Abdomen History Taking PDF

Abdomen History Taking Dr. Saeed Gumaa Ahmed Associate Professor Consultant- Acute Medicine History taking: Patient personal data Cardinal Complain(S) HPI & analysis the cardinal(main) complaints and system involved Systemic review Past Medical History Drug Histor...

Abdomen History Taking Dr. Saeed Gumaa Ahmed Associate Professor Consultant- Acute Medicine History taking: Patient personal data Cardinal Complain(S) HPI & analysis the cardinal(main) complaints and system involved Systemic review Past Medical History Drug History Family History Social History GIT Symptoms and it’s analysis Abdominal pain : Mononymous (SOCRATES) S : SITE O: ONSET C : CHARECTER R : RADIATION A : Association T :TIMING (more at morning or at night or all over the day) / duration E : Exacerbating / relieving factors S : SEVERITY  Acute abdominal pain: exclude surgical Abdomin, pancreatitis in differential diagnosis, Renal colic, biliary colic, PUD , infection, DKA. Chronic abdominal pain DD: IBD, IBS, Malabsorption, Malignancy.  Vomiting : - Colour , and amount. - Does it contain blood? - Duration For how long? - Is it projectile or not? - Exacerbation and relieving factor - Associated symptoms: abdominal pain, abdominal distention, diarrhoea, constipation, heart burn, dysphagia, sensation of fullness or indigestion, fever, symptoms of increase intracranial pressure ( headache, blurred vision).  If the patient is female must ask about gynaecology history to consider pregnancy as cause of vomiting In pt with vomiting Ask in PMH : HX of CKD HX DM HX PUD Psychiatric problem In DH ask about : - Chemotherapy use. - Opiate. Haematemesis : Onset ( sudden ,gradual ) Amount Frequency Fresh blood or not Bleeding from other orifices (epistaxis , hemoptysis , gum bleeding , hematuria , rectal bleeding , Melena, Menorrhagia etc.…) Symptoms of anemia &HF ( SOB , palpitation , fatigue, LLE) Symptoms of blood loss or hypovolemia (dizziness , confusion or loss of consciousness) Associated heartburn, abdominal pain, abdominal distension, jaundice, Wt loss, loss of appetite. HX of trauma HX of Bleeding disorder Taking blood thinning medication (e.g. warfarin , aspirin) Symptoms of hepatic encephalopathy (e.g: Sleep disturbance.)  In PMH ask about similar condition, liver disease, DM (NASH), Bilharsiasis, blood transfusion, surgical operation, hospitalisation, bleeding disorder. DH :NSAIDs, warfrine, drug addiction. SH: Alcohol in details, smoking, Job, sexual HX. Melena: Melena is the medical term for the black, tarry stool that comes from bleeding in your upper gastrointestinal (GI) tract. Jaundice : Onset (sudden /gradual) Course (Progressive with time or static or on & off) Duration Associated symptoms ( fever, anroxia, urine color, stool color, itching, symptoms of anaemia, haematemesis, Wt loss) Symptoms of hepatic encephalopathy.  PMH : similar problem, liver disease, heriditary anemia,DM, Blood transfusion, surgical operation, tattoo, hospitalisation. DH: Paracetamol , Antituberclus, statin, illicit drugs. FH: similar condition, heriditary anemia, Liver disease SH: alcohol, travel, sexual activity, Job Change in bowel habits: Any loose motions : Diarrhoea Or hard motions : Constipation  Diarrhoea: First time or recurrent Color, amount, frequency Consistency (mucous, blood) Dose it awake you from sleep Symptoms of sever loss (dehydration,dizziness, hypotension, fatigue) Aggrevating and relieving factor (increase with special type of food) Association ( abdominal pain, abdominal bloating, fever, rectal bleeding, skin rash , Wt loss) HX of travel Watery Diarrhoea: Infection (E coli, HIV, Cholera) Drugs Dm Thyrotoxicosis IBS Malabsorption: Celiac disease Chronic pancreatitis Tropical sprue Gardiasis IBD (UC, CD) Bloody diarrhoea: Infection (dysentery, Campylobacter infection) Ulcerative colitis Ca colon Ischemic colitis Diverticulosis local cause (haemorrhoid, anal fissure) Constipation : Duration How many time you pass /week Did you mean hard or less frequancy last Motion Do you pass flatus or not Association (abdominal pain, abdominal distension, vomiting, Wt loss, rectal bleeding) Is it ulternated with diarrhea aggravating and relieving factor Symptoms of hypothyroidism Symptoms of Hypercalcemia Abdominal distension : Onset First time or recurrent Duration Progression (increase, decrease, static) Do you have swelling Anywhere else (periorbital, LL) Association ( Liver, cardiac, Renal and constitutional symptoms, abdominal pain) Symptoms of hepatic encephalopathy Dysphagia / Odynophagia: Dysphagia is the medical term for swallowing difficulties Odynophagia refers to pain on swallowing. Dysphagia What do You mean by difficulty in swallowing? For How long(duration) Since started increase, decrease or static Started to solid, liquid or both at same time Do you have pain with swallowing Association : chest pain, heart burn, Wt loss, regurgitation, vomiting, cough, anaemia symptoms)  PMH : GERD, Radiotherapy, travel HX DH: long use of NSAIDs SH: alcohol, smoking, diet. Other : Heart burn Indigestion Oral ulcer Regurgitation Genitourinary Are your water works all right? Amount, color, any pain during passing urine, frothy urine Do you have any pain in the back or flanks? Do you have any blood in urine? Any problems with your periods? (Female) Any vaginal discharge? (Female) Difficult to initiate water work? Hesitancy (prostate) Sudden need to pass urine? Urgency Leakage of urine when there is sudden need to pass urine? Urge incontinence Poor urine stream and drippling. Haematuria : First time or recurrent Amount Frequency Duration At the beginning or at the end or all through Painfull or painless Hx of trauma Symptoms of anemia Hx of passing stone  Association ( frothy urine, periorbital edema, flank pain, constitutional symptoms) Hx of chest infection before Hx of Bleeding disorder Hx of use of blood thinning medications Bleeding from other orifices If male ask about symptoms of prostatism PMH of high BP, Kidney problem FH of Kidney problem or bleeding disorders. Polyuria : Amount Of urine/24hrs More at the day or at night The amount of water you drink in 24 hours Association : - Ask about other symptoms of DM(polydipsia, polyphagia, Wt loss) - Ask about other symptoms of hyper Ca(abdominal pain, constipation, excessive thirst, low mood, passage of stone, confusion) Use of diuretics Hx of head trauma or surgery or infection. THANK YOU