3 History taking: abdomen

Question 1

Medical history structure

Answer 1

1. Presenting complaint
2. History of presenting complaint
3. Past medical history
4. Drug history (including allergies)
5. Family history
6. Social history
7. Systems enquiry/review (remaining systems: CVS, RS, Endocrine, MSK, CNS, GU)

Question 2

History of presenting complaint Gastrointestinal (abdomen) questions

Answer 2

• Abdominal pain
• Anorexia and weight change
• Dyspepsia / Indigestion
• Dysphagia
• Nausea and vomiting
• GI tract bleeding
• Jaundice
• Change in bowel habit – constipation / diarrhoea
• Look out for ‘Red Flags’!

Question 3

What are the questions to ask regarding pain?

Answer 3

• Does it stop them doing anything?
• Are they lying still or writhing around?
• Do symptoms tie in with signs? – Does what they say fit with how they look?
• Aide memoire of SOCRATES - Site, onset, character, radiation, associated symptoms, timing, exacerbators/relievers, severity

Question 4

What are the names of the 9 regions for identifying pain?

Answer 4

• Right hypochondrium
• Epigastric region
• L hypochondrium
• R flank/ lumbar region
• Umbilical region
• L flank/ lumbar region
• R iliac fossa
• Hypogastric/ suprapubic region
• L iliac fossa

Question 5

What are the names of the 4 quadrants?

Answer 5

• Right upper quadrant
• Left upper quadrant
• Right lower quadrant
• Left lower quadrant

Question 6

What condition do the following pain radiations suggest:
– Radiation to the back
– Shoulder tip
– Radiation from loin to groin

Answer 6

• Radiation to the back – pancreatitis
• Shoulder tip- diaphragmatic irritation
• Radiation from loin to groin- renal colic (kidney stone)

Question 7

What are the associated symptoms relating to GI pain? (5)

Answer 7

• Sweating / Fevers
• Vomiting /nausea
• Diarrhoea
• Urinary symptoms
• Vaginal bleeding / discharge

**Ask about WEIGHT LOSS

Question 8

What are the common exacerbators (4) and relievers (4) for GI pain?

Answer 8

• Common exacerbating factors:
– Eating/ not eating
– Movement/ lack of movement
– Position
– Exercise (think cardiac disease)

• Common relieving factors: 
– Eating/ not eating
– Movement/ lack of movement
– Position
– Vomiting/ opening bowels

Question 9

What could be colicky RUQ pain?

Answer 9

Gallstones

Question 10

What is epigastric pain with associated mass and dysphagia

Answer 10

Gastric carcinoma

Question 11

Define anorexia?

Answer 11

Reduction in appetite +/or lac of interest in food

Question 12

4 causes of weight gain

Answer 12

1. Fluid gain e.g. cardiac failure, liver disease, nephrotic
syndrome
2. Hypothyroidism
3. Depression
4. Increased energy input/ output ratio

Question 13

5 causes for unexplained weight loss

Answer 13

1. Malignancy
2. Malabsorption e.g. chronic pancreatitis / coeliac disease / Crohn’s disease
3. Metabolic diseases e.g. diabetes, hyperthyroidism, renal disease, chronic infection (TB/ HIV)
4. Psychiatric causes e.g. depression / dementia / anorexia nervosa
5. Malnutrition

Question 14

Dyspepsia?

Answer 14

Indigestion

Question 15

What are the symptoms of dyspepsia?

Answer 15

• Heartburn
• Acidity
• Pain
• Discomfort
• Nausea
• Wind
• Fullness
• Belching

Question 16

What makes dyspepsia better or worse?

Answer 16

• Usually triggered by food

* May be relieved by antacid/ “Gaviscon”

Question 17

What is dyspahgia?

Answer 17

• Difficulty in swallowing

* Can be confused with ‘globus’ sensation

Question 18

Causes of dysphagia:

1. Oral (2)
2. Neurological (2)
3. Neuromuscular (4)
4. Mechanical (5)

Answer 18

1. Oral:
   • Painful mouth ulcers
   • Tonsillitis / pharyngitis / glandular fever
2. Neurological:
   • CVA
   • Bulbar or pseudobulbar palsy

3. Neuromuscular:
• Achalasia
• Pharyngeal pouch 
• Myasthenia Gravis
• Diffuse oesophageal spasm

4. Mechanical:
• Oesophageal carcinoma
• Peptic oesophagitis
• Benign stricture
• Extrinsic compression (e.g. lung tumour, lymph nodes, goitre)

Question 19

What is haematemesis?

Causes?

Answer 19

• Vomiting blood - fresh red or 'coffee-ground'
• Causes: 
– Gastric/duodenal ulcer** 
– Gastric erosions
– Varices
– Mallory-Weiss syndrome
– Reflux oesophagi's
– Gastric carcinoma

Question 20

What is the commonest cause of serious and life-threatening GI bleeding?

Answer 20

Peptic ulceration

Question 21

What is melaena?

Causes?

Answer 21

• Malaena - passage of black tarry stools
• Usually secondary to bleed in oesophagus, stomach or duodenum
• Caused by peptide ulceration

• Stools will also appear dark when taking oral iron

Question 22

What are the 2 signs of upper GI tract bleeding?

Answer 22

1. Haematemesis

2. Malaena

Question 23

Sign and cause of lower GI bleeding?
Questions to ask?
Associated symptoms?

Answer 23

• Usually fresh red blood

• Questions to ask:
– Duration and frequency? / Is it mixed with stool? / associated symptoms?

• Associated symptoms
– E.g. Diarrhoea, constipation, abdominal pain, change in bowel
habit, weight loss, rectal / anal pain

• Causes
– Haemorrhoids / anal fissure / diverticular disease / large bowel polyps or carcinoma / inflammatory bowel disease

Question 24

Jaundice:
• What is it?
• Causes?
• Questions to ask?
• Painless jaundice suggests..

Answer 24

• Yellow discolouration of sclerae / skin

• Causes:
– Pre-hepatic/ Hepatic/ Post-hepatic

• Questions to ask:
– Duration/ associated symptoms (pain, weight loss, fevers) / Colour of stool and urine / Travel / Consumption of shellfish / Blood transfusion / Alcohol consumption / Changes in medication / Intravenous drug use / Unprotected sex

• N.B. Painless jaundice suggests carcinoma of head of pancreas

Question 25

When to investigate persistent change in bowel habit? Questions to ask?

Answer 25

• > 4 weeks • Questions to ask: – ‘Has there been any change in your bowel habit?’ – Duration – Colour of stool – mucous / fresh or altered blood – Constipation/ diarrhoea, or mixture of both ‘In what way?’ – Associated symptoms e.g. pain / nausea or vomiting / weight loss / appetite / tenesmus (feeling of not fully emptying bowels) – Changes in diet or medication/ other illnesses

Question 26

What are common causes of constipation?

Answer 26

``` – Diet/ dehydration – Painful anal conditions (e.g. anal fissure) – Immobility – Medication e.g. opiates – Hypothyroidism – Colonic / rectal carcinoma – Neuromuscular e.g. spinal cord disease / Parkinson’s disease – Hypercalcaemia (may be related to malignancy) – Irritable bowel syndrome ```

Question 27

What are common causes of diarrhoea?

Answer 27

– Diet – Stress – Infection e.g. viral gastroenteritis / food poisoning – Inflammation e.g. ulcerative colitis / Crohn’s – Endocrine e.g. hyperthyroidism – Malabsorption e.g. coeliac disease / pancreatic disease – Medication – Irritable bowel syndrome

Question 28

What are upper GI tract red flags? (10)

Answer 28

* Dysphagia * Evidence of blood loss * Unexplained weight loss * Upper abdominal or epigastric mass * Unexplained back pain * Painless jaundice * Persistent vomiting * Unexplained iron deficiency anaemia * Unexplained worsening dyspepsia without other symptoms if >55 yrs old * New onset upper GI pain if >55yrs old OR if risk factor (e.g.+ve FH)

Question 29

What are lower GI tract red flags? (7)

Answer 29

• Bleeding: – Repeated rectal bleeding without an obvious anal cause – Any blood mixed with stool • Bowel habit: – Persistent change in bowel habit especially to looser stools (> 4 wks) • Mass: – Right-sided abdominal mass – Palpable rectal mass • Iron deficiency anaemia: – Unexplained iron deficiency anaemia • Other: – Past history of lower GI cancer with any of symptoms above