ABDOMEN

Name /Age /Sex / Occupation /Address

H/O Presenting illness

Pain
Duration

Site

Nature( continuous /intermittent)

Character(constant/colicky)

Severity

Radiation

Aggravating/ relieving factors

Associated features (Fever, Nausea, Vomiting or Defecation )

H/o Abdominal Distension

Onset (insidious/acute)

Site(localized or uniform)

Progress

CVS Features (RVF)

Leg swelling

Breathlessness

Chest pain

Liver features
Asso. Loss of appetite/Jaundice/Pruritus

Haematemesis

Malena

Renal
oliguria
 Puffiness off face

Frothy urine( Nephrotic syndrome)

Vomiting /Blood in vomit

No of episodes

Duration

Projectile/associated with nausea(Head ache, blurring of vision)

Quantity

Character(Colour/Smell, Blood streaks Y/N)

Associated with food intake

Associated features, pain, Malena/Haemetemesis)

CCF

Palpitation

Dyspnoea

Chest pain

No H/O Fever

No H/O Vomitting, Dysphagia, Heart burn

No H/O pain, burning micturition

No H/O Bleeding diathesis

NO H/O Trauma

No H/O prolonged bleeding after trauma

If Cirrhosis(Hepatomegaly)

H/O dyspnea, Fatigue ability(Nutritional Cirrhosis)

H/O Thyroid swelling (Billiary cirrhosis)

No H/O Sleep disturbance, loss of consciousness , tremors, be havioral disturbances

H/O Previous similar episodes

H/O DM,HT,TB,BA

H/O Abdominal surgeries

H/O Renal Colic

Jaundice
H/O Tattoing

H/O drug intake

H/O Blood transfusion

H/O Exposure to STDs

H/O vaccination

Family History

Any similar History

Wilson’s disease

Alpha-1 Anti trypsin deficiency

Hep A, Hep B, Hep E

Personal History

Smoking

Alcoholism

Diet(Appetite)

Sexual History

Menstrual History

Obstetric History

Treatment History

Summary
 Age/Sex/Name Personal H/O  Family H/O presenting complaints other relevant positive
features

General Examination

Conscious

Co- operative

Afebrile

Pallor

Jaundice

Clubbing

Built

Pedal Edema

Cyanosis

Significant lymphadenopathy

Signs of Liver cell failure

Head
Alopecia

Eye
Bitots Spots

Sub conj. Haemorrhage

Anemia

Jaundice

KF ring

Xanthelasma

Face
Medial supraciliary madarosis

Sunken eyes, cheeks

Loss of facial hair

Mouth
Bleeding gums

Fetor hepaticus

Chest
spider nevi

Gynacomastia

Atrophy of breast

Loss of pectoral hair axillary hair

Pectoral muscle atrophy

Dilated veins

Hand
Pallor

Bounding pulse

Clubbing

Dupuytrens contra ctions

Palmar erythema

Flapping tremor

Leuconychia

Abdomen
Distention

Dilated veins

Testis
Atrophy

Pubic hair loss

Tumour

Lower limbs
Pedal edema
 Chronic leg ulcer

General
Pruritis

Spider man appearance

Markers of TB

Markers of HIV

Vital Signs

Pulse Rate
Rate, Rhythm, Volume, Character, RF Delay, Felt in all peripheral vessels,
condition of vessel wall

BP

Respi. Rate
Rate , Rhythm, Type

Temp

JVP

Inspection

Shape
Saphoid/Flat /Distended(May be Uniform or localized)

Flanks free/full

Umbilicus

Position

Shape(Slit/everted/inverted)

Nodules(Sister Mary joseph’s )

Movements of abdomen

Movement with respiration

Visible peristalsis(VGP/VIP)
 Skin and surface of abdomen
Supine Position
Stretched, Shiny, Scars, Surgeries, Sinuses, Striae

Cushing : Purple Striae

Head rising

Divarication of recti

Standing position

Dilated veins

External genitalia

Herinal orifice

Palpation

Superficial palpation

Warmth

Tender / Non tender

Deep palpation

Liver
A tender/ non tender swelling is palpable ……………cm below Rt costal margin in
Extending from ……………..(medial )to …………..(lateral). With …….. (smooth/Nodular
)surface, & ………………(Sharp/Round) margin_______(soft/ firm/hard) in consistency.

It______(moves/ does not move) with respiration , not bimanually palpable, not
able to insinuate fingers under costal margin

Spleen
Site, Surface, Extent, Notch on medial border, consistency (firm), tender

It moves with respiration not bimanually palpable, non ballotable

Upper border cannot be felt, colonic band of resonance not f elt

Kidneys

Moves with respiration, bimanually palpable, ballotable

Colonic band of resonance felt

Direction of Blood flow

Fluid thrill(>2lit)

Abdominal girth measurement

Inguinal / Para aortic / Supra clavicular nodes

Percussion

Fluid
Shifting dullness( 1lit)

Puddle sign (100ml)

Liver

Dullness and Span

Spleen

Dullness/Traube’s Space

Auscultation

Bowel Sounds

10-15 /min –small bowel

3-5 / min – larger bowel

Bruit
Renal artery

Liver

Aortic Bruit

Venous Hum

Midway between umbilicus and Rt costal margin

PDV

Collaterals in portal HT

Cruveilheir baumgarter syn.

Perisplenitis

Perihepatitis

Succusion Splash

Other Systems

CVS

RS

CNS