M I N T S History Taking and Physical Examination for GIT

M I N T S Gastrointestinal Tract GIT Pathology EsophagusStomach IntestinesAppendix Peritoneum

M I N T S Aims Understand why history-taking is important Understand different frameworks and apply them Be aware of potential pitfalls

M I N T S What’s The Point?

M I N T S Aims Communication - To build rapport with patient Diagnosis Ensuring that care is individualised –relating to age / social history etc –identifying factors that affect / interfere with treatment To pass information to others - Documentation

M I N T S How to Do It

M I N T S Framework – Single System Focus on Presenting problem –Often appropriate for single system injury Skill involves –Gathering relevant information for relevant systems –Making safe and appropriate decisions on what to include /exclude Important issues may be missed

M I N T S Framework - Systematic Full exploration of symptoms and medical history Full head to toe assessment Decide if this framework is necessary Be aware of time and resources (YOU) 

M I N T S Format 1.Presenting Complaint 2.History of Presenting Complaint 3.PMH 4.Drug History a)Allergies / Immunisations 5.Social / Occupational history 6.Family History 7.Systemic enquiry

M I N T S Components 1 Time Who is giving history? Presenting Complaint (PC) – patient’s own words History of Presenting Complaint (HPC) - What is problem ? - When, where, why and how did it happen ? - What happened next ? - Was first aid / analgesia administered ?

M I N T S Components 2 Past Medical History Drug History Allergies Tetanus and immunisations for children Family History where relevant Social History Occupation, hobbies, drugs CONSIDER – Systemic Enquiry necessary ? Clarification with patient / third party may be necessary to ensure correct information

M I N T S Components 3 – System Review GIT – Gastrointestinal Tract Resp – Respiratory System CVS – Cardiovascular System Uro – Urological System Neuro – Neurological System Loco – Locomotor System

M I N T S Pitfalls Patient’s Assumptions / Expectations / Fears Age Confusion Communication Difficulties Language Difficulties –Physical –Cultural Problems affecting social interaction –e.g claustrophobia =>Adapt methods of history taking and examination accordingly

M I N T S Documentation - General Tips  Write notes ASAP  Attention to detail  INFORMATION NOT RECORDED = INFORMATION LOST  Be relevant  Apply Structure  Apply chronological order of events  Abbreviations  When a mistake is made  cross it out with a single line, initial and date

M I N T S Chief complaints Note down the chief complaints in few headings with the duration in descending order : –E.g. Pain abdomen 4 days – Vomiting 3 days – Fever 2 days

M I N T S Quick Reminder 1.Presenting Complaint 2.History of Presenting Complaint 3.PMH 4.Medications a)Allergies / Immunisations 5.Social / occupational history 6.Family History 7.Systemic enquiry

M I N T S Practice Session Consider –What problems need addressed? –What are patient’s concerns?

M I N T S Summary Importance of History Taking Frameworks for Skill Potential Pitfalls

M I N T S Analysis of symptoms Patient can present with : –Specific symptoms –Nonspecific symptoms –Or combination of both You must analyze and find the specific symptoms for which he has come to the doctor. e.g. difficulty in swallowing, burning pain while passing urine

M I N T S Pain Onset Duration Progression Location Intensity Character Radiation Aggravating factors Relieving factors

M I N T S Types of pain Somatic pain: –Inflammation of parietal peritoneum, pleura or skin surface Colicky pain: –Indicates obstructed hollow organs e.g. intestinal colic, ureteric colic, biliary colic Burning pain: –Mucosal injury or inflammation e.g.heart burn in APD and burning urination in UTI

M I N T S Vomiting Onset Duration Progression Frequency Vomitus: quantity, content ? Blood, –? Bile Relation with food Associated symptoms

M I N T S Vomiting Nature of vomits –Color and content : e.g. in pyloric obstruction, there will be no bile, frank blood in vomits in the case of variceal bleeding. –In pyloric obstruction : the vomit contains portion of food ingested several hour or days before –In intestinal obstruction : bile colored or even faeculent (stool like) copius vomit associated with abdominal distention and constipation.

M I N T S Examination General examination Inspection Palpation Percussion Auscultation Hernial sites, supraclavicular lymph nodes, renal angle tenderness DRE

M I N T S Inspection Shape of abdomen Position of the umbilicus Visible scar marks Venous dilatation Visible swelling Visible peristalsis Movement with respiration Hernial orifices

M I N T S Palpation –Patient should be in supine position with knee flexed –Done with flat hand-do not poke –Start with the non-tender area –Do not repeat painful maneuvres –Look at the patient ‘ s face –Ask patient to relax and take deep breaths –Engage patient in conversation if necessary.

M I N T S Palpation

M I N T S Percussion

M I N T S Auscultation

M I N T S Examination of inguinal region

M I N T S Rectal examination