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Guidelines
• Second level
• Third level
for History Taking and
Examination of Patients with
• Fourth level
• Fifth level

Abdominal Surgical Disorders

History Components
• Personal history
• Complaint
• History of present illness
• Past history
• Personal history
• Family history
• Treatment history
IMPORTANT POINTS BEFORE HISTORY-
TAKING
 Introduce yourself

 Treat with respect

 Explain the need to take a history

 Ensure the patient is comfortable

 Let patient talk

 Guide, not dictate

 No leading question

 Try not to write and talk at the same time

Common Complaints
• Complaint + Duration

1. Abdominal pain

2. Abdominal mass or swelling

3. Disturbed function:
• Vomiting
• Abdominal distension
• Changes in bowel habit
• Discharge (abdomen, perineum)
SYSTEMIC INQUIRY

Begin with the involved or affected (chief complain) system

Example:
If chief complaint is related to gastrointestinal
system(GI)- continue with the GIT inquiry.
Present History
Analysis of C/O How did you discover the C/O?
Onset And decide whether the onset was acute, insidious or
accidentally discovered

Course Decide whether the course was stationary,

progressive, fluctuant, or regressive.

Insidious, intermittent onset signifies benign disease;

a rapidly progressive course implies malignancy
1- Analysis of pain
• Onset :
• Slow- inflammation
• Sudden- perforation, ischemia

• Severity:
• Mild in beginning- inflammation

• Severe- perforation, ischemia

Pain locations (Great degree of overlap)
• Is pain localized to a specific area of the abdomen?
• Right iliac fossa – appendicitis / Crohn’s disease

• Left iliac fossa – diverticulitis

• Epigastric – gastritis/esophagitis

• Right upper quadrant – cholecystitis/hepatitis

• Flank – pyelonephritis / ureteric colic

• Suprapubic – cystitis
 Analysis of pain, cont.
• Radiation or referred pain:
• Shoulder- cholecystitis,
• Groin- ureteric colic

• Shifting or migration:
• Periumbilical to RIF in acute appendicitis

• Cause:
• Trauma,
• Suspicious food- gastroenteritis
• Medication (NSAID)- perforation, bleeding
Analysis of pain, cont.
• Nature:
• Dull (inflammation),

• Sharp (rupture viscus)

• Colic (intermittent)

• Throbbing (abscess)

• Progression:
• Intermittent – colics e.g. renal colic/biliary colic/bowel obstruction

• Continuous or Steadily increases –inflammation e.g. cystitis/peritonitis

 Analysis of pain, cont.
• Aggravating factors:

• Fatty foods increases pain in gallstone disease

• Relieving factors:

• Sitting & leaning forward eases pain in acute pancreatitis.

• Eating relieves pain in duodenal ulcer

2- Swelling or mass
• When noticed? Acute (hematoma, abscess) chronic- neoplasm,
organomegaly
• How noticed? Incidentally noticed swelling may be present for longer
duration
• Painful or painless? Inflammatory, neoplasm
• Change in size since first noticed? Increase- neoplasms, disappear or
reduce in size-?hernias
• Aggravating/relieving factors: Hernias increase in size with straining
• Any cause? Trauma- hematoma, cough- hernia
3- Disturbed function- GIT
• Esophageal symptoms
• Anorexia, nausea, vomiting
• Haematemesis
• Heartburn
• Abdominal pain or colic
• Abdominal distension
• Diarrhea
3- Disturbed function- GIT
• Constipation
• Dysentery
• Tenesmus
• Bleeding per rectum
• Melena
• Anal pain or swelling
• Symptoms of liver failure
Analysis of Disturbed function - GIT
Analysis of Vomiting
• Frequency and volume – high frequency and volume increases risk of
dehydration
• Projectile vomiting – obstruction
• What does the vomit look like?
• Undigested food – pharyngeal pouch / achalasia / esophageal stricture
• Non-bilious vomit – pyloric obstruction (i.e. pyloric stenosis)
• Bilious vomit/ fecal matter – lower GI obstruction
• Blood: Duodenal ulcer, esophageal varices, tumor
• Vomiting relieves pain- gastric ulcer
• Vomiting food taken few days ago: pyloric stenosis
Anorexia/weight loss

• How much weight over how long? – always suspect malignancy –

especially in the elderly

• Decreased appetite – may suggest malignancy, or in younger

patients possibly anorexia nervosa
Dysphagia - Odynophagia
• Dysphagia – Onset / Progression / Solids and/or liquids

• Odynophagia – pain on swallowing – esophageal candidiasis

Progressive dysphagia (difficulty swallowing solids at first, then

eventually difficulty with liquids) suggests the presence of a malignant
stricture. Especially in elderly patients with associated weight loss and
iron deficiency anemia.
Hematemesis
• Color:
• Fresh red blood – undigested – acute bleed – Mallory Weiss tear / esophageal
variceal rupture
• Coffee ground – digested – bleeding peptic ulcer

• Preceded by forceful retching? – Mallory Weiss tear

Abdominal distension
• Common causes of abdominal distension:
• Fat – obesity
• Flatus – paralytic ileus/obstruction
• Feces – constipation
• Fluid – ascites
• Fetus – pregnancy
Altered bowel habit
• Diarrhea
• Consistency – how formed is it? (Bristol stool chart)
• Color of stool: Bright red (anal, rectum), maroon (colon) black- melena (upper GI)
• Mucous – Inflammatory bowel disease (IBD) / Irritable bowel syndrome (IBS)
• Blood – Fresh red blood (anal fissure/hemorrhoids/IBD). Melena (upper
gastrointestinal bleed)
• Urgency– IBD/IBS/gastroenteritis
• Recent antibiotics? – C. Difficile
• Recent suspect food? – food poisoning
• Laxative use?
• Constipation
• Duration of constipation

• Absolute constipation? – not passing flatus – obstruction

Colour of the stool
• Black (Melaena) – peptic ulcer / duodenal ulcer / malignancy
• Fresh red blood – anal fissure / hemorrhoids / IBD / polyp / lower GI
malignancy
• Pale (steatorrhoea) – biliary obstruction (gallstones / malignancy)
 History of discharge
• Site: anal, perineum, wound
• Duration
• Nature:
• purulent (anal fistula),
• bloody (hemorrhoid),
• fecal from wound (int. fistula)
• Relation to defecation/stool:
• mixed with stool- IBD,
• independent of stool- hemorrhoid
• Any pain?
• Hemorrhoids- painless,
• anal fistula- painful
Jaundice

• Yellowing of the skin and sclera

• Dark urine?
• Common causes of jaundice:
• Infectious – hepatitis B and C / malaria
• Gall stones
• Malignancy – pancreatic cancer / cholangiocarcinoma
• Alcoholic liver disease
• Autoimmune – autoimmune hepatitis / primary sclerosing cholangitis
• Congenital – Gilbert’s syndrome (benign)
OTHER SYSTEMS INQUIRY-
• Respiratory system

Cough, sputum, hemoptysis, wheeze, dyspnea, chest pain

• Cardiovascular system:
Angina (cardiac pain), dyspnea ( rest/ exercise),

Palpitations, ankle swelling, claudication

OTHER SYSTEMS INQUIRY-
• Urology
• Frequency
• Urgency
• Precipitancy
• Drippling
• Difficulty in micturition
• Burning micturition
• Pain
• Haematurea
• Urine
• Symptoms of renal failure
SYSTEMIC INQUIRY- Obstetric & Gynecology
• (For females)
• Menstrual history
 LMP
 Vaginal discharge
 Vaginal bleeding

• Obstetric history
 Pregnancies

• Lactational history
SYSTEMIC INQUIRY- NERVOUS SYSTEM
 Headache

 Fits

 Depression

 Facial/limb weakness
SYSTEMIC INQUIRY- MUSCULOSKELETAL
 Muscular pain

 Bone & Joint pain

 Swelling of joints

 Limitation of movements

 Weakness
SYSTEMIC INQUIRY- METABOLIC/ENDOCRINE
 Bruising/ bleeding (nutrients deficiencies)

 Sweating (thyrotoxicosis)

 Thirst (diabetes)

 Pruritus (skin infection, jaundice, uremia, Hodgkin’s)

 Alcohol

 Weight- ?dieting, amount and duration

Examination
General Local
 General
Examination
General Examination
• Patient is conscious, alert, cooperative & well oriented to time, place
& persons.
• Vital data:
• Pulse
• Temp
• Bl/P
• Respiratory rate
• 3 colours
• Pallor
• Jaundice
• Cyanosis
• Examination from head to toe.
General Examination
• Always start by G.E.
• Important data that you should look for include:
• Hands exam. For palmar erythema, flabby tremors
• Eyes for jaundice, conjunctival pallor
• Lt supraclavicular LNs: Troisier’s sign (the presence of a palpable
metastatic scalene lymph node in the left supraclavicular fossa.) The
enlarged node itself is called Virchow’s node, and can be caused by
any abdominal or breast cancer but is classic of gastric cancer.
• Scratch marks, Bruising, Spider naevi, gynaecomastia
• Rectal and vaginal ex. To exclude pelvic or abdominal masses.
• Lymph node examination
Head & Neck
• Scalp nodules
• Cranial nerves –3,4,5,6,7,9,11&12 – examined
• Eyes – Jaundiced Sclera, conjunctival pallor, visual field, pupils, movements
• Mouth & pharynx –
• hydration, breath (ketosis/halitosis),thrush?
• Perioral and oral mucosal hyperpigmentation spots (?Peutz Jeghers Syndrome -PJS)
• Angular stomatitis
• Glossitis
• Apthous ulcer

• Movements of neck, lymph glands (including the suprclavicular), carotid

pulse, neck veins & thyroid gland
Upper Limbs
• Axillae:
• Lymph nodes,
• Acanthosis Nigricans (associated with GI adenocarcinoma, insulin resistance, or familial)

• Arms & hand :

• Power, tone, reflexes, sensations,
• Liver flaps, palmar erythema, Dupuytren’s contracture

• Finger nails:
• Clubbing, Leuconychia / koilonychia

• JOINTS
• Acanthosis Nigricans
Clubbing
Leuconychia / koilonychia
Dupuytren’s
contracture
Lower Limbs
• Power, tone, reflexes & sensations
• Varicose vein
• Edema
• Peripheral pulsations
• JOINTS
Chest
• Spider Naevi, Pupura, Scratch marks (icteric), Dilated
vessels & pulsations
• Breasts –Gynaecomastia, masses
• Position of trachea
• Apex beat
• Lungs – whole
• Heart – whole
 Spine
• Curvature of spine observe for:-
• Lordosis / Scoliosis / Kyphosis
• Tenderness
• Swellings