Abdominal case

I. Particulars of the patient

II. Chief complaints (With duration)

• 1. Pain abdomen

  2. Vomiting

  3. Sensation of fullness after meals

  4. Vomiting of blood

  5. Passage of black tarry stools

  6. Yellowish discolouration of eyes and urine

  7. Loss of appetite

  8. Weight loss

  9. Alteration of bowel habbit

  10. Fever

  11. Swelling in the Abdomen

III. History of present illness

• • Detailed history about pain:

    • Onset- Sudden/Insidious

    • Duration- Short lived/ Persistent

    • Initial site of pain

    • Radiation/ Shifting/ Referral

    • Character of pain- dull aching(chronic cholecystitis)/ Stabbing(Pancreatitis)/ Colicky (Renal pain)

    • Periodicity of pain- appearance after a definite period of days/ months.

    • Relation with food intake- before/ after ie., on empty stomach or full stomach.

    • Relation with vomiting- relief/ aggravation

    • Aggravating and relieving factors- food (duodenal ulcer/ gastric ulcer)/ vomiting/ Medicines.

    • Relation with defaecation and micturition

  • Details of vomiting:

    • Duration

    • Frequency-the exact number

    • Relationship with food intake

    • Character of the act- projectile or effortless

    • Character of the vomitus:-

      • • amount

        • colour

        • taste

        • smell

    • Any blood in vomiting- suggestive of upper G.I.bleeding

    • Any relation with pain

  • Details of blood in vomiting (Haematemesis):

    • Duration

    • Number of bouts of blood in vomiting

    • colour

    • amount

    • whether associated with black tarry stool or not

  • Details of Jaundice:

    • Duration

    • Onset

    • Any prodromal symptom before onset of jaundice- fever/ arthralgia/ generalised weakness/ loss of appetite/ skin rash- suggestive of viral hepatitis

    • Any history of biliary colic preceding the onset of jaundice

    • Progress of jaundice

      • • progressively increasing

        • diminishing after an initial deepening

        • waxing and waning

        • static

    • Associated symptoms with jaundice

      • • Pruritus- obstructive jaundice

        • clay coloured stool- obstructive jaundice

        • history of fever with chill and rigor- cholangitis

        • history of biliary colic

        • history of black tarry stool with waxing and waning of jaundice

  • Bowel Habit-

    • • • What was the usual bowel habit before the illness started?

        • What is the present bowel habit?

        • What is the change in bowel habit?

        • Any history of bleeding P/R or black tarry stool, passage of mucus in stool?

        • Any history of sensation of incomplete defaecation?

        • Any history of tenesmus?

  • Details of loss of weight- To mention approximate loss of body weight in kilograms.

  • History of loss of appetite- Whether patient has loss of appetite or patient is afraid to take food because of abdominal discomfort or pain.

  • Details of swelling in the abdomen-

    • • • Duration

        • Site where first noticed

        • Progress of the swelling

  • Details of urinary symptoms-

  • Other systemic symptoms-

IV. Past History:

V. Personal History:

VI. Family History:

VII. Treatment History:

VIII. Any History of allergy:

B. Physical Examination

I. General Survey

II. Local Examination of the Abdomen

(A) Inspection: (Patient supine with arms extended and exposed from midchest to midthigh)

• • Shape and contour of abdomen

    • Normal

    • Scaphoid

    • Distended

  • Umbilicus

    • Position

    • Normal / deeply inverted / flushed / everted

  • Skin over the abdomen

    • Scar- (if operative scar- describe as upper midline/ lower midline/ upper paramedian/ Rt or Lt subcostal incision scar)

    • Pigmentation

    • Striae ( white striae found in multiparous women is to be described as striae albicantes).

    • Engorged vein

  • Movements

    • Respiratory movements whether all region are moving normally with respiration

    • Visible peristalsis

    • Pulsatile movements- usually vascular tumour

  • Visible Swelling

    • Site and extent

    • Size

    • Shape

    • Surface

    • Margin

    • Moving with respiration or not

    • Rising test- whether swelling is parietal or intra-abdominal

  • Hernial sites

    • Any swelling

    • Any expansile impulse on cough

  • External genitalia

(B) Palpation:

(I) Superficial palpation-

(a) Temperature- Examine all the regions of the abdomen ( compare temperature of abdomen with temperature of chest with the dorsum of finger).

(b) any superficial tenderness

(c) feel of the abdomen

• • • soft and elastic feel is normal

      • muscle guard

      • rigidity

      • lump palpable- details of the lump is to be described under deep palpation

(II) Deep palpation-

(C) Percussion:

(D) Auscultation:

(E) Auscultopercussion:

(F) Per Rectal Examination:

(G) Per Vaginal Examination: