The clinical decision-making process begins at the first contact with the patient.
The physician forms a first impression and estimates the severity and urgency of the situation based on the primary symptom and the manner in which the patient (or his representative) first sought medical help. How concerned is the patient? At what point did the patient seek help? Is the symptom acute, recently occurring, or has it existed for some time? Is the patient very ill, or are they more or less capable of functioning normally?
A second important impression of disease severity is based on the way in which the patient takes a seat in the examining room (e.g. carefully and with difficulty) or the condition in which the physician finds the patient (e.g. lying still) at home.
A well-executed history-taking and physical examination form the basis for initial categorisation and later establishing a (differential) diagnosis and determining the further diagnostic path and treatment plan.
Catagorisation of disorders based on aetiology
- Congential or developmental disorders
- Trauma
- Infectious disorders
- Inflammatory / autoimmune disorders
- Neoplasms
- Metabolic / endocrinological disorders
- Degenerative disorders
- Functional / psychosomatic disorders
- Toxic / iatrogenic disorders
The patient is asked to describe the symptoms and their progression over time. A thorough description can yield a great deal of valuable information. Therefore, the patient should be given ample time to describe the symptoms. Many disease processes have a signature pattern of symptoms and symptom dynamics.
Knowledge of general disease processes and more specifically of disorders related to organs found in the abdomen is essential to obtaining a good patient history, particularly for posing the right questions in order to obtain relevant details.
This chapter provides an overview of information that can be obtained (spontaneously or through questioning) during a history-taking and which is relevant to the diagnosis of abdominal disorders. It is rare that all of these topics are explored in detail. Given that pain is a frequently-occurring symptom, this topic will be discussed more comprehensively.
Schematic overview of the history-taking for patients with absominal pain
Personal data
– name
– date of birth
– sex
– address
– profession
– name of general practitioner
Pain
– location
– radioation
– time of onset
– duration
– course
– type
– severity
– factors that influence the pain
– fever, chills
– urge to faint
– loss of appetite, weight loss
Other symptoms
– swollowing and passage disorders
– nausea, vomiting
– change in bowel mevement pattern
– jaundice
– miction symptoms
– inguinal symptoms
– gynaecological symptoms
Past medical history
– prior illnesses
– medication use, hebits
– family history