History Questions
- Abdominal pain and or cramping. Location and radiation. Constant or intermittent.
- Pain aggravated or relieved by movement or food?
- Pain associated Symptoms: Nausea, vomiting, fever.
- Red Flags: Night pain, significant unexplained weight loss, fever/chills.
- Diarrhoea or constipation
- Change in texture of stools or presence of mucous or blood
- Changes to bladder habits? burning /pain on urination?
- Difficulty or pain when swallowing?
- Pain or bloating or heart burn with specific type to food
- Reflux?
- Pre-existing food intolerances
- History of GIT problems or surgeries
- Any recent illnesses or travel or has the patient eaten unusual type of food for them
- Female: Chance of pregnancy? Previous Gynae problems? Vaginal discharge or bleeding.
Medication history
Patient Preparation
Procedure explained to patient
Consent obtained
Patient positioned appropriately
Observation of Patient Position
appearance, posture, movement
- Patient’s posture and movement: Flexed or extended? avoiding movement (peritonitis), or moving constantly (colic pain)
- Patient appearance: wasting, underweight, sweating, pale, jaundiced, signs of distress
Inspection of Hands and Arms
Perfusion
Palmar creases
Nails (Clubbing and nail changes)
Asterixis
Arms (Bruising)
- State of perfusion : Colour, Temp, Sweaty / Peripheral cyanosis
- Palmar creases : Anaemia or Erythema (liver disease), Dupuytren’s contractures.
- Nails – Leukonychia (hypoalbuminemia), koilonychia (iron deficiency), Clubbing
- Asterixis (hepatic encephalopathy) ask patient to extend arms forward and extend wrist; may provoke with passive wrist extension.
- Arms : petechiae, Scratch marks, Spider naevi, bruising
Inspection of Head
Eyes
Mouth
Tongue
Lips
Breath
- Eyes: Conjunctivae pallor; Scleral icterus, Iritis/Uveitis, Xanthelasma
- Mouth: dentition, leucoplakia, ulcerations
- Tongue: Leucoplakia, glossitis (iron/ B12 deficiency)
- Lips: Central cyanosis, Angular stomatitis
- Breath: foetor hepaticus (sweet), Uraemia breath (fishy), alcohol breath
Inspection of Chest and Abdomen
Chest Abdomen (general, contour, distension, abnormal movements)
- Chest: Spider naevi (Cirrhosis) , Body hair distribution or gynaecomastia (high Estrogen), scars Abdomen
- Contour: round/flat , bulges. Umbilicus-contour and position (hernia?)
- Distension: may be caused by 6 Fs: Fluid , Foetus , Faeces, Fat, Flatus, Fulminating malignancy.
- Movement: pulsations (Aneurysm), peristaltic waves (obstruction), rigidity
- General: Scars, masses, bruising, prominent dilated veins (Caput Medusa), striae, scratch marks.
Auscultation
Bowel Sounds
AA, renal and iliac arteries
Percussion
Percuss 9 regions Shifting dullness (if indicated only)
Palpation
Superficial
Deep (mention if there is pain would check for rebound tenderness and would test for hernia if there are any bulges/superficial masses)
Liver Palpation
Liver: Percuss upper border: From 3rd ICS downwards along mid-clavicular line.
Palpation of lower border: Palpation from RIF towards inferior edge of liver. Palpation is synchronised with breathing: Palpate deep and hold, ask patient to breath while maintaining palpation pressure (with deep inspiration diaphragm pushes the liver inferiorly towards the hand); ask patient to breath out during which time your move your contact superiorly. Repeat.
Gall Bladder
Gall Bladder: McBurney’s point . Palpate deep with reinforced thumb or tip of hand/fingers at junction of the R rectus abdominus and the right costal margin (~ mid-clav line). Ask patient to breath in while maintaining pressure. Positive sign is pain with sudden arrested inspiration.
Spleen
Spleen: Place patient in R side-lying position. Support the patient with one hand around lower ribs. Palpate from RLQ diagonally towards the spleen. Synchronise palpation with breathing as per Liver palpation.
Appendix
Appendix: Palpation at McBurney’s point. Rebound tenderness at McBurney’s if pain present: quick withdrawal of hand from deep palpation to check for peritonitis Ilipsoas sign, obturator sign.
Rovsing’s: AP/Lat to Med pressure applied to LLQ and observes for pain in RLQ (appendicitis and/or Peritonitis)
Kidneys
Kidneys: Ballot kidneys (supine) and renal angle punch test (siting)
Hernias
Hernias: Patient standing. Palpate site of hernia (abdominal/inguinal) after explanation and permission. Support patient posteriorly around iliac crest with one hand. Ask patient to cough.
