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GIT checklists_240514_155417

The document outlines the process of taking a gastroenterology history and performing a physical examination, including obtaining patient consent and gathering personal, past, drug, family, and psychological histories. It details the steps for inspecting and palpating the abdomen, liver, and spleen, as well as assessing for ascites. The information is organized in a systematic manner to ensure comprehensive evaluation of gastrointestinal symptoms.

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Abdurrahman Moustafa
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9 views

GIT checklists_240514_155417

The document outlines the process of taking a gastroenterology history and performing a physical examination, including obtaining patient consent and gathering personal, past, drug, family, and psychological histories. It details the steps for inspecting and palpating the abdomen, liver, and spleen, as well as assessing for ascites. The information is organized in a systematic manner to ensure comprehensive evaluation of gastrointestinal symptoms.

Uploaded by

Abdurrahman Moustafa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Gastroenterology History Taking

Introduction:
 Explain the need to take a history.
 Gain oral consent from patient.
Personal history:
Complain: Patient’s own words + duration
History of present illness
Upper GI symptoms: Appetite, Vomiting, Epigastric pain…
Lower GIT symptoms:-
 Diarrhea
 Constipation.
 Dysentery, Flatulence.
 Bleeding per rectum, melena
 Lower abdominal pain
 Painful defecation
Hepatobiliary symptoms:-
 Biliary colic
 Jaundice
 Other symptoms: edema of lower limb, wasting muscle, hand tremors,
gynecomastia, decrease or loss libido, bleeding tendency, abdominal enlargement,
bad mouth odor, ……
Take the history in an organized and chronological order
Past history
Drug history
Family history
Psychological history
Thank your patient
Provisional diagnosis (Etiological, anatomical, pathological, functional,
complications)

1
Inspect the abdomen and palpate the liver
GETTING READY
• Greeted the patient. Introduce yourself in a friendly manner.
• Explained the procedure to the patient.
• Stood by the right side of the patient. Warm hands.
Inspection:
Look from the foot end of the patient tangentially
Looked tangentially and comment on epigastric pulsation
asked the patient to rise from supine position without using his arms and comment on
divarication of recti
comment on:
Contour, Abdominal movements with respiration, Pulsations, Visible peristalsis, Costal
margin, Umbilicus (site, shape, discharge, pigmentation, ulceration, infiltration), Hernial
orifices, Skin (pigmentations, scars, striae, sinuses, hair distribution, dilated veins).
liver palpation
Instructed the patient to flex the hips and knees in order to relax the abdominal muscles

Place right hand on the right iliac fossa in mid clavicular line resting transversely
parallel to the costal margin

Ask the patient to take a deep breath. Keep the hand still during inspiration. Ask the
patient to expire, slide the hand a little nearer to the right costal margin till the lower
border of the right lobe of the liver is palpated.

Put the hand in the midline and repeat the above steps till the lower border of the left
lobe of the liver is palpated.

Put one hand on the liver anteriorly and the other hand at the back. Ask the patient to
hold his breath and feel for pulsation

Comment on the liver

2
Palpate the spleen and percuss for ascites
GETTING READY
• Greeted the patient. Introduce yourself in a friendly manner.
• Explained the procedure to the patient.
• Stood by the right side of the patient. Warm hands.
• Instructed the patient to flex the hips and knees in order to relax the abdominal muscles

• Instructed the patient to open the mouth and breathe quietly in and out.
• Started palpation from the right iliac fossa with the tips of the examining hand directed towards
the left axilla, move toward the left hypochondrium until the spleen is felt.
• Bimanual examination: Start from right iliac fossa with the tips of the examining hand directed
towards the left axilla Place the left hand over the lateral aspect of the left costal margin,
exerting a certain amount of compression and move toward the left hypochondrium until the
spleen is felt.
• Right lateral position method: Ask the patient to turn to the right side, Insinuate the hand
below the costal margin Ask the patient to take a deep breath Press till the lower edge of the
spleen is felt
• Hooking method: Stand on the left side of the patient‘s head Place the fingers of both
hands over the costal margin. Instruct the patient to take deep breath.
• Comment on spleen
Percussion of ascites
• Place the fingers parallel to the flanks (in the longitudinal axis). Start percussion from the
midline down to the flank till eliciting a dull tone.
 On detecting dullness, ask the patient to turn to the opposite side, while keeping the examining
hand over the exact site of dullness.

 Keep the hand in position till the patient rests on the opposite side, Percuss again in this new
position

 Repeat percussion on the other side of the abdomen

 Knee elbow position (If shifting dullness is negative)

Comment on ascites

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