Đang tải... (xem toàn văn)
(BQ) Part 2 book Bates'' pocket guide to physical examination and history taking presents the following contents: The abdomen, the peripheral vascular system, male genitalia and hernias, female genitalia, the anus, rectum, and prostate, the musculoskeletal system, the nervous system,... and other contents.
CHAPTER The Abdomen 11 The Health History Common or Concerning Symptoms Gastrointestinal Disorders Urinary and Renal Disorders ◗ Abdominal pain, acute and chronic ◗ Indigestion, nausea, vomiting including blood, loss of appetite, early satiety ◗ Dysphagia and/or odynophagia ◗ Change in bowel function ◗ Diarrhea, constipation ◗ Jaundice ◗ Suprapubic pain ◗ Dysuria, urgency, or frequency ◗ Hesitancy, decreased stream in males ◗ Polyuria or nocturia ◗ Urinary incontinence ◗ Hematuria ◗ Kidney or flank pain ◗ Ureteral colic PATTERNS AND MECHANISMS OF ABDOMINAL PAIN Be familiar with three broad categories: Visceral pain—occurs when hollow abdominal organs such as the intestine or biliary tree contract unusually forcefully or are distended or stretched ● May be difficult to localize ● Varies in quality; may be gnawing, burning, cramping, or aching Visceral pain in the right upper quadrant (RUQ) from liver distention against its capsule in alcoholic hepatitis 179 180 ● Bates’ Pocket Guide to Physical Examination and History Taking When severe, may be associated with sweating, pallor, nausea, vomiting, restlessness Parietal pain—from inflammation of the parietal peritoneum ● Steady, aching ● Usually more severe ● Usually more precisely localized over the involved structure than visceral pain Visceral periumbilical pain in early acute appendicitis from distention of inflamed appendix gradually changes to parietal pain in the right lower quadrant (RLQ) from inflammation of the adjacent parietal peritoneum Referred pain—occurs in more distant sites innervated at approximately the same spinal levels as the disordered structure Pain of duodenal or pancreatic origin may be referred to the back; pain from the biliary tree—to the right shoulder or right posterior chest Pain from the chest, spine, or pelvis may be referred to the abdomen Pain from pleurisy or acute myocardial infarction may be referred to the upper abdomen THE GASTROINTESTINAL TRACT Ask patients to describe the abdominal pain in their own words, especially timing of the pain (acute or chronic); then ask them to point to the pain Pursue important details: “Where does the pain start?” “Does it radiate or travel?” “What is the pain like?” “How severe is it?” “How about on a scale of to 10?” “What makes it better or worse?” Chapter 11 | The Abdomen 181 Elicit any symptoms associated with the pain, such as fever or chills; ask their sequence Upper Abdominal Pain, Discomfort, or Heartburn Ask about chronic or recurrent upper abdominal discomfort, or dyspepsia Related symptoms include bloating, nausea, upper abdominal fullness, and heartburn Find out just what your patient means Possibilities include: ● Bloating from excessive gas, especially with frequent belching, abdominal distention, or flatus, the passage of gas by rectum ● Nausea and vomiting ● Unpleasant abdominal fullness after normal meals or early satiety, the inability to eat a full meal Consider diabetic gastroparesis, anticholinergic drugs, gastric outlet obstruction, gastric cancer Early satiety may signify hepatitis ● Heartburn Suggests gastroesophageal reflux disease (GERD) Lower Abdominal Pain or Discomfort—Acute and Chronic If acute, is the pain sharp and continuous or intermittent and cramping? Right lower quadrant (RLQ) pain, or pain migrating from periumbilical region in appendicitis; in women with RLQ pain, possible pelvic inflammatory disease, ectopic pregnancy Left lower quadrant (LLQ) pain in diverticulitis 182 Bates’ Pocket Guide to Physical Examination and History Taking If chronic, is there a change in bowel habits? Alternating diarrhea and constipation? Colon cancer; irritable bowel syndrome Other GI Symptoms ● Anorexia Liver disease, pregnancy, diabetic ketoacidosis, adrenal insufficiency, uremia, anorexia nervosa ● Dysphagia or difficulty swallowing If solids and liquids, neuromuscular disorders affecting motility If only solids, consider structural conditions like Zenker’s diverticulum, Schatzki’s ring, stricture, neoplasm ● Odynophagia, or painful swallowing Radiation; caustic ingestion, infection from cytomegalovirus, herpes simplex, HIV ● Diarrhea, acute (