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

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

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)

45. PUH

46. 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

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

50. 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)