Abdominal History
OST 501- Outline for Lecture
H.S. Teitelbaum, D.O., Ph.D., MPH

I. Introduction

If someone comes into your preceptors office (in less than one year from now!!) and has a CC: that is Gastrointestinal in presentation, I am going to ask you to evaluate:
Symptoms to Explore in a GI complaint
Abdominal Pain 

Anorexia and related symptoms of appetite disturbance

Nausea and Vomiting

Dysphagia 

Diarrhea

Constipation

Hematemesis

Hematochezia and melena

II. PP-QRSTa

QUALITY - dull, achy, cramping, sharp, burning, gnawing, stabbing, knifelike colicky, pressure.

SEVERITY - compare to previous pain if any, 1-10 scale.

TIMING - persistent, intermittent, recurrent, pattern

REGION and RADIATION - couple the quadrants of the abdomen with the organs which lie beneath the location.

III. Examples
A. Peptic Ulcer Disease
 

B. Gastroesophageal Reflux Disease (GERD)

IV. Basic Terminology
A. Anorexia
B. Polyphagia

C. Nausea and Vomiting and Related Terms

i. Basic Definitions
ii. Regurgitation
iii. Rumination
D. Dysphagia and Odynophagia
i. Dysphagia - Cerebrovascular accidents, reflux esophagitis, tumors, motor disorders, infections.
ii. Follow-up questions
Does food seem to hang up in a particular place during the swallowing process?
Is it painful? (Infections - candidiasis, Herpes, sometimes Tetracycline)
Do you have problems swallowing both liquids and solids or just solids? (Motor disorder vs obstructive lesion)
Has your condition become more severe? (Obstructive lesion, if significant weight loss think CA)
Any regurgitation? (Motor disorder, overfilled stomach)
Are these symptoms intermittent? (Rings, globus hystericus)
E. Diarrhea
i. Common Disorders
Common Disorders Associated with Acute Diarrhea
Acute infectious enteritis (viral, bacterial, protozoal

Ingestion of contaminated food (Staphylococcus, Bacillus cereus, Salmonella, Shigella, Campylobacter)

Food Intolerance (Lactose Intolerance)

Antibiotic-associated diarrhea 

Inflammatory Bowel Disease

Systemic infections

ii. Additional Questions
Number of bowel movements per day?

Consistency of BM? (Solid vs loose vs watery)

Are the movements painful or does it relieve pain?

ANY RECENT CHANGES IN BOWEL HABITS?

MEDICATION CHANGE OR NEW MEDS

Travel?

Different foods or eating places?

ANYONE IN FAMILY ILL?

Signs of infections (FEVER, MUSCULOSKELETAL COMPLAINTS, CHILLS, NAUSEA, VOMITING, ABDOMINAL PAIN, AND DIARRHEA)

Anorexia and weight loss

Blood in stool? (Think Campylobacter, Shigella and Salmonella, E. Coli)

Incontinence?

F. CONSTIPATION
i. Definition (< 2 stool per week).
 

ii. Additional Questions

Describe food and fluid intake in the past month? (Decreased in either can induce constipation).

MEDICATIONS (anticholinergics, antidepressants, opiates, HTN meds)

Hypothyroidism

Chronic Disease

One also needs to ask about stool caliber. HISTORY OF CONSTIPATION WITH A DECREASED STOOL CALIBER SUGGESTS CA.

G. Hematemesis
 

H. Hematochezia and Melena

i. Definition
 

ii. Common etiologies Melena

Medications
Iron containing products
Bismuth
Foods
iii. Common etiologies Hematochezia
Hemorrhoids
CA
Polyps
Diverticula disease
Angiodysplasia
INFECTIOUS ENTERITIS
Proctitis
Ischemic Colitis
iv. Additional questions
Blood on toilet tissue? Hemorrhoids

Do you feel anything like a hemorrhoid?

Constipation or hard stools? - possible hemorrhoid

Change in bowel habits (constipation or diarrhea) with hematochezia and change in caliber (Usually smaller); unexplained weight loss? Think CA

Painless hematochezia? Diverticula disease, angiodysplasia

Maroon colored stools and unstable vital signs? Massive blood loss - think bleed.


Abdominal Examination
Physical Examination
OST 501 Fall 1999
H.S. Teitelbaum, D.O., Ph.D.



History Additional Points

Because many over the counter medications are available many patients will self medicate prior to seeking medical attention. Thus questions about medication are very important. Be sure to press for the over the counter meds like antacids, non-steroidal anti-inflammatory drugs and antidiarrheal meds. One of the by products of the broad spectrum antibiotics is GI upset. Make sure the medication history is complete. I should like to underscore the important notion of referred pain. This viscero-somatic transmission should be appreciated in the abdominal exam. For example:
 
Area of Pain
Organ Affected
Clinical Example
Substernal Esophagus Esophagitis
Shoulder Diaphragm Subphrenic abscess
Epigastric Stomach 

Duodenum

Gallbladder

Liver

Bile ducts

Pancreas

Peptic gastric ulcer

Peptic duodenal ulcer

Cholecystitis

Hepatitis

Cholangitis

Pancreatitis

Right scapula Biliary Tract Biliary colic
Midback Aorta

Pancreas

Aortic dissection

Pancreatitis

Periumbilical Small intestine Obstruction
Hypogastrium Colon Ulcerative colitis

Diverticulitis

Sacrum Rectum Proctitis

Perirectal abscess

Another question you have asked "WHAT MAKES IT BETTER" will sometimes be answered by the patient as maneuvers or actions, such as:
 
Maneuver Affected organ Clinical Example
Belching Stomach Gastric distension
Eating Stomach, duodenum Peptic ulcer
Vomiting Stomach, duodenum Pyloric obstruction
Leaning forward Retroperitoneal structures Pancreatic cancer 

Pancreatitis

Flexion of knees Peritoneum Peritonitis
Flexion of RIGHT thigh Right psoas muscle Appendicitis
Flexion of LEFT thigh  Left psoas muscle Diverticulitis

ANATOMY
 


 
 
 
 


 
 

Given the above diagrams, the surface markings of the anterior abdominal wall are: Techniques of the Examination
A. Scars
B. Straie
C. Dilated veins
D. Rashes
2.  Abdominal wall - Contour, Symmetry, Umbilicus
A.  General contour - flat, scaphoid, rounded
B.  Generalized distention/position of umbilicus
1. Mnemonic - 6F's (fat, fluid, flatus, fetus, feces, fatal growth)
C. Flaccid
D. Visible pulsations and peristalsis
E. Venous engorgement
The points identified are for possible bruits. Make sure to listen in all quadrants and/or the nine regions of the abdomen for bowel sounds.
 

1. Peritoneal irritation