History Taking: Abdomen Flashcards
Identify GI symptoms to ask about as part of the history of presenting complaint.
- Mouth symptoms
- Abdominal pain
- Anorexia and weight change
- Heartburn and reflux
- Dyspepsia and indigestion
- Odynophagia and dysphagia
- Abdominal distension and swellings / lumps
- Nausea and vomiting
- GI tract bleeding (Haematemesis, malaena)
- Jaundice
- Change in bowel habit – constipation / diarrhoea
Identify examples of mouth symptoms.
- Bad breath = halitosis (may be secondary to gingival, dental, pharyngeal infection)
- Dry mouth = xerostomia
- Altered taste = dysgeusia
- Foul taste = cacogeusia
- Gingivitis
What are questions to ask about abdominal pain ?
SOCRATES (where A stands for associated symptoms, and E for exacerbators/relievers)
List the possible sites of abdominal pain.
9 regions:
- Right hypochondriac region (R hypochondrium)
- Epigastric region
- Left hypochondriac region (L hypochondrium)
- Right lumbar region (R flank, loin)
- Umbilical region
- Left lumbar region (L flank)
- Right iliac/inguinal region (R iliac fossa, groin)
- Hypogastric region (pubic, suprapubic region)
- Left iliac/inguinal region (L iliac fossa, groin)
4 quadrants (separated by an transumbilical plane at level of L3/4 intravertebral disc, and a median plane, through xiphoid process and pubic symphysis) Upper R Upper L Lower R Lower L
List possible associated symptoms in abdominal pain.
– Sweating / Fevers – Vomiting /nausea – Diarrhoea – Urinary symptoms – Vaginal bleeding / discharge
Identify common exacerbators and relivers of abdominal pain.
Exacerbators: – Eating/not eating – Movement/lack of movement – Position – Exercise (think cardiac disease)
Relievers: – Eating/not eating – Movement/lack of movement – Position – Vomiting/opening bowels
When asking them about the severity of the pain on a scale of 1 to 10, what does a 10 correspond to ?
Worst pain ever had
What do we mean by anorexia when asking about weight change/anorexia as part of history of presenting complaint ?
Anorexia = reduction in appetite +/or lack of interest in food
What are potential causes of weight gain ?
– Fluid gain e.g. cardiac failure, liver disease, nephrotic syndrome
– Hypothyroidism
– Depression
– Increased energy input/ output ratio
What are potential causes of 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
Define heartburn.
Hot burning retrosternal discomfort
What are possible exacerbators of heartburn/reflux ?
Food
Lying flat
Bending forwards
How may patients characterise heartburn/reflux ?
Associated with water brash and acid taste
What is the likely diagnosis with:
- hot burning retrosternal discomfort
- exacerbated by food, lying flat or bending forwards
- water brash and acid taste
GORD (not cardiac)
What are the typical characteristics of dyspepsia as a presenting complaint ?
♦ Pain or discomfort centred in upper abdomen
♦ Exacerbated by food, relieved by antacid (e.g. Gaviscon)
♦ Associated with nausea, belching, bloating
Ingestion is often mentioned by patients as a presenting complaint. What do they mean by that ?
It’s ill defined so you should clarify what they mean
What are the typical characteristics of odynophagia as a presenting complaint ?
Pain on swallowing
Exacerbated by how liquids
+/- dysphagia
What are possible causes of odynophagia ?
Oesophageal ulcers
Oesophagitis
Oesophageal candidiasis
Define dysphagia.
Difficulty in swallowing (=Sensation of obstruction during passage of liquid or solid
food through pharynx or oesophagus’)
What other GI issue is dysphagia often confused with ?
Globus sensation, a feeling of having lump in the throat (when there is in fact none)
What are possible causes of dysphagia ?
ORAL: Painful mouth ulcers
Tonsillitis
NEUROLOGICAL: Cerebrovascular accident
NEUROMUSCULAR: Myasthenia Gravis
Diffuse oesophageal spasm
MECHANICAL: Oesophageal carcinoma Gastric cancer (upper)
What are questions to ask about dysphagia ?
– Where do they feel it sticking?
– Intermittent / progressive?
– Solids / liquids?
– Associated symptoms e.g. heartburn / weight loss
– Pain- odynophagia
– Complete obstruction and regurgitation of foodstuffs?
What are the different kinds of vomitus ?
- Food
- Bile
- Blood- ‘coffee ground’ or fresh red
What are questions to ask about nausea/vomiting ?
- Frequency and duration ?
- Other symptoms (abdominal pain, diarrhea, constipation) ?
- Pregnancy ?
- Change in medication ?
Identify and define the main kinds of GI tract bleeding.
Haematemesis (upper GI tract bleeding, i.e. vomiting blood – fresh red or ‘coffee-ground’)
Melaena (upper GI tract bleeding, i.e. passage of black tarry stools)
Lower GI tract bleeding (usually fresh red blood)
What are possible causes of haematemesis ?
Gastric or duodenal ulcer
Gastric erosions
Varices
What is the the commonest cause of serious and life-threatening GI bleeding ?
Peptic ulceration
What are possible causes of malaena ?
Bleeding in stomach, esophagus, duodenum
Most commonly chronic peptic ulcers
What is a possible other reason for dark stools other than upper GI bleeding.
Taking oral iron
What are associated symptoms with lower GI tract bleeding ?
Diarrhoea, constipation, abdominal pain
What are questions to ask about lower GI tract bleeding ?
Duration and frequency?
Is it mixed with stool?
Associated symptoms?
What are causes of lower GI tract bleeding ?
Haemorrhoids
Anal fissure
Large bowel polyps or carcinoma
Define jaundice.
Yellow discolouration of sclerae / skin
Identify possible causes of jaundice.
Pre-hepatic
Hepatic
Post-hepatic
What are questions to ask about jaundice ?
Duration
Associated symptoms (pain, weight loss, fevers)
Colour of stool and urine
Travel
What is the likely diagnosis for painless jaundice.
Carcinoma of head of pancreas
What is meant by “persistent” in persistent change in bowel habit ?
> 4 weeks
What are possible questions to ask about persistent changes in bowel habit ?
Duration
Colour of stool (mucous / fresh or altered blood)
Constipation or diarrhea or mix of both
What are possible causes of constipation ?
- Diet/dehydration
- Painful anal conditions (e.g. anal fissure)
- Immobility
- Medication (e.g. opiates)
What are possible causes of diarrhea ?
- Diet
- Stress
- Infection (e.g. viral gastroenteritis)
- Inflammation (e.g. Crohn’s)
Identify upper GI tract red flags.
- Dysphagia
- Evidence of blood loss
- Unexplained weight loss
- Painless jaundice
- Persistent vomiting
Identify lower GI tract red flags (suspicion of cancer).
- Persistant rectal bleeding without obvious anal cause
- Blood mixed with stools
- Palpable rectal mass
- Unexplained iron deficiency anaemia
