Constipation -what does pt mean by constipation (hard stool/infrequent), ask normal bowel habit Question asked Can you

tell me about your stool? Can you tell me about your diet? Is there pain on opening of your bowel? Have you noticed any blood? Have you noticed any lump? Any medical disorder? Why Faecal retention can cause soiling. Small pellet or ribbon-like suggest IBS Commonest is idiopathic/functional. Deficient in fibre (fruit/vege/wholemeal) Fissure in-ano, thrombosed haemorrhoids Suggest carcinoma, haemorrhoids, diverticular disease, and IBD Haemorrhoids hypothyroid/hypercalcaemia can cause this. Can be associated with Parkinson. Immobility Hypokalemia on diuretic treatment Abdominal pain + (>= 2 diagnose IBS)
Abdominal pain that relief after defecation? Loose and frequent stool at onset of abdo pain? Mucus per rectum? Abdomen distended?

PE & Investigation Palpation reveal mass-neoplasm, faecal retention. ask pt to bear down to demonstrate haemorrhoids/mucosal prolapse/perianal descent. DRE: rectal tumour, faecal impaction, rectal size and tone Flexible sigmoidoscopy/colonoscopy -Hb, ESR -FOBT -TFT, serum Ca, serum K, tumour marker -double contrast Ba enema (megacolon)

Management Non-pharmaco: -drink plenty water/prune juice -regular exercise -high fibre food -dont neglect the call -relaxed lifetsyle Pharmaco: st -1 line:bulking agent nd -2 lline:osmotic laxative rd -3 line:recheck/stimulating agent

Abdominal pain?

Intestinal obstruction:
Distention, vomiting, abdo pain, constipation

Any medications? Narcotics and laxative abuse can cause rebound constipation. Weight loss? Family history of cancer? Alternating episode of diarrhea? If lady, pregnancy can also cause this. In infant, consider hirchsprung.

Some drugs can cause this. -codeine, antidepressant, anatacids, antiepileptic Usually relieve when drug withdrawn Carcinoma of colon/rectum/anus

Diarrhoea What does pt mean by diarrhea, normal bowel habit? Acute (<7d)- AGE/abx rxn/dietary indiscretion Chronic- IBS/drug rxn (abuse)/chronic infection Question asked Where do you eat yesterday? What food you eat? Anyone eat with you have similar episode? Assoc symptoms-fever/vomit/abdo pain Why Food poisoining (toxin) -within hours -abdo cramp/headache/vomit/ dehydrate -watery Acute gastroenteritis -within days -+/- blood -abdo cramp Profuse bright bleeding consider diverticulitis/carcinoma. Mucus+blood consider IBD. central suggest small bowel, lower down suggest large bowel. Malabsorption Organic cause more likely. IBD /hyperthyroidism/thyrotoxicosis Suggest carcinoma. Penicillin derivatives Methyldopa/digoxin/methotrexate/PPI/ propanolol IBD Chronic alcohol abuse Travellers diarrhea esp India, China. PE & Investigation IBD: iritis, skin lesion, athralgia, spondyloathropathy Hypethyroid: Warm moist palm, tremor, eye sign Mass-carcinoma Signs of dehydration -stool culture and microscopy -Hb, WCC, MCV, ESR, TFT -antibody test: IgA antiemdomysial -flexible sigmoidoscopy/colonoscopy Management Maintain hydration. Give ORS. Correct fluid & electrolyte loss. AGE: -Avoid alcohol/coffee/fatty food/spicy/ fried. -eat low fat food -

Can you tell me about your stool?

Abdominal pain? Are your stools pale, greasy, offensive, and difficult to flush away? Have you been woken at night from sleep by diarrhea? Any medical disorder? Loss weight? Family hx of cancer/IBD/celiac dz Have you had treatment with abx recently? Any medications? Have you had trouble with pain in your joints, back pain, eye trouble, mouth ulcer? How much alcohol do you drink? Travel hx Laxative use

Cough Question asked How long have you had the cough? Why Acute suggest URTI, LRTI Chronic suggest COPD/GERD/asthma/bronchiectasis
Barking-croup Loud and brassy-tumor causing tracheal compression Worst at night-asthma/HF

Character of the cough Do you cough up anything? What and how much?

PE & investigation See pt dyspnoea at rest or not Wheeze Additional sounds? Chest abnormalities -sputum culture -PEFR -FBC (WCC)

Management

Dry->productive (yellow/green): pneumonia Copious sputum +/- blood: bronchiectasis Dark colored, foul smelling: lung abscess Blood: carcinoma/TB Upper airway cough syndrome: Cough, postnasal
drip, sinus congestion, headache

Have you had sinus problem? Have you had fever? Does cough particularly occur at night? Have you become shortness of breath? Have you had lung problem in the past? Are you smoking? Do you ever smoke? Notice any wheezing? Any medication? Sick contact? TB previously? Family hx?

URTI/ LRTI Acid reflux- burning chest pain Cardiac failure Cardiac failure-dyspnoea, PND Risk factor for COPD/carcinoma Asthma/COPD s/e of ACE inhibitor can cause dry cough.

asthma

Oedema Site of the oedema? Any fever/sore throat before? Any SOB? Pain and redness? Itchy, skin changes? Gradual or sudden? Any medical illness? Are you mobile? Any allergy? Food Insect bite Recent changes in medication Trauma/surgery/past DVT/cancer/obese/pill If lady pregnant, BP, proteinuria Does it worst in the evening and improve during the night? Unilateral: DVT/cellulitis/insect bite Bilateral: cardiac failure/hypoalbumin Post strep infection cause nephritic syndrome. Cardiac failure Sign of inflammation Venous insufficiency Venous insufficiency: Acute-prolonged sitting Renal and liver failure can cause this. Impaired mobility suggests trauma, baker cyst and arthritis. Check pitting, T, red? Pulse Non pitting: -hypothyroid -lymphoedema (allergx, congentl, malignant, infectious) -RFT -LFT -urine FEME -hand held Doppler -ESR, CRP -blood culture -FBC

Vasodilating durg (CCB) Risk of DVT

Pre-eclampsia Suggest cardiac origin.

Palpitations Can u describe how u feel? Ask to tap the rhythm