Gastrointestinal System

Approach to abdominal pain

Exclude:
a. Gynae causes Ectopic pregnancy, abortion, pelvic
inflammatory disease, endometriosis in lady of reproductive
age group
b. GIT cause: Acute appendicitis, cholecystitis, peptic disease,
perforated viscus( appendix, duodenal ulcer ), intestinal
obstruction, strangulated hernia
c. Renal conditions: Renal calculi, pyelonephritis
History taking
Menstrual history: Last menstrual period, menorrhagia, pelvic
discharge

Details of abdominal pain: site, radiation, character, severity,

associated
symptoms, aggravating and relieving factors

Periumbilical pain, later right iliac fossa pain(appendicitis)

Nausea, vomiting, constipation (intestinal obstruction,

impacted stool)

Fever, chills, right hypochondriac pain, jaundice(cholangitis)

Physical examination:
Guarding

Rebound tenderness

Abdominal pelvic mass (location e.g. right iliac fossa, RIF etc.

Per rectal and per vaginal exam

Investigations:
Urine pregnancy test (UPT)
FBC
ESR
U FEME
HVS C&S
Ultrasound abdomen/pelvis

Approach to vomiting
History taking (look for red flags for sinister pathology):
Exclude:
Physiological e.g. Pregnancy
Pathological e.g. food poisoning, increased ICP, acute
appendicitis, molar pregnancy, acute labyrinthitis
Drug induced e.g. Opiates
Electrolytes e.g. hypercalcaemia
Causes:
a. GI causes
- acute gastroenteritis
- poisoning
- peptic disease
- acute appendicitis
b. CNS causes
- increased ICP
- migraine with aura
- CBL/ brain stem lesion
- prolactinoma
Physical
-

examination
signs of dehydration
abdominal tenderness, guarding, mass
focal neurological deficits, or signs of increased ICP

General
-

Investigations
Urine pregnancy test if pregnancy suspected
FBC
BUSE, creatinine
Urine FEME
Calcium, phosphate and albumin

Approach to pedal oedema

Differential diagnoses
a. Local causes
- lymphedema
- DVT
- cellulitis
- thrombophlebitis
- pelvic tumour
b. Systemic causes:
- liver cirrhosis
- nephrotic syndrome/chronic renal failure
- protein losing enteropathy
- hypothyroidism
- congestive cardiac failure
- malignancy
- drugs
HOPI
a. Onset, duration, unilateral vs. bilateral
b. Associated symptoms
- SOB, calf pain, period of immobilization
- non pitting oedema, enlarged lymph nodes
- abdominal mass, per vaginal bleed, ascites
- symptoms of hypothyroidism such as weight gain,
constipation, cold
intolerance, lethargy
- frothy urine, haematuria, reduced urine output
- autoimmune disease
- recent sore throat
- jaundice, PR bleed, bruising
- steathorrhoea, abdominal pain
- LOA, LOW, night sweats, fever
- Chest pain, orthopnoea, PND
c. Aggravating factors
- NSAIDS
d. Relieving factors
- Diuretics
Past medical history
- IHD/DM/HPT
- Connective tissue disease
- Myeloma

STD
Rheumatological disease
Pancreatitis
Coeliac disease
Any pap smear done before

Medication history
- gold, penicillamine
- NSAIDS
- Traditional medicine
- Oral contraceptive pills
Family history
- malignancy
- DM
Plan of action
- admit
- urinalysis
- FBC/BUSE/LFT/RBS/HbA1C
- Stool for fat
- CXR
- ECG
- free T4/TSH
- thrombophilia screening
- HBsAg/Anti HCV/ASOT
- CTD screen

Ascites

TB abdomen

Abdominal
malignancy
No pedal oedema
Budd Chiari

Lymphatic
obstruction

CCF
Ascites

Raised JVP

Consticti
pericard

Right Heart

With pedal
oedema

Stigmata of
chronic liver
disease

Periorbital
puffiness,
proteinuria

No jaundice, JVP
not raised, no
proteinuria

Chronic li
disease +/hypertens

Nephrot
syndrom

Hypoalbumi
a secondar
malabsorpt
CA stoma