Mark Scheme 1 - WASHES HANDS (1 mark) 2 - Appropriate Introduction- own name, greeting, role, patient’s name, age and what they are going to do (all required to score) (1 mark) 3 - Obtains consent (1 mark) 4 - Establishes duration of jaundice (one week) (1mark) 5 - Asks about previous episodes of jaundice (none) (1mark) 6 - Establishes fever and lethargy and their duration (all to score) (1mark) 7 - Asks about associated symptoms: no abdominal pain/nausea and vomiting/change in appetite. Itching present (1/2 mark each, total 2 marks) 8 - Establishes weight loss (3kg in 6 months) (1 mark)

26. Abdo Hx - Mark Scheme 9 - Establishes nature of stools (normal colour and consistency) (1 mark) 10 - Asks about recent travel (no), recent contacts (no), IV drug abuse (yes) and previous transfusions (yes) (1/2 mark each, total 2 marks) 11 - Establishes alcohol consumption and amount (1mark) 12 - Asks about systemic symptoms (nil relevant) (1mark) 13 - Asks about past medical and surgical history (drug abuse, RTA) (1mark) 14 - Family History (nil relevant) (1mark) 15 - Drug History (nil relevant) (1 mark)

27. Abdo Hx - Mark Scheme 16 - Drug Allergies (penicillin) (1 mark) 17 - Adequate social history (1 mark) 18 - Open to closed questioning (1 mark) 19 - Avoids or explains jargon (1 mark) 20 - Elicits patient’s ideas, concerns and expectations and responds sensitively (1 mark) 21 - Presents findings in a clear manner (1 mark) 22 - EXAMINER: Ask student to give differential diagnosis = Alcohol Hepatitis, Viral hepatits (must be in differential to score) (1 mark)

28. Conclusion Well done, I told you it was simples! I hope you feel more confident and structured with Hx taking and presenting For OSCE’s you have 10min stations but time yourself to 8 mins (including summary + time for differentials!) A great book on Hx: PasTest: History Taking in Medicine and Surgery (J and L Fishman) Any questions: sso06@ic.ac.uk