Abdominal Examination Techniques

Anamnesis and Physical Examination in General Surgery

• Anamnesis is the process of obtaining information to diagnose or determine the status of a disease.
• A specific order and sequence of questions are used in anamnesis.
• A good anamnesis provides more diagnostic clues than physical examination.
• Questions should follow the format of the anamnesis form.
• Avoid medical jargon; instead, strive for clear communication.
• The interviewer should aim for a diagnosis from the patient's complaints. Further questions may be used to test this preliminary diagnosis.

Anamnesis / Environment and Communication

• The interview should take place in a quiet and private setting.
• The interviewer needs to be approachable, accessible, and friendly.
• A welcoming environment is crucial, reflecting respect for the patient.
• Sociocultural considerations should be taken into account.
• The interviewer should introduce themselves and explain the purpose of the interview.
• Obtain patient consent before proceeding.
• Maintain respect, attention, and ensure patient comfort and privacy.
• Ensuring a suitable chair is available is essential.

Anamnesis / Expecting Dressing and Behavior

• Plain, clean clothing is preferred, avoiding denim and low-cut shirts.
• Hospitals provide uniforms according to their own policies.
• Name tags should always be worn.
• Hair should be neatly styled, with long hair tied back.
• Jewelry is limited; only rings, earrings (screwed on), and necklaces (simple chains) are allowed.
• Bracelets and wristbands are not permitted.
• Nails should be short and clean; false nails are prohibited.
• Comfortable shoes (excluding sneakers, heeled shoes, and open-toed shoes) are required.

Anamnesis / ID Information

• Record patient name and surname.
• Obtain patient age.
• Record medical history, including incidence of diseases.
• Account for decreased organ functions, co-morbidities, and the occurrence of symptoms (e.g., appendicitis, peritonitis, loss of consciousness).
• Specific details regarding gender and cancer types are important for diagnosis.
• Note non-cancer diseases and conditions specific to a patient's gender.
• List relevant details about frequency, prognosis, and type of diseases.

Anamnesis / ID Information (continued)

• Record Marital Status.
• Record height, weight, and BMI.
• Include details about relevant diseases (e.g., high blood pressure, diabetes, coronary issues, gallstones, osteoarthritis, and sleep disorders).
• Note any relevant history of diseases (e.g., cancers of the colon, breast, uterus, and endometrium).
• Address Endemic Goiter, Familial Mediterranean Fever (FMF), and exposure to radioactivity.
• List the patient's occupation.
• Include pertinent professional information (e.g., doctor, veterinarian related to animals, chemist).
• Record relevant occupational exposures like pesticides, metal dust, cotton dust, or asbestos.
• Document any history of carpal tunnel syndrome or tenosynovitis.
• Note any post-traumatic stress disorder related to employment.
• Record follow-up, examination, or biopsy results, if applicable.

Anamnesis / Disease Information

• Document the diagnosis, both preliminary and definitive.
• Include treatment details, including those given at discharge and any surgical procedures.
• Detail relevant pathology reports and findings.
• For future reference, record the patient's hospital file number.
• Record the service number. (This is separate for each different service)
• Note the specialist doctor responsible for the patient.
• Record information about the assistant doctor following the patient.

Anamnesis / Complaint

• All complaints, particularly pain descriptions, should be thoroughly documented.
• Active listening without interruption ensures accurate and comprehensive information.
• Confirm understanding nonverbally (body language) to ensure accurate interpretation.
• If the patient experiences other complaints, record them (weight loss, abdominal pain, nausea, vomiting).
• List all complaints systematically.

Anamnesis / Story

• Examine each complaint one by one.
• If the conversation veers off-topic, politely redirect it back to the issue at hand.
• Maintain accurate records during the interview/examination.
• Avoid overlooking the patient's distress or pain.
• Document any inquiries about the patient's condition.
• Thoroughly document diagnosis and treatment information upon request.

Anamnesis / Examination of Complaints

• Document all complaints, especially pain.
• Specifically note the location and type (sharp/blunt) of the pain.
• Determine the possible severity of the specific condition (e.g., ischemic, pancreatitis)
• Record the timeline of the complaint: when it started, how it started, and how it ended.
• Note duration, frequency, and periodicity of complaints.
• Detail factors that exacerbate or alleviate the complaint, such as treatments.
• Record any accompanying symptoms (dysphagia, loss of appetite, nausea).
• Document any other pertinent information.

Anamnesis / Resume

• Note the relevant medical history, including diseases (e.g., diabetes, hypertension).
• Include related conditions (heart disease, asthma, COPD, and chronic kidney failure).
• Document surgeries performed (operations) along with the dates.
• Identify any history of cigarette and alcohol use, including quantity and duration.
• Fully document any medications taken, their reasons, and dosage.
• Include a history of bleeding diathesis, hypermenorrhea, and allergies, especially to prescribed medications.
• Document family history including the health history of the patient's parents, siblings, and up to second-degree relatives.
• State the causes of death of deceased parents using appropriate medical terminology.

Anamnesis / Query of Systems

• Documenting systems complaints ensures no detail missed.
• Note any symptoms in individual body systems to provide a thorough evaluation.
• Focusing on the patient's main complaint to make the examination more efficient.

Anamnesis / Query of System (continued)

• Include issues in cardiovascular, respiratory, gastrointestinal, genitourinary, central nervous system.
• Note endocrine abnormalities (e.g., menstrual disorders, abnormal secondary sex characteristics).
• Account for musculoskeletal complaints (pain, swelling, limited movement) and skin conditions.
• Other data and information should be recorded accurately.
• Record details related to physical examination techniques and findings.

Anamnesis / Abdominal Examination

• Record findings of weight loss in the abdomen.
• Evaluate the shape and symmetry of the abdomen.
• Note any abnormalities in the shape, size, consistency or location of organs, masses or distention areas.
• Record details of any surgical incisions present.
• Document any hernias (distortion of the navel, etc.).
• Account for involvement of the abdomen in respiration.
• Document any findings in the bowel sounds.
• Record observations during palpation, including pressure points, tenderness, and abnormalities.

Anamnesis / Abdominal Examination (continued)

• Note any issues with the liver, spleen, kidneys, or other organs during palpation.
• Note relevant special findings, such as Cullen's sign (edema/ecchymosis around the belly button).
• Include details about Grey Turner's sign (ecchymosis in the lumbar region).
• Document any special findings during percussion (e.g. a change in the tympanic sound to a dull tone might indicate fluid buildup or ascite).

Anamnesis / Abdominal Examination (continued)

• Document any additional signs or symptoms related to anorectal examination.
• Specify the positions used for pelvic or pelvic examinations.
• Note the procedures used for specific areas of the body.
• Record relevant physical examination positions (e.g., supine, prone, knee-chest, dorsal recumbent, or lithotomy).

Anamnesis / Breast, Thyroid, and Hernia Examination

• Record results of breast, thyroid, and hernia examinations.
• Note the position of patient and any relevant characteristics like location of tenderness or herniation.
• Note relevant findings during the examination of the thyroid gland or hernia related to abdomen.

Anamnesis / Special Findings and Nomenclature

• Describe any special findings, such as Courvoisier-Terrier sign (non-tender enlarged gallbladder), Sandblom triad, Saint triad, Courvoisier triad, and Virchow triad.
• Record findings for Clapotage.
• Document potential symptoms and results of laboratory tests.

Anamnesis / Special Findings and Nomenclature (continued)

• Account for Borborygmi, Virchow node, Sister Mary Joseph node.
• Note other relevant findings or additional nomenclature as needed.
• Document the details surrounding all of the special findings and nomenclature.

Anamnesis / Laboratory Examinations

• List laboratory tests relevant to examination, including hemogram, urinalysis, routine tests.
• Include details of specific tests.
• Record any other lab tests including tumor markers, imaging, and scans (ultrasonography, mammography, CT scan, MR, X-rays (medicated)).
• Document gastroenterological examinations.

Anamnesis / Medical History Form

• Record patient's demographics (name, DOB, age).
• Document medical or surgical history.
• List family history.
• Include allergies, medications.
• Obtain smoking and alcohol history.
• Collect dietary information.

Anamnesis / Physical Exam Notes

• Summarize findings from each part of the physical examination.
• Provide details about general condition, blood pressure, temperature, pulse, and respiratory rate.
• Specific details about relevant areas should be documented/noted (e.g. heart, lung, abdominal, extremities, or other body systems).
• Include details about the results of all relevant examinations.
• Results of investigations (e.g., x-rays, ultrasounds, tests conducted), should be documented. Note any abnormalities/abnormalities noted in the lab tests.

Test your knowledge on the proper techniques and signs to look for during an abdominal examination. This quiz covers patient positioning, signs of dehydration, liver assessment, and more. Enhance your understanding of crucial abdominal examination practices for accurate diagnosis.