IPC I: Gastrointestinal H&P
HPI
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PMH
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PSH
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Abdominal pain: knowing the different systems involved
in abdominal pain is very important! GI (of course!), GU
(UTI, pyelonephritis, PID, ectopic pregnancy, torsion) and
other systems (DKA)
o Quadrant: important in forming DDx (see
diagram!)
o Onset/duration: acute, gradual
o Characteristics: sharp, dull, aching, colicky
o Pattern/timing: intermittent, continuous, moving
o Severity: rate on pain scale
o Sexual activity: possibility of pregnancy? STD’s?
o Urinary symptoms: dysuria, hesitancy, frequency,
hematuria, polyuria, nocturia, weak stream
o Associated sx: fever, nausea, vomiting, diarrhea
Diarrhea: onset, frequency, amount, color/quality
(mucus, watery), blood, recent food, recent travel,
associated sx (fever, nausea, vomiting)
Nausea/vomiting: onset, frequency, description,
quantity, blood, recent foods, ETOH, associated sx (LOC)
Heartburn: chest pain, quality, onset/timing (how many
hours after dinner?), aggravated by lying down, alleviated
with antacids, current meds (PPI, H2 blockers), associated
sx (coughing)
Jaundice: when it started, color of urine/stool, pruritis
Indigestion: onset/duration, association with specific
foods, family history,
Anorexia: odynophagia, dysphagia, postprandial pain
GERD, GI bleeding, PUD, esophageal varices, hepatitis,
cirrhosis, alcoholism, cholelithiasis, cholecystitis,
pancreatitis (acute, chronic), SBO, LBO, ulcerative colitis,
Crohn’s, IBS, Celiac’s, Hirschprung’s, polyps, hemorrhoids,
cancer, renal calculi, pyelonephritis, multiple UTI’s, STD’s,
DM
EGD, colonoscopy/polypectomy, cholecystectomy,
appendectomy, bowel resections
Meds/Allergies
 Especially ASA, NSAID’s!
FHx
 Hx of GI bleeding, cirrhosis, PUD, CA, FAP, IBD, celiac’s,
etc.
SocHx
 Diet, smoking, ETOH, IVDA
 Sexual history!!!
Physical Examination
Inspection
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Identify major landmarks on the abdomen: xiphoid process, CVA, iliac crest, vertebrae, costal edge, McBurney’s
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Appreciate general shape of abdomen (obese, distended) and always note scars!
o Distention below umbilicus: ovarian tumor, pregnancy, uterine fibroids, distended bladder
o Distended above umbilicus: carcinoma, pancreatic cyst, gastric dilation
o Asymmetric distention or protrusion: hernia, tumor, cysts, bowel obstruction, organomegaly
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Jaundice (look for scleral icterus!), caput medusae, spider angiomas, gynecomastia, ascites, ecchymosis
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Pulsations, masses, hernias, distention, ripples
Auscultation
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Bowel sounds: hyperactive (gastroenteritis), hypoactive (ileus), absent (much have NO bowel sounds in quadrant for 5
minutes!), normoactive. High-pitched (obstruction). Remember to listen with diaphragm!
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Bruits: over aorta, renal, and iliac arteries. Remember to listen with bell!
Percussion
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Tympany/dullness: also check for shifting dullness if abdomen distended (ascites). Note that different areas are expected to
have some tympany (air in stomach) or dullness (solid masses like liver).
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Liver span (7-12 cm or >3cm below costal edge) and spleen to check for enlargement. To percuss liver, begin at L midclavicular line where it is tympanic, then percuss towards the head until you hear dullness (inferior edge of liver). Then keep
percussing until you hear resonance (superior liver edge going into lungs).
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CVA tenderness: gently thump on patient’s back above kidneys to check for pain
Palpation: light  moderate  deep palpation x 4 quadrants (may help to have patient bend knees)
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Feel for masses at different levels (light, moderate, deep). If the mass cannot be palpated when patient lifts their head up
(flexing abdominal muscles), then mass is in abdominal cavity, not in abdominal wall. Check for hernias (umbilical, incisional
hernias are a result of weakness of the abdominal wall)
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Check for guarding, rebound (“does it hurt more when I push in or when
I let go?”)
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Liver and speen: try to push fingers under the ribcage and have patient
breathe in (may be only able to palpate normal sized livers in thin
individuals).
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Pulses: check for a midline pulsatile mass (aortic aneurysm), femoral
Specific tests: see below!
Cullen's sign
Bluish periumbilical discoloration
Retroperitoneal hemorrhage (hemorrhagic
pancreatitis, abdominal aortic aneurysm rupture)
Kehr's sign
Severe left shoulder pain
Splenic rupture
Ectopic pregnancy rupture
McBurney's sign
Tenderness located 2/3 distance from anterior iliac spine to
umbilicus on right side
Appendicitis
Murphy's sign
Abrupt interruption of inspiration on palpation
of right upper quadrant
Acute cholecystitis
Iliopsoas sign
Hyperextension of right hip causing abdominal pain
Appendicitis
Obturator's sign
Internal rotation of flexed right hip causing
abdominal pain
Appendicitis
Grey-Turner's
sign
Discoloration of the flank
Retroperitoneal hemorrhage
(hemorrhagic pancreatitis,
abdominal aortic aneurysm rupture)
Chandelier sign
Manipulation of cervix causes patient to lift buttocks off table
Pelvic inflammatory disease
Rovsing's sign
Right lower quadrant pain with palpation of
the left lower quadrant
Appendicitis
Blumberg’s sign
Rebound tenderness (pain when releasing deep palpation)
Peritoneal irritation
Markle’s sign
Have patient stand and hit heels on floor or hit heels
(unexpectedly) to elicit pain
Appendicitis
Peritoneal irritaiton