CHRONIC/MASS ABDOMEN CASE PROFORMA [A __ year old patient, supine decubitus who is __ built __

nourished is conscious, coherent, cooperative, and

Name: Age: Sex: Occupation: Address: comfortably seated/lying on the bed, well oriented to time,
HISTORY place and person]
There is No Pallor, Icterus, cyanosis, koilonychias,
Chief Complaints: generalised lymphadenopathy and no pedal edema.
Pain Abdomen since VITALS: Temperature: Pulse, RR, BP.
Vomiting since
LOCAL EXAMINATION-Abdomen
Sensation of fullness after meals since
Hematemesis since After taking informed consent, patient is in supine position
Passage of black stools since with arms by the side of her body.
Yellowish discolouration of eyes since INSPECTION:
Loss of appetite since 1. Skin and Subcutaneous tissue: Any visible swelling,
Alteration of bowel habit since engorged veins, any nodules
Fever since 2. Umbilicus: Tanyol’s sign, appearance (flat, everted,
Lump in the abdomen since inverted]
History of Present Illness: 3.Contour of abdomen
Patient was apparently asymptomatic __ days back when he 4.Movement (of abdomen) with respiration, any visible
developed peristalsis, any pulsatile movements
1. Pain- site, onset, duration, character, relation with food, 5.Swelling/lump: condition of skin over lump, position, size,
micturition, defecation, Aggravating and relieving factors. shape, movements with respiration,
2. Lump- Onset (noticed how), duration, progression, size when 6. Hernia orifices, scrotum, renal angle, left supraclavicular
first noticed, site, fever, any other lumps fossa
3. Vomiting: character, amount, frequency, relation with food, PALPITATION:
relief of pain, projectile/effortless, colour, taste, smell, and any Superficial Palpation: Temperature, tenderness, feel of
blood in vomit. abdomen, any palpable lump (extra abdominal like lipoma,
4. Dyspepsia: fullness after food, heart burn, belching myoma, fibroma, hematoma)
5. Hematemesis: Duration, number of bouts of vomit, colour, Deep Palpation: Check for tender spots- Gastric point,
amount, associated with melena or not duodenal point, gall bladder point, amoebic point, Mc
6. Jaundice: onset, duration, any prodromal symptoms, H/O Burney point, renal point. Also check Murphy Sign
biliary colic, progression of jaundice, associated symptoms Fluid Drill
(itching, stool, urine colours) Organs: Liver, Spleen, Kidney, gall bladder, stomach,
H/O fever, rigor, pain in Right upper Quadrant (cholangitis) pancreas, colon.
7. Bowel Habit: Any change, any bleeding PR or black tarry stools, Any other lump: Local temp, tenderness, position, size,
mucus in stools, tenesmus, colour, quantity of stool, smell surface, margin, consistency, movement with respiration,
Any Loss of appetite, Any loss of weight mobility, ballotable.
H/O fever See if its parietal or intraabdominal [Carnett’s test (leg lifting
Urinary symptoms: loin pain, frequency, difficulty, altered stream, test)
burning micturition, hematuria, pyuria Pulsatile or not
PAST HISTORY: Hernia sites (expansile impulse should be tested)
H/O similar complaints Palpate spleen, liver, kidney, supraclavicular fossa
-Any H/O HTN, DM, CAD ,TB, Hypo/Hyperthyroidism/ Epilepsy/ PERCUSSION: Liver span, Shifting Dullness, Percussion over
Asthma/COPD/ / Blood transfusions lump, renal angle, supraclavicular fossa., Hydatid thirll
Any H/O Jaundice, Tonsillitis, Typhoid, Syphilis AUSCULTATION: Kenawy Sign
MEASUREMENTS: Xiphisternum to umbilicus, Umblicus to
Drug and Treatment History: H/O aspirin intake, any surgeries SP, Spino umblical, abdominal girth.
PV and PR should be done.
FAMILY HISTORY: OTHER SYSTEMS:
None of the patient’s parents, siblings or first degree relatives have or CVS- Normal S1 S2 heard, No murmurs.
have had similar complaints or any significant co morbidities
Respiratory: Normal vesicular breath sounds, No
PUD, Crohns, Ulcerative Colitis
adventitious sounds, GIT- Per Abdomen Bones- Normal
PERSONAL HISTORY: [Important] CNS- No Facial asymmetry, all reflexes are normal
Diet, Appetite, Bowel, Bladder, Sleep, Addictions (Alcohol and PROVISIONAL DIAGNOSIS:
Smoking), Any Allergies This is a case of single, fixed, hard lump in upper outer
quadrant of rt/lt breast suggestive of carcinoma of TNM
PHYSICAL EXAMINATION stage with no evidence of local or systemic complications
1. GENERAL SURVEY [This is a case of single mobile firm lump in lower outer
- General assessment of Illness- ECOG (Zubroad scale)/Karnofsky quadrant of Lt/Rt breast, probably benign, most probably a
score) fibro adenoma of the Lt/Rt breast.]
-Mental state and intelligence (CCC)
-Build, state of nutrition NOTES:
-Decubitus and Attitude, Any facies
 Right Hypochondrium Epigastric Left Hypochondrium
Cholecystis, Hepatomegaly, Splenomegaly, Gastric Murphy's sign can be elicited by placing your examining
Cholangiocarcinoma, Pancreatic Ca, Pancreatic fingers over the gallbladder area and then asking the patient
Hepatmegaly, Liver Ca abscess, pseudocyst, Abscess, to take a deep breath. If Murphy's sign is positive, there will
pseudocyst, Kidney-PCKD, TB, be sudden accentuation of the pain on inspiration and
Gastric Ca Hydronephrosis, Colon inspiration will be inhibited.
ca
Right Lumbar Periumblical Left lumbar
Hydronephrosis, RCC AAA, Tumour, Hydronephrosis, RCC
Hernia, Crohn’s
Right Iliac Suprapubic Left Iliac
Colon Ca, Crohn’s, Distended Diverticular abscess,
Appendix, Amoebic bladder, Hernia, Colorectal Ca
abscess Neuroblastoma

Courvoisier’s law

This states that in the presence of jaundice, a palpable gallbladder

makes gallstone obstruction of the common bile duct an unlikely
cause (because it is likely that the patient will have had gallbladder
stones for some time and these will have rendered the wall of the
gallbladder relatively fibrotic and therefore non-distensible).
However, the converse is not true, because the gallbladder is not
palpable in many patients who do turn out to have malignant bile
duct obstruction.

Liver Palpation:
Starting in the right iliac fossa, deeply palpate in this region and ask
the patient to take a deep breath (this contracts the diaphragm,
pushing the liver down) Repeat this a little superiorly until the liver
edge is felt (NB normally, the liver edge is not palpable below the rib
cage. On deep inspiration, the liver edge may be felt in a normal
individual) Examine/comment on size (cm or fingerbreadths) from
costal margin; any tenderness Percuss the lower and upper liver
borders By percussing from the thorax inferiorly and from the iliac
fossa superiorly, the liver may be identified as dull (cf the resonant
chest and less dull normal bowel)

Spleen Palpation:

Percussion can be done in an identical fashion except on the left.

However, others prefer to percuss inferolaterally across Traube’s
space. This is a crescent shaped area bordered superiorly by the left
6th rib; anteriorly by the left anterior axillary line and inferiorly by
the left costal margin. Normally, the stomach lies deep to Traube’s
space and it is resonant to percuss. In splenomegaly, it can be dull.
If resonant percussion is present at the left 6th rib, anterior axillary
line, ask the patient to breathe in deeply and reassess.
Palpation is also done in a similar fashion except palpation usually
begins at the right iliac fossa and makes its way diagonally across
the abdomen. Some also might reach over with their left hand to
push forward the lower left rib cage and soft tissues with the right
hand palpating below the costal margin on inspiration.

Kidneys Palpation:
To ballotte the kidneys, reach around with your opposite hand to
place under the patient (just under the 12th rib) and lifting the
tissues anteriorly. With your free hand, deeply palpate the upper
quadrant, trying to feel the kidney between both hands. This is also
usually best done with deep inspiration.
To percuss the kidneys, ‘thump’ the costovertebral angles with the
ulnar surface of a fist (enough to be forceful without trying to cause
pain). This may reveal kidney tenderness. NB It is only really used
when kidneys appear tender on ballotting.