Abdominal History Flashcards
1
Q
Abdominal Primary Surevy
A
- Pt is GCS 15
- No obvious pain/respiratory distress
- good colour, not obviously jaundiced
- no obvious signs of trauma
- no obvious distension or hernia
2
Q
GU History
A
- any pain in lower back/groin/flank/suprapubic region?
- does it hurt to urinate? = dysuria
- do you have the urge but can’t go? = UTI, enlarged prostate in men
- do you need to go more often = polyuria
- do you need to go more at night? = nocturia
- any blood in urine?
- any incontinence? = age, nerve dmg, pregnancy
- any could smells or dark coloured urine? = dehydration, cloudy= infection/kidney stones
3
Q
GU PMH
A
- kidney stones
- UTIs
- catheterised?
4
Q
Reproductive History
A
“If this was a real pt I would ask about”
- any previous pregnancies/miscarraiges?
- when was your last period?
- any abnormal PV bleeding? = STIs, starting/missed pill, cancer
- any abnormal discharge?
- any masses (testes)
- do you have a hex of STDs?
5
Q
Reproductive PMH
A
- endometriosis
- pelvic inflammatory disease (PID)
- polycystic ovaries
- fibroids
6
Q
Abdominal Focused History Topics
A
- diet/weight
- abdo pain
- nausea/vomiting
- bowel movements
- indigestion/dysphagia
7
Q
Abdo Pain
A
- do you have any pain in your abdomen?
- I would, fully assess pain using SOCRATES
- have you taken any pain relief?
- do you normally get similar pain?
- depending on the site of the pain I would do certain tests
8
Q
Bowel Movement Questioning
A
- any constipation or diarrhoea?
- how long has that been happening for?
- is it normal for you?
- do your stools look black or tarry? = Jelena, peptic ulcers, gastritis, iron supplements)
- signs of dehydration=turgor, low BP, confusion, shock with prolonged D&V
9
Q
Indigestion/Dysphagia Questioning
A
- what was your last meal?
- do you suffer from indigestion?
(chronic =food types, stress, hernia, GORD) - have you been increasing use of antacids?
- any difficulty swallowing? (GORD)
10
Q
Nausea/Vomiting Questioning
A
- how much have you vomited?
- presence of coffee grounds? Haemetemesis (peptic ulcers, cancer, blood thinners)
- Frank blood (upper GI bleeding)
11
Q
Diet/Weight Questioning
A
- do you have a healthy diet?
- any recent changes to your diet?
- any loss of appetite?
- any sudden or gradual weight loss? = cancer, diet, exercise
12
Q
Abdo PMH
A
- are you diagnosed with any digestive problems? = IBS, ulcerative colitis, diabeetes, diverticulitis, GORD, hernia
- Any liver or pancreas or fall bladder problems?
- any allergies or intolerances?
- any regular medication? = omoperazole, NSAIDs = peptic ulcers, antacids, laxatives
- are you diabetic?
- alcohol dependant? = liver problems
- smoker? = increase risk of chronic disease, gall stones and gastritis
- any removal surgeries?