HISTORY TAKING IN ABDOMEN CASE

Name/Age/Sex/Occupation/Place

PRESENTING COMPLAINTS
H/o PRESENTING COMPLAINTS:

● Abdominal pain
● Duration
● Site
● Nature (Continuous/ intermittent)
● Character (constant/colicky)
● Severity
● Radiation
● Aggravating/ Relieving factors
● Associated features (fever/ nausea/ vomiting/ defecation)
● Abdominal distension
● Duration
● Onset (insidious/ acute)
● Site (localized/ uniform)
● Progress
● RVF features
■ Leg swelling
■ Breathlessness
■ Chest pain
● Liver features
■ Loss of appetite
■ Hematemesis/ Melena
■ Constipation/ Obstipation
● Renal
■ Oliguria
■ Puffiness of face
■ Frothy urine ( Nephrotic syndrome)

● Vomitting/ Blood in vomit

● No. of episodes
● Duration
● Projectile
● Associated with nausea/ headache/ blurring of vision
● Quantity
● Character (colour/ smell/ blood stricken)
● Associated with food intake
● Associated features (pain/ melena/ hematemesis/ loss of consciousness)
● H/o drug intake(NSAIDs, steroids)

● Jaundice
 ● Duration
● Itching
● Colour of urine/ stools
● Any fever with rigor
● Treatment taken

● Stools
● Frequency
● Colour (dark/ tarry black/ pale)
● Consistency (solid/ liquid)
● Nature (sticky/ mucoid)
● Associated pain
● Blood streaks

● Mass in abdomen
● Site
● Duration
● Progression
● Associated pain

NEGATIVE HISTORY

● Fever
● Duration and time of occurrence
● Grade (high/ low)
● Nature (continuous/remittent)
● Associated with rigors/ sweating

● Upper GIT
● Dysphagia( solids/ liquids/ both)
● Heat burn
● Vomitting

● Urinary Tract
● Dysuria
● Pain/ burning micturition
● Oliguria
● Hematuria
● Frequency
● Fever with rigor

● H/o bleeding diathesis

● Epistaxis
● Bleeding gums
● Menorrhagia
 ● Prolonged bleeding after trauma

● H/o loss of appetite/ weight loss – TB and malignancy

● H/o swelling of legs – CVS
● H/o puffiness of face – renal
● H/o pruritides, bleeding per rectum – liver
● H/o altered sleep pattern

PAST HISTORY
● H/o previous similar episodes
● H/o surgery/ drug intake
● Jaundice
● H/o tattooing
● H/o drug intake
● H/o blood transfusion
● H/o exposure to STDs
● H/o vaccination

● Ascites
● Previous abdomen surgeries(scar irritation)
● H/o TB, DM, IHD, HT
● H/o renal colic

FAMILY HISTORY
● Any similar history (Cirrhosis/ Wilson’s disease/ a-1-AT/ HepA /HepB/ HepE)

PERSONAL HISTORY
● Smoking
● Alcohol
● Diet (appetite)
● Sexual history
● Menstrual history/ obstetric history

TREATMENT HISTORY

SUMMARY : Age/ Sex/ Name? Personal h/o? Family h/o? Presenting complaints? Other
relevant positive features.

EXAMINATION OF ABDOMEN CASE

GENERAL EXAMINATION

● Conscious
● Cooperative
● Built
● Afebrile
● Cyanosis
● Anemia
● Jaundice
● Clubbing (Cirrhosis/ IBD/ Malabsorption syndrome)
● Significant lymphadenopathy
● Pedal edema
● Markers of LIVER CELL FAILURE
● Head
■ Alopecia
● Eye
■ Bitot Spots (Vit A)
■ Sub conjunctival hemorrhage (Vit K)
■ Colour (anemia – pale/ Jaundice – yellow)
■ Metabolism (KF Ring – Wilson’s/ Xanthelasma – Fat)

● Face
■ Medial surpaciliary madarosis
■ Sunken eyes, cheeks
■ Loss of facial hair
■ Parotid enlargement

● Mouth
■ Bleeding gums
■ Fetor hepaticus
● Chest
■ Spider nevi
■ Gynaecomastia
■ Atrophy of breast
■ Loss of pectoral hair, axillary hair,
■ Pectoral muscle atrophy
■ Dilated veins
● Hands
■ Anemia
■ Bounding pulse
■ Clubbing
■ Duputryen’s contracture
■ Flapping tremor/ asterexis
■ Erythema palmar
■ Leuconychia
● Abdomen
■ Distension
■ Dilated veins ( Caput medusa)
● Testis
■ Atrophy
■ Pubic hairloss
■ Tumor
 ● Lower limbs
■ Pedal edema
■ Chromic leg ulcers
● General
■ Pruritis/ Spiderman appearance

● Markers of TB
● Markers of HIV

PALPATION

● Superficial Palpation
● Warmth
● Tenderness
● Thrills
● Deep Palpation
● Liver
A tender/ non tender swelling is palpable ______ cm below right costal
margin in MCL extending from ________ (medial) to _____ (lateral) ,
with ______ (smooth/ nodular) surface and _____ (sharp/ rounded)
margins, _____ (soft/ firm/ hard) in consistency.
It _____ (moves, not) with respiration, not bimanually palpable, not able
to insinuate fingers under the costal margin.
● Spleen
■ Site
■ Surface
■ Tender Splenic abscess, IMV
■ Extent
■ Notch on medial border
■ Consistency
It moves with respiration, not bimanually palpable, not ballotable,
upper border, cannot be felt, colonic band of resonance not felt.
● Kidney
(Normally lower rt pole in thin individuals)
It moves with respiration, bimanually palpable, ballotable, colonic band of
resonance felt.
● Others
■ Direction of blood flow
■ Fluid thrill
■ Abdominal girth measurement
■ Inguinal/ Para Aortic/ Supraclavicular nodes

PERCUSSION
● Fluid
● Shifting dullness
● Puddle sign