3 History taking: abdomen Flashcards
Medical history structure
- Presenting complaint
- History of presenting complaint
- Past medical history
- Drug history (including allergies)
- Family history
- Social history
- Systems enquiry/review (remaining systems: CVS, RS, Endocrine, MSK, CNS, GU)
History of presenting complaint Gastrointestinal (abdomen) questions
- Abdominal pain
- Anorexia and weight change
- Dyspepsia / Indigestion
- Dysphagia
- Nausea and vomiting
- GI tract bleeding
- Jaundice
- Change in bowel habit – constipation / diarrhoea
- Look out for ‘Red Flags’!
What are the questions to ask regarding pain?
- Does it stop them doing anything?
- Are they lying still or writhing around?
- Do symptoms tie in with signs? – Does what they say fit with how they look?
- Aide memoire of SOCRATES - Site, onset, character, radiation, associated symptoms, timing, exacerbators/relievers, severity
What are the names of the 9 regions for identifying pain?
- Right hypochondrium
- Epigastric region
- L hypochondrium
- R flank/ lumbar region
- Umbilical region
- L flank/ lumbar region
- R iliac fossa
- Hypogastric/ suprapubic region
- L iliac fossa
What are the names of the 4 quadrants?
- Right upper quadrant
- Left upper quadrant
- Right lower quadrant
- Left lower quadrant
What condition do the following pain radiations suggest:
– Radiation to the back
– Shoulder tip
– Radiation from loin to groin
- Radiation to the back – pancreatitis
- Shoulder tip- diaphragmatic irritation
- Radiation from loin to groin- renal colic (kidney stone)
What are the associated symptoms relating to GI pain? (5)
- Sweating / Fevers
- Vomiting /nausea
- Diarrhoea
- Urinary symptoms
- Vaginal bleeding / discharge
**Ask about WEIGHT LOSS
What are the common exacerbators (4) and relievers (4) for GI pain?
• Common exacerbating factors: – Eating/ not eating – Movement/ lack of movement – Position – Exercise (think cardiac disease)
• Common relieving factors: – Eating/ not eating – Movement/ lack of movement – Position – Vomiting/ opening bowels
What could be colicky RUQ pain?
Gallstones
What is epigastric pain with associated mass and dysphagia
Gastric carcinoma
Define anorexia?
Reduction in appetite +/or lac of interest in food
4 causes of weight gain
1. Fluid gain e.g. cardiac failure, liver disease, nephrotic syndrome 2. Hypothyroidism 3. Depression 4. Increased energy input/ output ratio
5 causes for unexplained weight loss
- Malignancy
- Malabsorption e.g. chronic pancreatitis / coeliac disease / Crohn’s disease
- Metabolic diseases e.g. diabetes, hyperthyroidism, renal disease, chronic infection (TB/ HIV)
- Psychiatric causes e.g. depression / dementia / anorexia nervosa
- Malnutrition
Dyspepsia?
Indigestion
What are the symptoms of dyspepsia?
- Heartburn
- Acidity
- Pain
- Discomfort
- Nausea
- Wind
- Fullness
- Belching
What makes dyspepsia better or worse?
- Usually triggered by food
* May be relieved by antacid/ “Gaviscon”
What is dyspahgia?
- Difficulty in swallowing
* Can be confused with ‘globus’ sensation
Causes of dysphagia:
- Oral (2)
- Neurological (2)
- Neuromuscular (4)
- Mechanical (5)
- Oral:
• Painful mouth ulcers
• Tonsillitis / pharyngitis / glandular fever - Neurological:
• CVA
• Bulbar or pseudobulbar palsy
3. Neuromuscular: • Achalasia • Pharyngeal pouch • Myasthenia Gravis • Diffuse oesophageal spasm
4. Mechanical: • Oesophageal carcinoma • Peptic oesophagitis • Benign stricture • Extrinsic compression (e.g. lung tumour, lymph nodes, goitre)
What is haematemesis?
Causes?
• Vomiting blood - fresh red or 'coffee-ground' • Causes: – Gastric/duodenal ulcer** – Gastric erosions – Varices – Mallory-Weiss syndrome – Reflux oesophagi's – Gastric carcinoma
What is the commonest cause of serious and life-threatening GI bleeding?
Peptic ulceration
What is melaena?
Causes?
- Malaena - passage of black tarry stools
- Usually secondary to bleed in oesophagus, stomach or duodenum
- Caused by peptide ulceration
• Stools will also appear dark when taking oral iron
What are the 2 signs of upper GI tract bleeding?
- Haematemesis
2. Malaena
Sign and cause of lower GI bleeding?
Questions to ask?
Associated symptoms?
• Usually fresh red blood
• Questions to ask:
– Duration and frequency? / Is it mixed with stool? / associated symptoms?
• Associated symptoms
– E.g. Diarrhoea, constipation, abdominal pain, change in bowel
habit, weight loss, rectal / anal pain
• Causes
– Haemorrhoids / anal fissure / diverticular disease / large bowel polyps or carcinoma / inflammatory bowel disease
Jaundice: • What is it? • Causes? • Questions to ask? • Painless jaundice suggests..
• Yellow discolouration of sclerae / skin
• Causes:
– Pre-hepatic/ Hepatic/ Post-hepatic
• Questions to ask:
– Duration/ associated symptoms (pain, weight loss, fevers) / Colour of stool and urine / Travel / Consumption of shellfish / Blood transfusion / Alcohol consumption / Changes in medication / Intravenous drug use / Unprotected sex
• N.B. Painless jaundice suggests carcinoma of head of pancreas
When to investigate persistent change in bowel habit?
Questions to ask?
• > 4 weeks
• Questions to ask:
– ‘Has there been any change in your bowel habit?’
– Duration
– Colour of stool – mucous / fresh or altered blood
– Constipation/ diarrhoea, or mixture of both
‘In what way?’
– Associated symptoms e.g. pain / nausea or vomiting / weight loss / appetite / tenesmus (feeling of not fully emptying bowels)
– Changes in diet or medication/ other illnesses
What are common causes of constipation?
– Diet/ dehydration – Painful anal conditions (e.g. anal fissure) – Immobility – Medication e.g. opiates – Hypothyroidism – Colonic / rectal carcinoma – Neuromuscular e.g. spinal cord disease / Parkinson’s disease – Hypercalcaemia (may be related to malignancy) – Irritable bowel syndrome
What are common causes of diarrhoea?
– Diet
– Stress
– Infection e.g. viral gastroenteritis / food poisoning
– Inflammation e.g. ulcerative colitis / Crohn’s
– Endocrine e.g. hyperthyroidism
– Malabsorption e.g. coeliac disease / pancreatic disease – Medication
– Irritable bowel syndrome
What are upper GI tract red flags? (10)
- Dysphagia
- Evidence of blood loss
- Unexplained weight loss
- Upper abdominal or epigastric mass
- Unexplained back pain
- Painless jaundice
- Persistent vomiting
- Unexplained iron deficiency anaemia
- Unexplained worsening dyspepsia without other symptoms if >55 yrs old
- New onset upper GI pain if >55yrs old OR if risk factor (e.g.+ve FH)
What are lower GI tract red flags? (7)
• Bleeding:
– Repeated rectal bleeding without an obvious anal cause
– Any blood mixed with stool
• Bowel habit:
– Persistent change in bowel habit especially to looser stools (> 4 wks)
• Mass:
– Right-sided abdominal mass
– Palpable rectal mass
• Iron deficiency anaemia:
– Unexplained iron deficiency anaemia
• Other:
– Past history of lower GI cancer with any of symptoms above
