history & examination of patients with abdomen, pelvis or perineum problems
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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History &
examination of patients with abdomen, pelvis or
perineum problems
Prof. M K Alam
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HISTORYCLINICAL EXAMINATIONCLINICAL DIAGNOSISINVESTIGATIONSFINAL DIAGNOSISTREATMENT
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IMPORTANT POINTS BEFORE HISTORY-TAKING
Introduce yourselfExplain yourselfFull attentionTreat with respectLet patient talkGuide, not dictateNo leading questionNo short-cutsTry not to write and talk at the same time
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Different parts of a historyPERSONAL DETAILSPRESENTING COMPLAINTHISTORY OF PRESENT ILLNESSSYSTEMIC INQUIRYPAST MEDICAL/SURGICAL HISTORYFAMILY HISTORYHISTORY OF MEDICATIONSSOCIAL HISTORYOTHER HISTORY
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PERSONAL DETAILSNAMEAGESEXNATIONALITYMARITAL STATUSOCCUPATION Record date of history taking and examination
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PRESENTING COMPLAINT
What are you complaining of? (record in patient’s own words)
When more than one complain: (record in order of severity)
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HISTORY OF PRESENT ILLNESS
Full analysis of the complain or complaints.
Get right back to the beginning of the trouble
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COMMON COMPLAINTS
• Abdominal pain• Abdominal mass or swelling• Change in bowel habit• Vomiting• Abdominal distension • Discharge (abdomen, perineum)
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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
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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
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Analysis of pain
• Nature: dull (inflammation),
sharp (rupture viscus), colic
(intermittent) throbbing (abscess)
• Progression: steady increase (inflammation), decreasing, fluctuating (colic)
• Duration: acute or chronic
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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
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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
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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
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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)
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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
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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
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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.
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SYSTEMIC INQUIRY- GIT
Weight- amount, duration
AppetiteDysphagiaNauseaVomitingHeartburnHaematemesisFlatulence
JaundiceAbdominal painFat intoleranceConstipationDiarrhoeaMelenaRectal bleedingStool
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SYSTEMIC INQUIRY
• Respiratory system:Cough, sputum, hemoptysis, wheeze,
dyspnea, chest pain
• Cardiovascular system:Angina (cardiac pain), dyspnea ( rest/
exercise), Palpitations, ankle swelling, claudication
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SYSTEMIC INQUIRYObstetric &
Gynecology
LMPVaginal dischargeVaginal bleedingPregnancies
Nervous system
Headache FitsDepressionFacial/limb
weakness
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SYSTEMIC INQUIRY MUSCULOSKELETAL
Muscular painBone & Joint painSwelling of jointsLimitation of movementsWeakness
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SYSTEMIC INQUIRY METABOLIC/ENDOCRINE
Bruising/ bleeding (nutrients deficiencies)
Sweating (thyrotoxicosis)
Thirst (diabetes)
Pruritus (skin infection, jaundice, uremia, Hodgkin’s)
AlcoholWeight- ?dieting, amount and duration
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PAST MEDICAL/ SURGICAL HISTORY
Rheumatic FeverTuberculosis/ asthmaDiabetesJaundice Operations/ accidentBlood transfusionMental illness
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FAMILY HISTORY
DiabetesHypertensionHeart diseaseMalignancyCause of death
Father/Mother/Siblings/Spouse/Children/Grand parents / Close relatives
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HISTORY OF MEDICATIONS
InsulinSteroidsNSAIDContraceptive pillsAntibioticsOthers
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SOCIAL HISTORY
Marital statusOccupationTravel abroadAccommodationHabits ( smoking, alcohol )Dependent relatives
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OTHER HISTORYPsychiatric/ emotional background
Allergies Food Drugs
Immunizations Tetanus Diphtheria Tuberculosis Hepatitis Others
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Review and analyse
More questions looking for clues?
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Clinical Examination
Before starting a clinical examination, analyze patient’s history for a possible diagnosis
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CLINICAL EXAMINATION
Observe your patient while history taking:
• General health- emaciated (? Malignancy)
• Intelligence
• Attitude
• Mental state (dehydration, encephalopathy)
• Posture ( peritonitis- flexed & still)
• Mobility
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CLINICAL EXAMINATION
• Permission• Privacy• Presence of a nurse• Precautions
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CLINICAL EXAMINATION
• Inspection• Palpation• Percussion• Auscultation
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CLINICAL EXAMINATION
• Practice a standard routine every time
• Hand- head to toe• Head to toe
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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
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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
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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
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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
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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)
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PUH
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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
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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
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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)
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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
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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)
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Abdominal wall hernias
• Swelling
• Vary in size: Disappear or reduce with rest.
Increase in size with activity- standing, coughing
• Pain- mild to severe
• Irreducibility
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Examination of abdominal wall hernias
• Inspection: (?standing vs lying)
Site ( groin, scars) Extension to scrotum, Scar, Cough impulse Reducibility
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• 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
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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
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• 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
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Thank you!