Compiled by Dr.

Shivesh Thakur,MD

Abdomen
I. Introduction
Name: Age: Sex: Handedness: Resident
of: Education: Occupation: Religion: Informant:
Reliability:
Chief Complaints (in chronological order)

II. HOPI
1. Dysphagia- Onset, Solids/Liquids/Both, Odynophagia, progression

2. Heart burn,Reflux,Indigestion,Flatulence

3. Vomiting-Onset,Duration,Projectile/Non
projectile,Bilious/Nonbilious,Content,Preceded by nausea,Asso. with
hematemesis, Frequency,Aggravated by,Releived by, Last episode

4. Hematemesis-Onset, Color,Quandity, Preceded by nausea,

Frequency, Aggravated by, Releived by, Last episode
5. Melena- Frequency, Color, Consistency, Odour, Lasted for, Last
episode

6. Abd.Pain-(OLDCAARTS)Onset, Location, Duration,

Character,Colicky/Noncolicky, Associated features, Aggravating and
Relieving factors,Relation with food Radiation, Time, Severity

7. Abd. Distension- Onset, Diffuse/Localised, Progress, Asso.with-

Pain/Fever/Constipation/Diarrhoea/Altered bowel habits/Nausea &
Vomiting/Hematemesis/Melena/BleedingPR/Jaundice/Menstrual
Irregularities/Oliguria/Anuria/Hematuria/Anorexia/Wt
loss/Periorbital puffiness[To r/o Fat,Fluid,Faeces,Flatus,Foetus,Fatal
growth,Liver & Kidney diseases], Releived by [diuretics/fluid tapping
etc…], Intermittent/persistent

8. Fever- Grade, Max Temp, Type, Associated with chills& rigors,

Diurnal variation, Evening rise of temp., night sweats, relieved by,
present status
 Compiled by Dr.Shivesh Thakur,MD

9. Anorexia & Weight loss- Quantified/Unquantified, lntentional

/Unintentional, Significant/insignificant
10. Constipation- Frequency, Fluid intake

11.Diarrhoea-
Onset,Duration,Frequency,Consistency,Quantity,Color,Odour,Painful
/Painless,Tenesmus,Stickyness,Steatorrhoea, Feeling of incomplete
evacuation,Mixed with blood/mucus/undigested food,Abd. Pain,
Abd. Distension

12.Bleeding Per Rectum

13.Oliguria/Anuria/Dysuria/Hematuria/Urine color/Periorbital
puffiness/loin pain

14.Jaundice- Onset, Sites [skin, eyes, urine], Urine color, stool color,
Preceded by any Prodrome/Pain abd / Abd. Distension, Progress,
Persistent/Intermittent/Fluctuating Pruritus, Bone pains, night
blindness, Easy bruisiability ,Bitot spots,Bleeding manifestations,
Altered sensorium, Lasted for, Releived by

15.Symptoms of Liver cell failure-Alopecia/Jaundice/parotid

swelling/loss of hair in axilla,Pubis/Loss of
libido/Gynaecomastia/palmar erythema/ Contratures/Testicular
atrophy/Ascitis/Spider nevi/Hematemesis/Melena

16.Altered Bowel habits

17.Joint pain/Rash/Photosensitivity/oral ulcers/Excessive hair
loss/Seizure/Abnormal behavior

18.Cough/Hemoptysis/Chest pain/Palpitation/dyspnoea
19.Well water drinking/Alternative medicine intake/Chronic drug intake
20.Blood transfusion
21.Pedal edema-Onset, Progression, Extension, Preceded/along
with/after Abd. Distension, relieved by
 Compiled by Dr.Shivesh Thakur,MD

III. Past History

DM/ HTN / TB/ Bronchial asthma/IHD
Childhood Jaundice
Jaundice/ Blood Txn
Allergies/ FB inhalation
Trauma/ Surgeries/ similar illness in the past
V. Personal History
Smoking - pack years/smoking index/ Chula smoking
Alcohol –Quandity in gm/day X yrs, Type of liquor,last consumed, Binge
drinking
Tobacco/Substance abuse
Veg / Non veg
Marital status/ Children
High risk behavior
Bladder/Bowel/Sleep
Menstrual History in detail
Occupation /Residence/Heavy metal exposure
Immunization history
Socio-economic status/ over crowding

VI. Family history

Similar illness in the family

VII. Treatment history

VIII. Summary at the end of the history

IX. Impression/ DD

Examination
General physical examination
 Conscious/oriented/comfortable
 Ht- Weight- BMI- Temp-
 Pulse- (Rate, Rhythm, Volume, Character, Peripheral pulses. R-R/ R-F
delay, Pulse deficit, Vessel wall, Carotid bruit)
 Compiled by Dr.Shivesh Thakur,MD

 BP- mmHg, Respiration - Rate, Rhythm, Type (Abdomino-Thoracic /

Thoraco-Abdominal)
 P/J/Cy/Cl/LNE/PE/JVP/rash/Lt supra clavicular LN /asterixis
 Signs of Liver Cell Failure-Alopecia, Jaundice, Bitot’s spots, Parotid
swelling, Foetor hepaticus, Spider nevi, Gynaecomastia, Loss of axillary/
pubic hair, Palmar erythema, Deputuryn contracture, Asterixis , Ascitis,
Testicular atrophy
 Nicotine stain- lips, Nail, teeth, gums, Vitamin deficiencies
 Spine – Kyphosis / Scoliosis /Gibbus, Skull
 Peripheral signs of TB / HIV

Systemic Examination
Abdomen
Inspection
 Symmetry
 Distension- Generalised/Localised
 Flanks
 All quadrants moves with respiration
 Umblicus
 Skin over the Abdomen- Striae/pigmentation/Injection marks/Ascitic
tapping/Petechiae/Ecchymosis
 Scars/Sinuses/Dilated/Prominent veins
 Visible peristalsis/Pulsations
 Hernial orifices
Palpation
 Inspectory findings confirmed
 Soft/ Guarding/ Rigidity
 Tenderness-Localised/Diffuse/Dull/Severe/Specific area tenderness/Signs
 Liver-Size/Extend/Border/Surface/Consistency/Tenderness/Moves with
respiration/intercostal tenderness
 Compiled by Dr.Shivesh Thakur,MD
 Spleen-
Size/Extend/Border/Surface/Consistency/Tenderness/Notch/Moves with
respiration
 Kidney- Above + Bimanually palpable, ballotability
 Any other mass
 Direction of venous flow
 Hernial Orifices
 Testicular examination
 Sister Joseph Nodules
 Pulsations
Percussion
 Fluid thrill/Shifting dullness/Puddle sign
 Liver span
 Traube’s Space
 Colonic band of resonance on the lt side
 Various methods of percussion of Spleen- Nixon/Castell/Traube space

Auscultation
 Bowel sounds/Hepatic bruit/Renal bruit/Venous hum
Perinium, Genitals
Per Rectal Examination
Per Vaginal Examination
Naked eye Urine & Stool Examination

Respiratory System
 Chest wall symmetry
 Respiratory movements
 Percussion- any e/o PE
 Air entry/NVBS/BB/Crackles/Rhonchi/Pl.Rub
 Compiled by Dr.Shivesh Thakur,MD

Cardio-Vascular System
 Apical Impulse
 Precardial buldge, Parasternal heave
 Palpable sounds, Thrill
 S1,S2,S3,S4
 Murmurs
Central Nervous System
 Consciousness,Orientation
 FND, Horner’s Syndrome, Planters

Summary after Examination

Diagnosis/DD

Investigation

Treatment