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    Compiled by DR - Shivesh Thakur, MD: Abdomen I

    Uploaded by

    BHARTI KHOWAL
    This document contains a detailed template for taking a patient's history and conducting a physical examination related to abdominal complaints. The history section includes questions about the chief complaints, history of present illness, past medical history, personal history, family history, treatment history, and review of systems. The examination section outlines examining the patient's general appearance, vital signs, abdominal inspection/palpation/percussion/auscultation, and systems like respiratory, cardiovascular and neurological. The document provides a structured approach to comprehensively evaluate a patient presenting with abdominal issues.

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    Compiled by DR - Shivesh Thakur, MD: Abdomen I

    Uploaded by

    BHARTI KHOWAL
    126 views6 pages
    This document contains a detailed template for taking a patient's history and conducting a physical examination related to abdominal complaints. The history section includes questions about the chief complaints, history of present illness, past medical history, personal history, family history, treatment history, and review of systems. The examination section outlines examining the patient's general appearance, vital signs, abdominal inspection/palpation/percussion/auscultation, and systems like respiratory, cardiovascular and neurological. The document provides a structured approach to comprehensively evaluate a patient presenting with abdominal issues.

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    It's topic wise details of abdomen

    Original Title

    Abdomen

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    This document contains a detailed template for taking a patient's history and conducting a physical examination related to abdominal complaints. The history section includes questions about the chief complaints, history of present illness, past medical history, personal history, family history, treatment history, and review of systems. The examination section outlines examining the patient's general appearance, vital signs, abdominal inspection/palpation/percussion/auscultation, and systems like respiratory, cardiovascular and neurological. The document provides a structured approach to comprehensively evaluate a patient presenting with abdominal issues.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    126 views6 pages

    Compiled by DR - Shivesh Thakur, MD: Abdomen I

    Uploaded by

    BHARTI KHOWAL
    This document contains a detailed template for taking a patient's history and conducting a physical examination related to abdominal complaints. The history section includes questions about the chief complaints, history of present illness, past medical history, personal history, family history, treatment history, and review of systems. The examination section outlines examining the patient's general appearance, vital signs, abdominal inspection/palpation/percussion/auscultation, and systems like respiratory, cardiovascular and neurological. The document provides a structured approach to comprehensively evaluate a patient presenting with abdominal issues.

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    © All Rights Reserved
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    Compiled by Dr.

    Shivesh Thakur,MD

    Abdomen
    I. Introduction
    Name: Age: Sex: Handedness: Resident
    of: Education: Occupation: Religion: Informant:
    Reliability:
    Chief Complaints (in chronological order)

    II. HOPI
    1. Dysphagia- Onset, Solids/Liquids/Both, Odynophagia, progression

    2. Heart burn,Reflux,Indigestion,Flatulence

    3. Vomiting-Onset,Duration,Projectile/Non
    projectile,Bilious/Nonbilious,Content,Preceded by nausea,Asso. with
    hematemesis, Frequency,Aggravated by,Releived by, Last episode

    4. Hematemesis-Onset, Color,Quandity, Preceded by nausea,


    Frequency, Aggravated by, Releived by, Last episode
    5. Melena- Frequency, Color, Consistency, Odour, Lasted for, Last
    episode

    6. Abd.Pain-(OLDCAARTS)Onset, Location, Duration,


    Character,Colicky/Noncolicky, Associated features, Aggravating and
    Relieving factors,Relation with food Radiation, Time, Severity

    7. Abd. Distension- Onset, Diffuse/Localised, Progress, Asso.with-


    Pain/Fever/Constipation/Diarrhoea/Altered bowel habits/Nausea &
    Vomiting/Hematemesis/Melena/BleedingPR/Jaundice/Menstrual
    Irregularities/Oliguria/Anuria/Hematuria/Anorexia/Wt
    loss/Periorbital puffiness[To r/o Fat,Fluid,Faeces,Flatus,Foetus,Fatal
    growth,Liver & Kidney diseases], Releived by [diuretics/fluid tapping
    etc…], Intermittent/persistent

    8. Fever- Grade, Max Temp, Type, Associated with chills& rigors,


    Diurnal variation, Evening rise of temp., night sweats, relieved by,
    present status
    Compiled by Dr.Shivesh Thakur,MD

    9. Anorexia & Weight loss- Quantified/Unquantified, lntentional


    /Unintentional, Significant/insignificant
    10. Constipation- Frequency, Fluid intake

    11.Diarrhoea-
    Onset,Duration,Frequency,Consistency,Quantity,Color,Odour,Painful
    /Painless,Tenesmus,Stickyness,Steatorrhoea, Feeling of incomplete
    evacuation,Mixed with blood/mucus/undigested food,Abd. Pain,
    Abd. Distension

    12.Bleeding Per Rectum

    13.Oliguria/Anuria/Dysuria/Hematuria/Urine color/Periorbital
    puffiness/loin pain

    14.Jaundice- Onset, Sites [skin, eyes, urine], Urine color, stool color,
    Preceded by any Prodrome/Pain abd / Abd. Distension, Progress,
    Persistent/Intermittent/Fluctuating Pruritus, Bone pains, night
    blindness, Easy bruisiability ,Bitot spots,Bleeding manifestations,
    Altered sensorium, Lasted for, Releived by

    15.Symptoms of Liver cell failure-Alopecia/Jaundice/parotid


    swelling/loss of hair in axilla,Pubis/Loss of
    libido/Gynaecomastia/palmar erythema/ Contratures/Testicular
    atrophy/Ascitis/Spider nevi/Hematemesis/Melena

    16.Altered Bowel habits


    17.Joint pain/Rash/Photosensitivity/oral ulcers/Excessive hair
    loss/Seizure/Abnormal behavior

    18.Cough/Hemoptysis/Chest pain/Palpitation/dyspnoea
    19.Well water drinking/Alternative medicine intake/Chronic drug intake
    20.Blood transfusion
    21.Pedal edema-Onset, Progression, Extension, Preceded/along
    with/after Abd. Distension, relieved by
    Compiled by Dr.Shivesh Thakur,MD

    III. Past History


    DM/ HTN / TB/ Bronchial asthma/IHD
    Childhood Jaundice
    Jaundice/ Blood Txn
    Allergies/ FB inhalation
    Trauma/ Surgeries/ similar illness in the past
    V. Personal History
    Smoking - pack years/smoking index/ Chula smoking
    Alcohol –Quandity in gm/day X yrs, Type of liquor,last consumed, Binge
    drinking
    Tobacco/Substance abuse
    Veg / Non veg
    Marital status/ Children
    High risk behavior
    Bladder/Bowel/Sleep
    Menstrual History in detail
    Occupation /Residence/Heavy metal exposure
    Immunization history
    Socio-economic status/ over crowding

    VI. Family history


    Similar illness in the family

    VII. Treatment history

    VIII. Summary at the end of the history

    IX. Impression/ DD

    Examination
    General physical examination
     Conscious/oriented/comfortable
     Ht- Weight- BMI- Temp-
     Pulse- (Rate, Rhythm, Volume, Character, Peripheral pulses. R-R/ R-F
    delay, Pulse deficit, Vessel wall, Carotid bruit)
    Compiled by Dr.Shivesh Thakur,MD

     BP- mmHg, Respiration - Rate, Rhythm, Type (Abdomino-Thoracic /


    Thoraco-Abdominal)
     P/J/Cy/Cl/LNE/PE/JVP/rash/Lt supra clavicular LN /asterixis
     Signs of Liver Cell Failure-Alopecia, Jaundice, Bitot’s spots, Parotid
    swelling, Foetor hepaticus, Spider nevi, Gynaecomastia, Loss of axillary/
    pubic hair, Palmar erythema, Deputuryn contracture, Asterixis , Ascitis,
    Testicular atrophy
     Nicotine stain- lips, Nail, teeth, gums, Vitamin deficiencies
     Spine – Kyphosis / Scoliosis /Gibbus, Skull
     Peripheral signs of TB / HIV

    Systemic Examination
    Abdomen
    Inspection
     Symmetry
     Distension- Generalised/Localised
     Flanks
     All quadrants moves with respiration
     Umblicus
     Skin over the Abdomen- Striae/pigmentation/Injection marks/Ascitic
    tapping/Petechiae/Ecchymosis
     Scars/Sinuses/Dilated/Prominent veins
     Visible peristalsis/Pulsations
     Hernial orifices
    Palpation
     Inspectory findings confirmed
     Soft/ Guarding/ Rigidity
     Tenderness-Localised/Diffuse/Dull/Severe/Specific area tenderness/Signs
     Liver-Size/Extend/Border/Surface/Consistency/Tenderness/Moves with
    respiration/intercostal tenderness
    Compiled by Dr.Shivesh Thakur,MD
     Spleen-
    Size/Extend/Border/Surface/Consistency/Tenderness/Notch/Moves with
    respiration
     Kidney- Above + Bimanually palpable, ballotability
     Any other mass
     Direction of venous flow
     Hernial Orifices
     Testicular examination
     Sister Joseph Nodules
     Pulsations
    Percussion
     Fluid thrill/Shifting dullness/Puddle sign
     Liver span
     Traube’s Space
     Colonic band of resonance on the lt side
     Various methods of percussion of Spleen- Nixon/Castell/Traube space

    Auscultation
     Bowel sounds/Hepatic bruit/Renal bruit/Venous hum
    Perinium, Genitals
    Per Rectal Examination
    Per Vaginal Examination
    Naked eye Urine & Stool Examination

    Respiratory System
     Chest wall symmetry
     Respiratory movements
     Percussion- any e/o PE
     Air entry/NVBS/BB/Crackles/Rhonchi/Pl.Rub
    Compiled by Dr.Shivesh Thakur,MD

    Cardio-Vascular System
     Apical Impulse
     Precardial buldge, Parasternal heave
     Palpable sounds, Thrill
     S1,S2,S3,S4
     Murmurs
    Central Nervous System
     Consciousness,Orientation
     FND, Horner’s Syndrome, Planters

    Summary after Examination

    Diagnosis/DD

    Investigation

    Treatment

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