Abdomen

I. Introduction
Name: Age: Sex: Handedness: Resident of: Education: Occupation: Religion:
Informant: Reliability:

II. Chief Complaints (in chronological order)

III. HOPI
1. Dysphagia- Onset, Solids/Liquids/Both, Odynophagia, progression

2. Heart burn,Reflux,Indigestion,Flatulence

3. Vomiting-
Onset,Duration,Projectile/Nonprojectile,Bilious/Nonbilious,Content,Precededby
nausea,Asso. with hematemesis, Frequency,Aggravatedby,Releived by, Last
episode

4. Hematemesis-Onset,Color,Quandity, Preceded by nausea, Frequency,

Aggravated by, Releived by, Last episode
5. Melena- Frequency, Color, Consistency, Odour, Lasted for, Last episode

6. Abd.Pain-(OLDCAARTS)Onset, Location, Duration, Character,Colicky/Noncolicky,

Associated features, Aggravating and Relieving factors,Relation with food
Radiation, Time, Severity

7. Abd. Distension- Onset, Diffuse/Localised, Progress, Asso.with-

Pain/Fever/Constipation/Diarrhoea/Altered bowel habits/Nausea &
Vomiting/Hematemesis/Melena/BleedingPR/Jaundice/Menstrual
 Irregularities/Oliguria/Anuria/Hematuria/Anorexia/Wt
loss/Periorbitalpuffiness[To r/o
Fat,Fluid,Faeces,Flatus,Foetus,Fatalgrowth,Liver& Kidney diseases], Releived by
[diuretics/fluid tapping etc…], Intermittent/persistent

8. Fever- Grade, Max Temp, Type, Associated with chills& rigors, Diurnal
variation, Evening rise of temp., night sweats, relieved by, present status

9. Anorexia&Weight loss- Quantified/Unquantified, lntentional /Unintentional,

Significant/insignificant
10. Constipation- Frequency, Fluid intake

11. Diarrhoea-
Onset,Duration,Frequency,Consistency,Quantity,Color,Odour,Painful/Painless,Te
nesmus,Stickyness,Steatorrhoea, Feeling of incomplete evacuation,Mixed with
blood/mucus/undigested food,Abd. Pain, Abd. Distension

12. Bleeding Per Rectum

13. Oliguria/Anuria/Dysuria/Hematuria/Urine color/Periorbital puffiness/loin pain

14. Jaundice- Onset, Sites [skin, eyes, urine], Urine color, stool color, Preceded by
any Prodrome/Pain abd / Abd. Distension, Progress,
Persistent/Intermittent/Fluctuating Pruritus, Bone pains, night blindness, Easy
bruisiability ,Bitotspots,Bleeding manifestations, Altered sensorium, Lasted for,
Releived by

15. Symptoms of Liver cell failure-Alopecia/Jaundice/parotid swelling/loss of hair in

axilla,Pubis/Lossof libido/Gynaecomastia/palmarerythema/
Contratures/Testicular atrophy/Ascitis/Spider nevi/Hematemesis/Melena
 16. Altered Bowel habits
17. Joint pain/Rash/Photosensitivity/oral ulcers/Excessive hair
loss/Seizure/Abnormal behavior

18. Cough/Hemoptysis/Chest pain/Palpitation/dyspnoea

19. Well water drinking/Alternative medicine intake/Chronic drug intake

20. Blood transfusion

21. Pedal edema-Onset, Progression, Extension, Preceded/along with/after Abd.

Distension, relieved by

IV. Past History

DM/ HTN / TB/ Bronchial asthma/IHD
Childhood Jaundice
Jaundice/ Blood Txn
Allergies/ FB inhalation
Trauma/ Surgeries/ similar illness in the past
V. Personal History
Smoking - pack years/smoking index/ Chula smoking
Alcohol –Quandity in gm/day X yrs, Type of liquor,last consumed, Binge drinking
Tobacco/Substance abuse
Veg / Nonveg
Marital status/ Children
High risk behavior
Bladder/Bowel/Sleep
Menstrual History in detail
Occupation /Residence/Heavy metal exposure
Immunization history
 Socio-economic status/ over crowding

VI. Family history

Similar illness in the family

VII. Treatment history

VIII. Summary at the end of the history

IX. Impression/ DD

Examination
General physical examination

 Conscious/oriented/comfortable

 Ht- Weight- BMI- Temp-

 Pulse- (Rate, Rhythm, Volume, Character, Peripheral pulses. R-R/ R-F delay, Pulse

deficit, Vessel wall, Carotid bruit)

 BP- mmHg, Respiration - Rate, Rhythm, Type (Abdomino-Thoracic / Thoraco-

Abdominal)

 P/J/Cy/Cl/LNE/PE/JVP/rash/Lt supra clavicular LN /asterixis

 Signs of Liver Cell Failure-Alopecia, Jaundice, Bitot’s spots, Parotid swelling,

Foetorhepaticus, Spider nevi, Gynaecomastia, Loss of axillary/ pubic hair,

Palmarerythema, Deputuryn contracture, Asterixis , Ascitis, Testicular atrophy

 Nicotine stain- lips, Nail, teeth, gums, Vitamin deficiencies

 Spine – Kyphosis / Scoliosis /Gibbus, Skull

  Peripheral signs of TB / HIV

Systemic Examination
Abdomen
Inspection
 Symmetry
 Distension- Generalised/Localised
 Flanks
 All quadrants moves with respiration
 Umblicus
 Skin over the Abdomen- Striae/pigmentation/Injection marks/Ascitic
tapping/Petechiae/Ecchymosis
 Scars/Sinuses/Dilated/Prominent veins
 Visible peristalsis/Pulsations
 Hernial orifices

Palpation
 Inspectory findings confirmed
 Soft/ Guarding/ Rigidity
 Tenderness-Localised/Diffuse/Dull/Severe/Specific area tenderness/Signs
 Liver-Size/Extend/Border/Surface/Consistency/Tenderness/Moves with
respiration/intercostal tenderness
 Spleen- Size/Extend/Border/Surface/Consistency/Tenderness/Notch/Moves with
respiration
 Kidney- Above + Bimanually palpable, ballotability
 Any other mass
  Direction of venous flow
 Hernial Orifices
 Testicular examination
 Sister Joseph Nodules
 Pulsations

Percussion
 Fluid thrill/Shifting dullness/Puddle sign
 Liver span
 Traube’s Space
 Colonic band of resonance on the lt side
 Various methods of percussion of Spleen- Nixon/Castell/Traube space

Auscultation
 Bowel sounds/Hepatic bruit/Renal bruit/Venous hum

Perinium, Genitals
Per Rectal Examination
Per Vaginal Examination
Naked eye Urine & Stool Examination

Respiratory System
 Chest wall symmetry
 Respiratory movements
 Percussion- any e/o PE
 Air entry/NVBS/BB/Crackles/Rhonchi/Pl.Rub
Cardio-Vascular System

 Apical Impulse
 Precardialbuldge, Parasternal heave
 Palpable sounds, Thrill
 S1,S2,S3,S4
 Murmurs

Central Nervous System

 Consciousness,Orientation
 FND, Horner’s Syndrome, Planters

Summary after Examination

Diagnosis/DD

Investigation

Treatment