History taking in abdominal

diseases

History taking

Family history
Colon cancer
Gallstones

History taking

Factors, habits and previous

diseases

Diet
Drugs
Alcohol
Smoking
Transfusion
Iv. drug abuse
Lifestyle

History taking - summary

Abdominal pain
Dysphagia
Nausea and vomiting
Anorexia and unexpected weight loss
Abdominal gas
Abdominal distension
Diarrhea
Constipation
Gastrointestinal bleeding
Jaundice

History taking

Abdominal pain

Localisation
Type
Severity
Chronology
Aggravating or relieving factors
Associated symptoms
Radiation of pain

Diffuse abdominal pain

Peritonitis
Intestinal obstruction
Irritable bowel syndrome
Tense ascites

Acute abdomen

Peritonitis
Appendicitis
Bowel or gastric perforation
Gallbladder perforation
Intestinal obstruction (ileus)
Mesenterial ischaemia
Extrauterine pregnancy (ectopic pregnancy)
Acute necrotising pancreatitis
Biliary colic
Renal colic

History taking

Other causes abdominal pain

Diabetic ketoacidosis
Hyperthyroidism
Acute intermittent porphyria
Hypercalcemia, hyperkalemia
Vasculitis
Pneumonia
Sickle cell crisis
Herpes zoster

Radiation of pain

Ulcer disease: to the back

Biliary pain: to the back, right scapula,
right shoulder
Pancreatic: band-like, to the back
Kidney, ureter: to the genitalia, groin
Splenic: left shoulder

History taking

Substernal pain
Cardiac pain

Esophageal pain

Radiation: left
Type: pressing,
constricting
Aggravating factors:
physical activity,
stress
Relieving factors:
nitrates
Associated symptoms:
dyspnoea, sweating

Radiation : back
Type:burning,
spasmodic
Aggravating factors:
body position, eating
Relieving factors:
antacid
Associated symptoms:
dysphagia,regurgitation

History taking

Dysphagiadifficulty in swallowing
Where is the food hanging up?
oropharyngeal or esophageal
Difficulty to swallow liquids?

Odynophagia- painful swallowing

History taking

Weight loss
Is it associated with anorexia?
Chronology
Severity (significant:> 5%
of body weight)
Underlying diseases
Causes:
general disorders: diabetes, hyperthyroidism,
chr.infections,malignancy, medications
behavioral disorders: anorexia nervosa, depression
GI disorders: malignancy, malabsorption,
hepatic, biliary, pancreatic diseases

History taking

Nausea and vomiting

Organic, functional or psychogenic?

connection with meals

accompanied by weight loss

Content of the vomit

Factors: taste, smell, color, pH

Subtypes: acid : reflux disease, duodenal ulcer
bile: bilio-pancreatic diseases
undigested food: obstruction of the
upper GI
faeces (miserere): bowel obstruction
(ileus)
blood: ie. ulcer, tumor, oes.varix

History taking

Abdominal gas
Belching, bloating (meteorism),
flatulence
Causes
Aerophagia (habitual, poor dentition, inadequate
chewing, rapid eating)

GI motor dysfunction or obstruction

Malabsorption, maldigestion
Bacterial overgrowth

History taking

Bowel movement
Factors: frequency, volume, fluidity, color,
associated sensations, change in bowel habits,
stool calibre

Diarrhea
> 300 g of stool/day
more than 3 loose or watery
stools/day
Constipation two or less stools/week

History taking

Bowel movement
Stool alterations
Color

Content

- hypocholic, acholic
- pleiochromic
- bloody
- mucus
- blood
- fat - steatorrhea
- undigested proteins creatorrhea

History taking

Bowel movement
Constipation
Chronic or recent onset

Causes

Decreased fluid and/or food intake

Functional (irritable bowel syndrome)
Medications
Hypothyroidism
Fecal impaction
Rectal or colon cancer
Chronic debilitating disease

History taking

GI bleeding
Classification
Hematemesis
Melena
Hematochezia

Occult bleeding

- fresh blood
- coffee ground
- blood on the stool
- blood mixed with the
stool

History taking

Jaundice
Observe it in bright, natural light
First time you can observe on the sclerae

History taking

Jaundice
Important anamnestic factors
Color of the skin: overproduction: lemon
obstructive: dark-yellow,
greenish
Color of the stool: overproduction: dark, greenish
(pleiochromic)
obstructive: hypocholic, acholic
Color of the urine: overproduction: cherry-red
obstructive: dark, brown
Associated symptoms: anemia, pain, fever,
hepatomegaly, splenomegaly, ascites

Physical examination of the

abdomen
1.Inspection
2.Auscultation
3.Percussion
4. Palpation

Position of the patient

Physical examination

Inspection

Configurations of the abdomen

in the level or above or below the chest
apple-type : visceral obesity - cardiovascular
risk
pear-type : gluteal obesity

Abdominal skin

striae : white, livid (pink)

hernias
veins : caput Medusae
visible peristalsis
visible pulsations
scars

Physical examination

Abdominal distension
Generalised

Localised

Obesity
Pregnancy
Ascites
Bowel obstruction ileus
Big ovarian cyst
Peritonitis

Hepatomegaly
Splenomegaly
Polycystic kidney
Gastric distension
Inflammatory mass
Tumor
Obstructed bladder
Hernia

Physical examination

Auscultation

Bowel sounds

above the umbilicus or in the RUQ

normal: 5-35/min, clicks and gurgles
altered: absent: paralytic ileus
hyperperistalsis: diarrhea,
mechanical bowel obstruction

Bruits
arterial

aortic, renal, iliac arteries

Friction rubs spleen, liver, peritonitis

Succussion splash normal: above the
stomach
pathologic: gastric or bowel obstruction

Physical examination

Percussion
Meteorism
Liver span midclavicular line: 6-12 cm
midsternal line: 4-8 cm

Splenic dullness

norm: in the midaxillary

line
pathological:dullness in the ant. axillary line
during inspiration
Liver or/and splenic dullness absent:
perforation

Ascites

shifting dullness

Physical examination

Palpation
Position
Warm hands, short fingernails
Approach slowly, avoid quick
movements
Exemine tender areas at last
Watch the patients face

Physical examination

Palpation
1. Light palpation
a.
b.

muscular resistance - guarding defense musculaire

alterations in the abdominal wall

Physical examination

Palpation
2. Deep palpation
a. assessing abdominal masses
b. assessing abdominal tenderness

Physical examination

Palpation
Characteristics of an abdominal mass
1.
2.
3.
4.
5.
6.
7.
8.

location
size
shape
consistency
surface
tenderness
movable or fixed
shifting by respiration

Physical examination

Palpation of the liver and

spleen
Characteristics:
1. size
2. surface
3. edge
4. consistency
5. tenderness
(6. liver pulsation)

Physical examination

Palpation of the gallbladder

Hydrops vesicae felleae
Curvoisiers sign - painless enlargement of
the gallbladder due to cancer of the head of
the pancreas

Murphys sign - RUQ pain aggravated by

inspiration - acute cholecystitis

Physical examination

Palpation of the aorta

to the left of the midline

normal: < 3-4 cm
>6 cm: aortic aneurysm
transmitted pulsations: pancreatic or
gastric tumor, pseudocyst of the
pancreas

Physical examination

Rectal digital examination

Perianal diseases fistulas, masses

Anal alterations hemorrhoids, fisssuras, masses
Rectal alterations polyp, neoplasm, ulcer
Prostate gland
Douglass space
Stool on the glove