Medical History Intake

Patient Information - Aslı Çifcibaşı Örmeci, 03.02.2025

• Medical history intake includes gathering patient identification, reason for visit ("chief complaint"), the history of that reason, past medical conditions, family history, social factors, medication details, lifestyle habits, a review of bodily functions, and a systems-based symptom review.

Gathering Details

• Identifying information includes full name, age, gender, birth date/place, current residence(s), address, and contact telephone number.
• The chief complaint focuses the kind of pain a patient is having, according to EKG:
  • Pain
  • Quality
  • Rate
  • Severity
  • Timing influences
  • EKG
• The history of the present illness includes the last time the patient was entirely healthy, previous tests run, and treatments given.
• Medical history includes chronic conditions, surgeries, and traumas.
• Family history contains any chronic conditions present in the family
• Social history will address marital status, profession, if employed, and insurance status.

Lifestyle and Bodily Functions

• Medications being taken should be listed.
• Poor lifestyle habits and when they were stopped should be noted.
• Bodily functions covers sleep patterns, appetite, changes in weight, bowel movements, urination, thirst, work drive, sensation, menstruation (for women), potency (for men), and libido.
• A systems-based review of symptoms is conducted.

Elements of a Physical Exam

• Inspection involves observing body characteristics, this includes identifying:
  • Distention via the ‘5 Fs and 1 M’
  • Ascites, gas, fat, feces, fetus, a mass
  • Evaluating the xiphoid-to-navel-to-pubic symphysis distance to assess issues like ascites, obesity, or pregnancy.
  • Observing sulci for prominence (fluid)
  • Assessing the umbilicus for bulging (ascites, hernia, Sister Mary-Joseph nodule, caput medusa)
  • Scar assessment, location, size, and orientation described
  • Presence of ecchymosis, striae, or nevi
  • Skin color noted along with Systemic skin manifestations of systemic illness
  • Assessing respiratory effort and umbilical drainage.
  • Cullen's and Grey-Turner's signs.

Auscultation, Palpation, and Percussion

• Auscultation identifies metallic sounds (ileus), borborygmi (obstruction), friction rubs (splenic infarct), murmurs (HCC), or bruits (AAA, renal artery stenosis).
• Palpation of painful area done carefully.
  • The face of any patient should be observed.
  • Assesing tenderness, masses, or organomegaly.
• Percussion assesses ascites/masses, tumor, and pregnancy.
  • Assesses liver size by percussing from the 2nd intercostal space, determining a liver span from 3-5 rib spaces.

Patient Case (February 3, 2025)

• A 55-year-old male presented in Tokat.
• Experienced pain, yellowed skin, weakness, and a runny/stuffy nose with cough for the past 15 days.
• Rated the pain 8/10, dull, constant for 2 days, unrelated to eating, partially relieved by pain relievers, located higher in the abdomen and radiating to the back, no nausea/vomiting.
• Ultrasound and CT scans at another hospital showed no abnormalities.
  • Liver test results were significantly elevated
  • Amylase and lipase levels were high
  • An MRCP was not performed
  • After feeling better with analgesics and IV fluids, the patient chose to transfer to İTF after 1 week.
• History includes:
  • the presence of type 2 diabetes
  • a cholecystectomy in 2022
  • a pilonidal sinus surgery in 2001
  • ASD closure
  • brachytherapy for ocular melanoma
• He reports his mother had diabetes.
• He had previously smoked 20 pack/years, stopped 20 years ago, and does not have alcohol use
• Presenting symptoms and lab values prompted a suspicion for a mild biliary pancreatitis.

Assessing Pancreatitis and MRCP

• Because the patient feels well enough, it suggests the start of biliary and amylase/lipase levels are raised
• It is generally accepted that pancreatitis requires at least 3x elevated amylase/lipase level for diagnosis and imaging confirmation.
• It is important to determine if gallstones are present in the bile ducts using MRCP.
• Past cholecystectomy also opens possibility of stones in the bile duct or new stones.
• Recommended is:
  • a review of history
  • physical examination
  • lab work
  • MRCP results
• An ERCP is recommended if stones are present.
• It is possible that spontaneously passed gallstones may not be seen on MRCP, but a disrupted papilla is visible.
  • In these cases, normal results would suggest passed stones.
  • The need for sphincterotomy is dependent on the presence of a non-disrupted papilla.
  • It is easier to perform the sphincterotomy through PTK, where the bile ducts must be dilated. Expect about 250–500 cc of bile during PTK.

Managing Fluid Loss

• IV fluids should be used to prevent electrolyte imbalance
• EUS can detect stones stones
• Supportive care includes bowel rest, IV fluids, pain control, and potentially ursodeoxycholic acid.
• Ascites requires paracentesis to prevent HRS
  • Consider albumin infusions both during and after large volume paracentesis is performed
• When performing a paracentesis without ultrasound guidance, identify appendix-cecum by using the opposite McBurney's point .
  • Use the tunneling technique to avoid iatrogenic liver damage due to hematomas.
• Decompensated Symptoms include: ascites, variceal bleeding, jaundice, encephalopathy.

Physical Exam Techniques - Assessing Jugular Venous Pressure and Ascites

• JVP evaluated with patient at 45-degree angle, with the head angled away. Measure the vertical distance to venous filling from the sternal angle; levels higher than 4-5 cm are considered high.
• Liver compression should be distinguished from hepatojugular reflux . Apply steady pressure over the liver for 1 min to observe any change.

Distinguishing Vascular Sounds

• Auscultation areas for the abdominal area include; the middle of the abdomen to check for systolic burps, organomegal, thrill, diameter 3cm, or other risks.
• An elderly male who smokes with upper quadrant areas, that have humm.
• Iliac and femoral arterials, that have small palpable kit.

Causes of Elevated Bilirubin (Over 30 mg/dL) - Liver Function

• Pre-hepatic cuases can include: Autoimmune hemolytic anemia, sickle cell disease, anemias, ineffective erythropoiesis or from HDN
• Hepatic origins: severe acute hepatitis (viral, drug-induced, alcoholic, autoimmune or ischemic), Wilson's disease, cirrhosis/hepatic failure, or Crigler-Najjar.
• Post-hepatic conditions include: choledocholithiasis, cholangitis, biliary atresia, periampullary tumors, HCC, PSC/PBC, or reactions to anabolic steroids/combined amoxicillin-clavulanate.

Neonatal and General Considerations

• Newborns at high risk of kernicterus include those with physiological issues, breast milk jaundice, congenital hemolytic anemia, Crigler-Najjar, Dubin-Johnson, or Rotor syndromes.
• If ascites is present: examination of ascitic fluid should be completed after the extra/intra USG
• Annual colonoscopies should begin within 10 years of the index diagnosis.
• The progression from metabolic-associated steatohepatitis (MASH) to cirrhosis must be prevented.
• Cholestasis presents with yellow color in the skin, dark urine, and light colored stools.
• A positive result is that when pain is experienced by the patient upon touching, there's a specific inflamed, irritating sensation.
• Symptoms of chronic liver disease include: spider angiomas, telangiectasias, parotid enlargement, redness of the palms, nails that look dull, contractions occurring in the hand, fluid starting to fill the abdominal area, collaterals that start to appear, muscle weakness, reduced hair, or gynecomastia.
• Benign recurrent intrahepatic cholestasis can be indicated by increased bilirubin and do a blood cleaning procedure.
• A person with a background from celiac sprue can lead into autoimmune hepatitis or cirrhosis.
• 50cc takes 14 hours to pass for melena; is the passage of stools that often resembles a tar like substance, and has a foul odor.
• hepatic encephalopathy, ascites, INR, bilirubin, and albumin

Managing Cholestasis - Diagnostic and Treatment Approaches

• Hepatocanalicular cholestasis best assessed by liver pathology..
• Biliary sepsis is a contraindication for liver biopsy.
• Alagille syndrome presents with bile duct paucity, while PSC impacts larger intrahepatic ducts and causes “onion skinning” fibrosis.
• Elevated serum bile acids is usually due to use of pharmaceutical products, family histories, jaundice with right upper of back pain, allergic dermatitis, abnormal viral results
• ERCP to open strictures.
• Etiology based and includes: diet change, gallbladder drainage.

Abdominal Assessment - Physical Exam

• Tense ascites = buldge in tissue
• Palpation requires touching the tissue and can reveal liver surface.
• Liver fluid sensation requires one hand where fluid can be detected.
• Free Ascites require soft abdominal area.
• Giving diuretics to a patient that is diuretic resistant can cause hyponatremia and increasing creatinine.
• Ascites can encourage gallstones to develop post surgery.
• High levels of bad cholesterol with low levels can be from pregnancy.
• Refractory ascites requires TIPs but needs a good MELD score.

Apppendicitis Diagnostic Criteria

• McBurney's point
• Morris' point
• Lanz's point

Hemoglobin Diagnostic Testing

• Leukopenia tests can only be performed on tissue areas, cells, or minute tissue, and only with limited use
• Gallstone patients have to be checked to determine kidney function.
• Suspect gallstones during early examination of tissue.
• Swollen areas can be hernia due to tissue coming out.

Symptoms During Examination

• Fatigue can be linked to Addison or Myasthenia gravis condition.
• Low oxygen levels can be caused by any condition that weakens oxygen
• Dark red stools can be because of bleeding.
• Premenopausal signs is due to anovulatory which means it will increase after 20 minutes. Intestine tests can show colon damage or damage to the intestines.
• It is possible low hemoglobin results can be treated with blood transfusion from different tissue.

Medical Assesments

• Tests for Kolestaz diagnosis require checking for allergies
• Allergies test is the most recurring
• Cholesterol assessment is only used for liver failure.
• Gallstone symptoms after removal of gallbladder is called koledokolityazis.
• Post procedures of gallstone is called colonjit.

Endoscopy notes and observations

• When a perforation occurs endoscopy is not authorized due to risk of infection
• Posterior Larenjit signs are reflux and fluid around throat
• Disfaji symptoms are difficulty catching breath
• Hepatitus has been known to be linked with tooth removal, transplant, transfusions, or diseases

Signs to look for during Sogeçmiste's check

• Diabetes signs is low sodium levels, and excess weight.
• Marriage should be the first question to ask during Sogeçmiste's check.
• In women pregnancies should be the first question to ask.
• Insomnia can because of a condition and is not a stand alone disease on it's own.

Signs to look for during Asidoz tests

• Headaches can be a sign
• Sifa's stool test is for stool related symptoms.
• With Istahsizlik is possible for people to lose weight but can be because they are using bad proteins and having low blood sugar.
• Fermentations can be caused during different times