Abdomen

Name :
Age :
Gender :
Occupation :
Address :

Cardinal Symptoms:

1. Abdominal pain:
Onset
Duration
Site
Pattern
Character
Severity
Radiation
Aggravating factors - food, posture
Relieving factors - medications, posture

2. Abdominal distension:
Onset
Duration
Progression

3. Vomiting:
Duration
Frequency
Nausea?
Nature of vomitus - bilious, feculent, blood-stained
Relation to food
Self induced?

4. Diarrhea:
Onset
Duration
Frequency
Consistency
Volume
Mixed with blood, mucus, pus?
Present also during night?
History of travel
Urgency, incontinence?
Associated with pain (tenesmus)?

5. Constipation:
Duration
Frequency of stools
Obstipation?
Alternating with diarrhea?
 Painful defecation?

6. Steatorrhea (oily, sticky stools)

7. Passing worms in stools?

8. Dysphagia:
Duration
Site of symptom
For which type of food? - solids, liquids, both
Associated with cough?

9. Odynophagia (painful swallowing)

10. Burning sensation in chest:

Duration
Relation to food, posture
Aggravating factors
Relieving factors

11. Eructations or retching:

Duration
Relationship to food

12. Water brash:

Duration
Quantity
Taste

13. Dyspepsia (indigestion):

Duration
Character - bloating, burning, rumbling, early satiety

14. Hiccough

15. Ball rolling movements:

Duration
Relationship to food
Site

16. Appetite:
Increased or decreased
Duration

17. Weight loss or weight gain?

Duration
Quantify

18. Fever
 Duration
Pattern
Grade - low, high
Associated with chills, rigor?
Associated with night sweats?
Diurnal variation?
Associated with rashes?

19. Jaundice:
Duration
Pattern
Progression
Colour of urine
Colour of stools - clay coloured, high coloured

20. Fatigue

21. Pruritus:
Duration
Associated with skin rashes

22. Hematemesis (vomiting of blood):

Duration
Frequency
Quantity
Colour - bright red, coffee ground

23. Malena (black, tarry, sticky stools)

24. Hematochezia (frank bleeding per rectum)

25. Bone pain

26. Gum bleeding

27. Facial puffiness

28. Pedal edema

29. Genito-urinary symptoms:

Oliguria, Polyuria, Nocturia
Hematuria, Pneumaturia
Dysuria, Frequency, Urgency, Precipitancy
Hesitancy, Poor stream, Sense of incomplete evacuation of bladder
Incontinence, Dribbling of urine at the end of micturition
Loss of libido, erectile dysfunction

30. Gynecomastia:
Painful?

31. Features of CCF:

Chest pain
Dyspnea
Past history:
1. Similar episodes in the past
2. Jaundice
3. Tuberculosis
4. Malaria
5. STI
6. Diabetes, Hypertension, Cardiac diseases
7. Chronic kidney disease
8. Malignancy
9. Connective tissue disease

Treatment history:
1. Current and past medications
2. Blood transfusion
3. Vaccination status by
4. Surgeries
5. Known allergies

Personal history:
1. Alcohol (quantify)
2. Smoking (quantify)
3. Diet
4. Tattooing
5. Drug addictions
6. Sexual promiscuity
7. Pet animals

Occupational history:
1. Exposure to toxins

Family history:
1. Similar illness in the family

General Examination:
Conscious level
Built, nourishment
Comfortable at rest or Tachypnoeic
Febrile?
Rash?
Pallor or Polycythemia
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Pedal edema

* Markers of liver cell failure

* KF ring, Bitot’s spots
* Petechiae, purpura, leg ulcers, bone tenderness
* Features of connective tissue diseases
* Skin pigmentation (if present)
* Tattoo marks

Vitals:
Pulse
Blood pressure
Respiration
Temperature

Examination of oral cavity:

Lips:
- colour, moisture
- swelling
- fissures, ulcers, crusts, herpes

Gums:
- colour, consistency
- bleeding
- hyperplasia, ulceration, growth

Teeth:
- absence
- colour
- caries

Tongue:
- anomalies
- size
- colour, bald and smooth?, pigmentation
- coating, moisture
- ulcers, candidiasis, hairy leukoplakia

Buccal mucosa:
- pigmentation
- ulcers, petechiae
- submucosal fibrosis

Palate:
- high arched?, anomalies
- petechiae, candidiasis

Tonsils:
- enlarged?
- colour
- abscess?

Examination of abdomen:
Inspection:
1. Shape - scaphoid, flat, distended
2. Umbilicus - position, shape
3. Visible mass?
4. Visible peristalsis?
5. Moves with respiration?
6. Pulsations?
7. Skin over the abdomen - scars, sinuses, distended veins
8. Flanks - full?
9. Hernial orifices
10. External genitalia

Palpation:
1. Warmth, tenderness, guarding, rigidity
2. Doughy feel? (if present)
3. Abdominal wall edema? (if present)
4. Liver
5. Spleen
6. Gall bladder, Kidney, Bladder (if palpable)
7. Mass

[Mass or organ enlargement:

Position, Size, Shape
Surface, Edge
Consistency
Tenderness
Movements with respiration
Pulsatile?]

Measurements:
1. Abdominal girth at umbilicus
2. Distance from xiphoid cartilage to umbilicus
3. Distance from umbilicus to pubis
4. Spinoumbilical line on both sides

Percussion:
1. Liver span
2. Traube’s space
3. Shifting dullness
4. Fluid thrill
5. Nixon’s and Castell’s methods of examining spleen

Auscultation:
1. Bowel sounds
2. Bruit
3. Venous hum
4. Hepatic rub, Splenic rub
5. Succussion sounds

Complete with other systems examination