ANAMNESIS AND PHYSICAL EXAMINATION

GASTROENTEROHEPATOLOGY SYSTEM

 

Definition

Anamnesis (history taking) is a very important initial step before moving on to physical examination procedures. The clues obtained during the anamnesis will aid the health care provider on performing the physical examination and listing the most likely diagnosis. Anamnesis procedure must be done systematically giving a fact that medical histories could sometimes be more useful than physical examination in forming a diagnosis. Many complaints related to gastroenterohepatology system are remanded by the patients when they come to physician. Eventhough many complaints are remanded by the patients, but sometimes the complaints due to abdominal disorder are not related to the digestive tract disorder, so that making the doctor must be patient in conducting anamnesis.

Generally physical examination in gastroenterohepatology are similar to the general physical examination include inspection, palpation, percussion, and auscultation whereas some of the doctor prefer to conduct auscultation firstly before palpation. During physical examination normal and abnormal result like abdominal distention, mass abnormality, the increase or loss of peristaltic sound can be found.

In the other side, diagnostic skill in rectal examination (rectal touche’) and nasogastric tube assembling technique are usefull in performing diagnose to the patient with digestive tract disorder.

 

Indication

Anamnesis dan physical examination in gastroenterohepatologi are usefull for :

1.      Determining diagnose

2.      Helping the doctor in conducting the next plan of action for the patient

3.      Determining the improvement of therapy in patient

4.      Using as treatment procedure standard for the patient

 

Learning Objective

 

General Objective

After conducting the skills in this manual, students are expected to be able to conduct anamnesis and physical examination systematically and can distinguish the normal and abnormal condition in Gastroenterohepatology system.

Spesific Objective

After conducting the skills in this manual, students are expected to be able to :

1.      Conduct complete anamnesis / history taking

2.      Prepare the patient prior to the physical examination

3.      Perform a systematic Physical Examination include Inspection, Palpation,

Percussion and Auscultation

4.      Conduct examination based on appropriate procedure

5.      Identify and determine the type of sound in the abdomen

Clinical Steps

1.         ANAMNESIS CHIEF COMPLAINT

 

1.      Welcome the patient, standing up and shaking patient’s hands.

2.      Introduce yourself in a warm, friendly manner

3.      Allowing the patient to has a comfortable sit in front of the doctor

4.      Give a positive response to build up a good relationship with your patient, Ensure comfort and privacy

5.      Asking patient identity : name, age, address, and occupation

6.      Asking patient’s chief complaint (intestinal disorder with vomiting and diarrhea) and Obtaining a comprehensive history of present illness from the patient

Asking :

• Onset and duration of intestinal disorder with vomiting and diarrhea
• The shape, color and amount of intestinal disorder with vomiting and diarrhea : clots, spotted, blood red, winecoloured or like coffee coloured
  
• The other symptom due to : epigastric pain, or epigastric discomfort, abdominal pain, distention sensation in the abdomen, nose bleeding (ephistaxis), melena
  

7.      Obtain past medical history focusing on any illnesses that are likely to be in conjunction with the present complaints like cirrhosis, cancer, coagulopathy, history of ulcer peptic operation

a.       History of habits : alcoholism, NSAID or medicinal herbs consumption, corrosive drinking

b.      Family history : History of illness prior to bleeding

c.       Obtain history of past illness that related to the health condition

 

B. PHYSICAL EXAMINATION

 

Inspection

 

1.      Asking the patient to lay down in supine position with light source in the backside of physician whether the light can illuminates feet to head, or whole abdomen

2.      The physician has a sit at the patient’s right side, and the physician’s head is higher than patient’s abdomen

3.      Examine skin and sclera

4.      Inspect or observe the abdomen contour, scar, venous congestion, peristaltic movement or mass in several minutes

5.      Observe abdomen distention, obesity, tympanitis, ascites, pregnancy, faeces, or neoplasm/ malignancy sign.

 

Auscultation

 

1.      Ask the patient to relax and breathe

2.       Put the stethoscope bell on the mid abdomen and Focus on listening to the sound in the abdomen

3.      Listen to the intestine noisy

4.      Determine the intestine noisy : normal or abnormal

5.      Locating the stethoscope on the fourth quadrants of abdomen

6.      Conducting auscultation

a.       Peristaltic sound can be heard underneath the umbilical, above the suprapubic, or in everywhere

b.      to hear thundering/tumultuous sound from hepatic rub in the upper and right side of umbilical

c.       to hear Abdominal aortic murmur approximately 5 cm below the xhypoideal processus or in epigastric area

7.      Auscultate Bruit sound of pancreatic carcinoma in the left side of epigastric and also sphlenic friction rub in the lateral abdomen

8.      If peristaltic sound can not be heard, keep auscultating for more minutes

9.      Note down the auscultation result

 

Palpation

 

1.      The physician’s hand must be warm or suitable with the room /body temperature

2.      Ask the patient to do flexion on the hip/pelvic and knee, and also breathe by open mouth

3.      Communicate with the patient during palpation

4.      Apply a gentle palpation :

a.       Placing the palmar surface with adduction position of fingers on the abdomen and palpate gently the abdomen partition into 1 cm depth

b.      The abdomen partition must be avoided from nail fingers

5.      Conducting the deeper palpation

6.      Put the fingers tip into abdomen partitian when conducting deeper palpation in about 4-5 cm pressure and try to find the structure under the abdomen

7.      Pay attention to the patients’ expression during palpation

8.      Palpate the abdomen in the left quadrant :

·         Goal : Finding palpable spleen, left kidney

·         Normal : No palpable mass

·         Perform bimanual palpation. The right hand is put into behind the left rib border on midaxillae line, and left hand is placed below the chest so that fingers bent over under the ribs

·         Ask the patient to take a deep breathe, and when patient inhale deeply, put the right hand deeply into the back of ribs border and raised it, and the left hand raised the back chest

·         Conduct this skill frequently conform to inspiration rhytm and placing right hand in a various position

9.      Palpate the abdomen in the right quadrant :

·         Goal : Finding palpable liver, right kidney

·         Put Right hand with adduction fingers into below border of rib which volar surface contacted to the surface of abdomen. Sensation tactile will be felt by tip fingers

·         Left hand supination is placed under the right chest

·         While inhale deeply, the right hand moving up and put it into at the end of inspiration and in concormity with inspiration, left hand elevating the chest

10.  The patient’s head should be elevated using pillow if pain manifest directly when abdomen palpation performed

11.  Conducting rebound palpation (bounced back pain) : compress the abdomen partition gently using finger tip and then withdraw the fingers suddenly. It is called Blumberg sign

12.  If the masses are found in abdomen; assess the location, size, consistency, rubberiness, mobility and pulsation

Percussion

 

1.      Percuss the fourth abdomen quadrant

2.      Percuss the liver upper border in the right midclavicule line, start from the middle of chest, percussion is done from upward into downward

3.      Resonance sound in the chest become dullness when the examiner percuss the liver and then dullness sound will be changed to thympanic when percussion is done on the large intestine

4.      Determine the location and the size of liver

C. ASCITES EXAMINATION

 

1. Puddle sign :

·         Patient lays down in prone position with raised elbow and knee for 5 minutes

·         The diaphragm part of stethoscope is located on the medial of lower abdomen

·         The physician (examiner) listening to sound which is appear when fingers percuss the lateral abdomen

·         Keep conducting finger percussion while stethoscope is being moved away from the physician

·         If the edge of fluid gather is being reached, sound intensity will be louder

2. Shifting dullness

·         Percuss abdomen from the medial side to the lateral side, determine the edge of thympanic and dullness sound

·         Ask the patient to lay down in lateral position

·         Ascites sign will be positive if thympanic sound is changed to dullness in the same location in the abdomen.

3.Fluid Wave (undulation test) :

·         Put the examiner ‘s hand or patient ‘s hand on the middle of abdomen vertically

·         Compress the hand on the abdomen partitian

·         Percuss one side in the waist while the other hand palpates the waist in the opposite area.

·        Feel the fluid wave in the abdomen