INTRODUCTORY

1. What is your name? 4. Are you working?

Как се казватe Работиш ли?

2. How old are you? 5. What is your job?

на колко години стe? Какво работитe?

3. Where are you from? Where do you live? 6. What did you work before? (if retired)
от къде стe? къде живеетe? Какво работихте преди?

PRESENTING COMPLAINTS

1. What is your diagnosis? 7. Do you have any other pain?

каква ти е диагнозата? Имате ли някакви други болки?

2. When were you admitted to hospital? 8. Do you have any breathing problems?
кога сте приети в болницата? имаш ли проблеми с дишането?

3. Do you have any pain? 9. Do you have any heart problems?

имаш ли някаква болка? имаш ли проблеми със сърцето?

4. Where is the pain? 10. Do you have any toilet problems?

къде е болката? имаш ли проблеми с тоалетната?

5. Does the pain move? 11. Did you have an operation recently?
болката движи ли се? оперирахте ли наскоро?

6. When did the pain start?

кога започнаxа болкитe?

SYMPTOMS ASSESSMENT

1. Do you have problem with appetite? 6. Do you have sputum?

имате ли проблем с апетита? иматe ли храчки?

2. Do you have nausea? 7. What colour is your sputum?

Гади ли ви се? Какъв цвят ca храчкитe?

3. Do you vomit? 8. Do you have trouble sleeping?

повръщатe ли имате ли проблеми със съня?

4. Do you have high temperature? 9. Did you take any medicines for the pain?
иматe ли висока температура? вземахте ли някакви лекарства за
болкитe?
5. Do you cough? 10. Did anyone in your family have this
кашлятe ли? problem before?
някой от семейството ви имал ли е този
проблем преди?

MEDICAL HISTORY

1. Have you had any previous operations? 5. Do you drink alcohol?

иматe ли някакви операции? пиетe ли алкохол?

2. Do you have any allergies? 6. How much do you drink?

иматe ли някакви алергии? колко пиеш?

3. Do you smoke? 7. Do you have diabetes?

пушитe ли? имате ли диабет?

4. How many cigarettes per day?

по колко цигари на ден?

EXAMINATION

Order of examination
1. Inspection 2. Auscultation 3. Percussion 4. Palpation

Observation checklist
- Skin discolouration? Signs of jaundice on skin and/or sclera?
- Colour of tongue?
o Pink = healthy
o Reddish = pernicious anaemia
o Pale = iron deficiency anaemia
- Swollen submandibular, sublingual, and/or thyroid glands?
- Clubbing of fingers?
- Edema of arms and/or legs?
- Abdominal symmetry?
- Umbilical region or navel (belly button) swollen or red?
- Any discoloration, bruising or bulging of abdomen and/or flanks?
- Any visible scars and lacerations?
- Varicose veins? Consider thrombophlebitis and DVT
- Sexual activity? (If the patient is young)

Secondary observations
- Drainage tubes?
- Urinary catheters?
- Nasogastric tube? Is the patient nil by mouth?
- Patient on fluids? If so, what?
- Visible stones? (usually in a plastic container beside the patient)
DIFFERENTIAL DIAGNOSES of ABDOMINAL COMPLICATIONS
 RIGHT HYPOCHONDRIUM EPIGASTRIUM LEFT HYPOCHONDRIUM

- Cholecystitis - Abdominal aortic aneurysm - Splenomegaly

- Choledocholithiasis - Peptic ulcer - Diverticulitis
- Cholangitis - Gastritis - Pneumonia
- Peptic ulcer - Pancreatitis
- Hepatitis - Bowel ischemia
- Pneumonia - Appendicitis
- Jaundice

RIGHT FLANK UMBILICAL REGION LEFT FLANK

- Pyelonephritis - Appendicitis - Pyelonephritis

- Renal colic - Bowel obstruction - Renal colic
- Ischemia - Diverticulitis
- Gastroenteritis

RIGHT ILIAC FOSSA SUPRAPUBIC REGION LEFT ILIAC FOSSA

- Appendicitis - Cystitis - Diverticulitis

- Hernia - Appendicitis - Hernia
- Cholecystitis - Diverticulitis - Ulcerative colitis
- Ovarian - Pelvic abscess - Ovarian
- Ovarian/testicular