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:
Anorexia and related symptoms of appetite disturbance
Nausea and Vomiting
Hematochezia and melena
QUALITY - dull, achy, cramping, sharp, burning, gnawing, stabbing, knifelike colicky, pressure.III. Examples
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.
A. Peptic Ulcer Disease
IV. Basic Terminology
B. Gastroesophageal Reflux Disease (GERD)
C. Nausea and Vomiting and Related Terms
i. Basic Definitions
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. Diarrheai. Common Disorders
|Acute infectious enteritis (viral, bacterial, protozoal)
Ingestion of contaminated food (Staphylococcus, Bacillus cereus, Salmonella, Shigella, Campylobacter)
Food Intolerance (Lactose Intolerance)
Inflammatory Bowel Disease
ii. Additional QuestionsF. CONSTIPATIONNumber 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
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?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)
One also needs to ask about stool caliber. HISTORY OF CONSTIPATION WITH A DECREASED STOOL CALIBER SUGGESTS CA.
H. Hematochezia and Melena
ii. Common etiologies Melena
Iron containing products
iii. Common etiologies HematocheziaHemorrhoids
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.
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:
|Peptic gastric ulcer
Peptic duodenal ulcer
|Right scapula||Biliary Tract||Biliary colic|
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|
|Eating||Stomach, duodenum||Peptic ulcer|
|Vomiting||Stomach, duodenum||Pyloric obstruction|
|Leaning forward||Retroperitoneal structures||Pancreatic cancer
|Flexion of knees||Peritoneum||Peritonitis|
|Flexion of RIGHT thigh||Right psoas muscle||Appendicitis|
|Flexion of LEFT thigh||Left psoas muscle||Diverticulitis|
A. Scars2. Abdominal wall - Contour, Symmetry, Umbilicus
C. Dilated veins
D. RashesA. General contour - flat, scaphoid, rounded
B. Generalized distention/position of umbilicus1. Mnemonic - 6F's (fat, fluid, flatus, fetus, feces, fatal growth)
D. Visible pulsations and peristalsis
E. Venous engorgement
B. Venous hums - rare. Heard both in systole and diastole. Indicates communication between portal and systemic circulation.
1. Peritoneal irritation
3. Lloyds sign - PYELONEPHRITIS - a gentle tap against the costrovertebral junction to elicit tenderness over the kidney
4. Murphy's Sign - CHOLECYSTITIS - While performing deep palpation, the examiner asks the patient to take a deep breath. As the descending liver brings the gallbladder in contact with the examining hand, the patient with Cholecystitis will experience pain and stop the inspiratory movement. This pain may also be present in someone with hepatitis.
5. Rovsing's Sign - APPENDICITIS - Pain in the right lower quadrant during left sided pressure.
7. Obturator Sign - Flex the patient's right thigh at the hip with the knee bent, and rotate the leg internally at the hip. This will stretch the internal obturator muscle. Right hypogastric pain constitutes a POSITIVE obturator sign suggesting irritation of the obturator muscle by an inflamed appendix.
8. Ventral Wall Hernias - These are hernias that are exclusive of hernias in the groin area. Ask the patient to raise their head and shoulders off the table. The bulge of the hernia will usually become evident. Inguinal and femoral hernias will be discussed during the genitalia exam.
9. Distinguishing between Intra-abdominal masses from a mass in the abdominal wall. First palpate to determine if a mass is present. If it is, then have the patient raise their head and shoulders off the table or to strain. The object is to tighten the abdominal muscles. Palpate again, if the mass is still present as before it is in the abdominal wall; if it is obscured by the musculature, then it is intra-abdominal.
g. Psoas Sign
h. Obturator sign
j. Positive heel tap on Right heel. Refers vibration to RLQ and may elicit pain.