1 / 65

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

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

dagan
Download Presentation

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

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

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 : Slow- inflammation Sudden- perforation, ischemia • Severity:Mild in beginning- inflammation Severe- 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 chief 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 illness

  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. 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)

  40. PUH

  41. PALPATION OF THE ABDOMEN • Gentle palpation: start away from the area of pain- for tenderness • Deep palpation- deeptenderness- acute pancreatitis, Murphy’s sign, Rovsing’s sign • Guarding: muscle contracted overlying the tender area- acute inflammations

  42. 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

  43. Palpable masses • Mass in RUQ: ca. hepatic flexure, enlarged gallbladder, enlarged right kidney, hepatomegaly • Massin epigastric region: liver, gastric carcinoma, abdominal aortic aneursym • Massin 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)

More Related