Abdominal History

Question 1

Abdominal Primary Surevy

Answer 1

• Pt is GCS 15
• No obvious pain/respiratory distress
• good colour, not obviously jaundiced
• no obvious signs of trauma
• no obvious distension or hernia

Question 2

GU History

Answer 2

• 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

Question 3

GU PMH

Answer 3

• kidney stones
• UTIs
• catheterised?

Question 4

Reproductive History

Answer 4

“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?

Question 5

Reproductive PMH

Answer 5

• endometriosis
• pelvic inflammatory disease (PID)
• polycystic ovaries
• fibroids

Question 6

Abdominal Focused History Topics

Answer 6

• diet/weight
• abdo pain
• nausea/vomiting
• bowel movements
• indigestion/dysphagia

Question 7

Abdo Pain

Answer 7

• 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

Question 8

Bowel Movement Questioning

Answer 8

• 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

Question 9

Indigestion/Dysphagia Questioning

Answer 9

• 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)

Question 10

Nausea/Vomiting Questioning

Answer 10

• how much have you vomited?
• presence of coffee grounds? Haemetemesis (peptic ulcers, cancer, blood thinners)
• Frank blood (upper GI bleeding)

Question 11

Diet/Weight Questioning

Answer 11

• 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

Question 12

Abdo PMH

Answer 12

• 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?