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CNS Case Sheet — Medicine Postings

Central Nervous System: Detailed History Taking & Examination Proforma

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SECTION 1 — PATIENT IDENTIFICATION

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SECTION 2 — CHIEF COMPLAINTS

1. _____________ — since ___________
2. _____________ — since ___________
3. _____________ — since ___________

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SECTION 3 — HISTORY OF PRESENTING ILLNESS

General Pointers

• Mode of onset: Sudden / Acute / Sub-acute / Chronic / Insidious
• Progression: Static / Progressive / Relapsing-remitting / Stepwise
• Course: Improving / Worsening / Fluctuating

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A. Headache (if present)

• Site: Unilateral / Bilateral / Holocranial / Occipital / Frontal / Peri-orbital
• Onset: Sudden ("thunderclap") / Gradual
• Character: Throbbing / Pressing / Band-like / Stabbing / Boring
• Severity: Mild / Moderate / Severe (VAS scale 1–10)
• Duration: Seconds / Minutes / Hours / Days
• Radiation: Neck / Face / Shoulder / Back
• Time of occurrence: Early morning / Nocturnal / Continuous
• Aggravating factors: Bending forward, coughing, straining, physical activity, light, noise
• Relieving factors: Rest, analgesics, darkness, sleep
• Associated features: Nausea/vomiting, photophobia, phonophobia, aura, visual changes, fever, neck stiffness
• Prior history of similar headache: Yes / No

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B. Seizures / Fits (if present)

• Type of onset: Focal / Generalised / Unknown
• Aura: Rising epigastric sensation / Visual / Auditory / Olfactory / Déjà vu / Fear (note: mesial temporal auras = rising epigastric sensation; occipital = elementary visual; lateral temporal = auditory)
• Motor manifestations: Tonic / Clonic / Tonic-clonic / Myoclonic / Atonic
• Lateralisation: Unilateral / Bilateral / Head/eye deviation (direction)
• Automatisms: Lip smacking / Oro-alimentary / Hand automatisms / Bipedal / Verbal
• Duration of episode
• Loss of consciousness: Yes / No
• Post-ictal state: Confusion / Headache / Todd's palsy / Sleepiness / Duration
• Tongue bite / Urinary/faecal incontinence
• Frequency: per day / week / month
• Precipitants: Sleep deprivation / Alcohol / Fever / Stress / Menstruation / Flashing lights
• Risk factors: Febrile seizures in infancy, meningitis/encephalitis (especially before age 5), head trauma, family history (Bradley & Daroff)

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C. Loss of Consciousness / Altered Sensorium

• Onset: Sudden / Gradual
• Duration
• Preceding symptoms: Prodrome, warning
• Depth: GCS at time of event
• Associated: Seizures, injuries, incontinence, cyanosis
• Recovery: Complete / Partial / Time to recovery

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D. Weakness / Paralysis

• Distribution: Monoplegia / Hemiplegia / Paraplegia / Tetraplegia / Diplegia
• Onset: Sudden (stroke) / Progressive (tumour, motor neurone disease) / Episodic
• UMN vs LMN features in history: Stiffness and spasticity (UMN) vs floppiness and wasting (LMN)
• Progression: Fixed / Ascending (Guillain-Barré) / Descending
• Associated sensory loss: Yes / No / Level
• Bladder and bowel involvement
• Diurnal variation: Morning stiffness / End-of-day fatigue (myasthenia)

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E. Sensory Symptoms

• Type: Numbness / Tingling / Paraesthesia / Pain / Burning / Electric shocks
• Distribution: Dermatomal / Peripheral nerve / "Stocking-glove" / Hemibody / Saddle area
• Loss of specific modalities: Pain/temperature vs vibration/joint position sense
• Lhermitte's sign (electric shock on neck flexion — demyelination)
• Trophic changes, pressure sores

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F. Visual Symptoms

• Blurring: Monocular (anterior to chiasm) / Binocular
• Diplopia: Horizontal / Vertical / Oblique; worse at distance vs near
• Visual field defects: Hemianopia / Quadrantanopia / Tunnel vision / Central scotoma
• Transient visual loss (amaurosis fugax)
• Oscillopsia / Visual obscurations / Photopsia

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G. Speech and Language

• Dysarthria: Slurring / Nasal / Scanning / Explosive / Low volume
• Dysphasia/Aphasia: Expressive (Broca's — non-fluent) / Receptive (Wernicke's — fluent) / Global
• Dysphonia: Hoarseness
• Dysphagia: Solids / Liquids / Both

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H. Gait and Balance

• Type: Wide-based (cerebellar/sensory ataxia) / Steppage / Scissor / Spastic / Festinant / High-stepping / Waddling
• Falls: Frequency, direction (retropulsion in Parkinsonism)
• Dizziness / Vertigo: True vertigo (rotational) vs light-headedness; positional

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I. Involuntary Movements

• Type: Tremor / Chorea / Athetosis / Ballismus / Myoclonus / Tics / Dystonia / Fasciculations
• For tremor: Rest (Parkinsonism) / Action (Essential tremor) / Intention (cerebellar)
• Relation to posture, activity, sleep

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J. Cognitive and Behavioural Symptoms

• Memory: Short-term / Long-term deterioration
• Orientation: Time / Place / Person
• Language deterioration
• Personality change / Disinhibition / Apathy
• Sleep disturbance: Insomnia / Hypersomnia / REM behaviour disorder
• Hallucinations: Visual / Auditory / Tactile

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K. Autonomic Symptoms

• Bladder: Frequency / Urgency / Retention / Incontinence
• Bowel: Constipation / Incontinence
• Sweating: Hyperhidrosis / Anhidrosis
• Postural dizziness (orthostatic hypotension)
• Sexual dysfunction

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SECTION 4 — PAST HISTORY

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SECTION 5 — FAMILY HISTORY

• Similar neurological illness in family members (epilepsy, migraine, muscular dystrophy, Huntington's, spinocerebellar ataxia)
• Three-generation pedigree if hereditary condition suspected (Bradley & Daroff)
• Consanguinity: Yes / No
• Neurodegenerative disorders (Parkinson's, Alzheimer's, Friedreich's ataxia)
• Sudden unexplained death

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SECTION 6 — PERSONAL HISTORY

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SECTION 7 — TREATMENT HISTORY

• Current medications (especially antiepileptics, antihypertensives, anticoagulants, steroids, immunosuppressants)
• Previous neurological treatments and response
• Herbal / OTC medications

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SECTION 8 — SOCIOECONOMIC & DEVELOPMENTAL HISTORY (Paediatric cases)

• Birth: Full-term / Premature; birth weight; mode of delivery
• Perinatal: Asphyxia, NICU stay, neonatal seizures
• Developmental milestones: Head control / Sitting / Standing / Walking / First words / Sentences
• School performance
• Immunisation history
• Regression of milestones: Yes / No

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SECTION 9 — GENERAL PHYSICAL EXAMINATION

Vitals

General Examination

• Built and nourishment: Good / Poor
• Pallor / Icterus / Cyanosis / Clubbing / Lymphadenopathy / Oedema
• Skin: Café-au-lait spots / Ash-leaf macules / Shagreen patches / Port wine stain / Neurofibromas (neurocutaneous markers)
• Head circumference (paediatric): Microcephaly / Macrocephaly
• Spine: Kyphosis / Scoliosis / Hairy patch / Spina bifida / Sacral dimple
• Neck stiffness: Kernig's sign / Brudzinski's sign (meningeal irritation)

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SECTION 10 — SYSTEMIC EXAMINATION

Cardiovascular: (embolic sources)

• Murmurs, AF, peripheral pulses, carotid bruits

Respiratory:

• Consolidation, effusion (TB, paraneoplastic)

Abdomen:

• Hepatosplenomegaly (storage disorders, Wilson's disease)
• Liver: cirrhosis (hepatic encephalopathy)

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SECTION 11 — NEUROLOGICAL EXAMINATION

A. HIGHER MENTAL FUNCTIONS (Cortical Functions)

1. Consciousness

• GCS: Eyes (1–4) / Verbal (1–5) / Motor (1–6)
• AVPU: Alert / Voice / Pain / Unresponsive

2. Orientation

• Time (day, date, month, year, time of day)
• Place (hospital, ward, city, country)
• Person (own name, examiner)

3. Attention and Concentration

• Digit span (forward ≥6, backward ≥4)
• Serial 7s subtraction from 100
• Months of year backwards

4. Memory

• Immediate: Digit repetition
• Short-term (recent): 3-object recall at 5 minutes
• Long-term (remote): Past events, autobiographical

5. Language

6. Praxis

• Ideomotor: Mimic brushing teeth, combing hair, salute
• Ideational: Use a key, fold a letter, light a match
• Constructional: Copy a figure (intersecting pentagons)

7. Visuospatial and Gnosia

• Clock drawing test
• Neglect: Line bisection, cancellation test
• Prosopagnosia / Object agnosia

8. Frontal Lobe Functions

• Abstraction (similarities/proverbs)
• Judgement
• Wisconsin card sorting / MMSE / MoCA (document score)
• Perseveration / Utilisation behaviour

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B. CRANIAL NERVE EXAMINATION

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C. MOTOR SYSTEM

1. Inspection

• Wasting / Hypertrophy (muscle bulk)
• Fasciculations (LMN, lower motor neurone)
• Involuntary movements

2. Tone

• Upper limbs: Clasp-knife spasticity (UMN) / Lead-pipe or cogwheel rigidity (extrapyramidal) / Hypotonia (LMN / cerebellar) / Gegenhalten (frontal)
• Lower limbs: Clonus — ankle / patellar (≥3 beats = pathological)

3. Power (MRC Grade)

4. Reflexes

• Right: Flexor / Extensor (UMN sign) / Equivocal
• Left: Flexor / Extensor / Equivocal

• Abdominal reflex: Upper (T8–T10) / Lower (T10–T12) — absent in UMN lesions
• Cremasteric reflex (males): L1–L2

• Palmomental / Grasp / Snout / Rooting / Glabellar tap

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D. SENSORY SYSTEM

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E. CEREBELLAR SYSTEM

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F. GAIT EXAMINATION

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G. AUTONOMIC EXAMINATION

• Postural BP (lying → standing; drop >20 mmHg systolic = orthostatic hypotension)
• Bladder distension
• Sweating asymmetry (Homer's — ipsilateral anhidrosis)
• Horner's syndrome: Ptosis + Miosis + Anhidrosis + Enophthalmos (sympathetic chain)

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H. MENINGEAL SIGNS

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I. SPINE EXAMINATION (if cord/radiculopathy suspected)

• Straight leg raise (SLR): ° at which pain reproduces; Lasègue sign
• Femoral stretch test: L2–L4 roots
• Spinal tenderness / Para-spinal muscle spasm
• Percussion over vertebrae

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SECTION 12 — PROVISIONAL DIAGNOSIS

1. Which level? — Cortex / Subcortex / Brainstem / Cerebellum / Spinal cord / Peripheral nerve / Neuromuscular junction / Muscle
2. Which side? — Left / Right / Bilateral / Crossed (brainstem)
3. UMN vs LMN?
4. Single lesion vs multiple lesions?

1. ---

2. ---

3. ---

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SECTION 13 — INVESTIGATIONS

Routine

• CBC, ESR / CRP
• Blood glucose (RBS/FBS/HbA1c)
• Renal function tests, Electrolytes (Na, K, Ca, Mg)
• Liver function tests
• Lipid profile
• Thyroid function tests (TSH, T3, T4)
• Urine routine + microscopy

Neuroimaging

• CT Brain: Non-contrast first (haemorrhage, calcification); contrast (abscess, tumour)
• MRI Brain ± Spine: DWI (acute infarct), FLAIR (periventricular lesions), T1+Gad, MRA/MRV
• CT Angiography / MR Angiography: Vascular lesions

CSF Analysis (after ruling out raised ICP)

Electrophysiology

• EEG: Epilepsy, encephalopathy
• Nerve conduction studies (NCS) + EMG: Peripheral neuropathy, myopathy, NMJ disorder
• Visual/Brainstem/Somatosensory Evoked Potentials

Special Investigations (targeted)

• Serum B12, Folate, Thiamine
• VDRL/TPHA (neurosyphilis)
• HIV ELISA
• ANA, Anti-dsDNA, ANCA, Anti-phospholipid antibodies (vasculitis, lupus)
• Paraneoplastic antibodies (anti-Hu, anti-Yo, anti-NMDAR)
• Urine porphyrins
• Serum ceruloplasmin + 24h urine copper (Wilson's disease)
• Muscle enzymes: CPK, LDH, aldolase

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SECTION 14 — MANAGEMENT PLAN

• Airway, Breathing, Circulation
• GCS < 8 → Consider intubation
• Seizure → IV Lorazepam → Phenytoin loading

• Disease-specific treatment
• Supportive: IV fluids, nasogastric feeding if dysphagia, pressure sore prevention, DVT prophylaxis, catheterisation if retention

• Physiotherapy, Occupational therapy, Speech therapy
• Antiepileptic therapy, Antiplatelets/anticoagulants, Neuroprotection
• Bowel and bladder care
• Psychological support / Counselling

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SECTION 15 — PROGNOSIS & DISCUSSION

• Natural history of the condition
• Complications anticipated
• Disability assessment
• Discussion of case with supervisor
• Correlation of clinical features with investigations

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QUICK LOCALISATION GUIDE (Aide-mémoire)

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• Localise before diagnosing — always answer: which level, which side, UMN or LMN, single or multiple lesion
• Aura type guides temporal lobe localisation (rising epigastric = mesial temporal; elementary visual = occipital)
• Risk factors for epilepsy include febrile status epilepticus in infancy, early meningitis/encephalitis, and head trauma — all correlate with specific pathologies
• Meningeal signs must always be tested in headache + fever presentations
• CSF analysis after ruling out raised ICP via fundoscopy or neuroimaging

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GIT CASE SHEET — MEDICINE POSTINGS

Gastrointestinal System: Detailed History Taking & Examination Proforma

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SECTION 1 — PATIENT IDENTIFICATION

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SECTION 2 — CHIEF COMPLAINTS

1. _____________ — since ___________
2. _____________ — since ___________
3. _____________ — since ___________

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SECTION 3 — HISTORY OF PRESENTING ILLNESS

"History taking remains the most important component of the initial evaluation of the patient with acute abdominal pain. A large number, if not the majority, of acute abdominal conditions could be diagnosed by considering carefully the history of onset." — Sir Zachary Cope (cited in Sleisenger & Fordtran's GI and Liver Disease)

General Pointers

• Mode of onset: Sudden / Acute / Sub-acute / Chronic / Insidious
• Progression: Static / Progressive / Relapsing-remitting / Episodic
• Course: Improving / Worsening / Fluctuating

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A. ABDOMINAL PAIN (If present — SOCRATES)

Site

• Location and mark on abdomen diagram:

• RUQ: Cholecystitis, cholangitis, pancreatitis, hepatitis, Budd-Chiari, pneumonia
• Epigastric: PUD, GERD, pancreatitis, gastritis, MI (referred), ruptured aortic aneurysm
• LUQ: Splenic infarct/rupture/abscess, gastric ulcer, pancreatitis
• RLQ: Appendicitis, Meckel's diverticulum, Crohn's, right ureteric colic, ovarian pathology
• LLQ: Diverticulitis, colitis, left ureteric colic, sigmoid volvulus
• Periumbilical: Early appendicitis, mesenteric ischaemia, SBO

Onset

• Sudden ("thunderclap"/catastrophic): Perforated viscus, ruptured aneurysm, mesenteric ischaemia
• Acute (minutes–hours): Biliary/renal colic, pancreatitis, appendicitis
• Gradual: Subacute obstruction, neoplasm, inflammatory bowel disease

Character (Sleisenger & Fordtran)

Radiation

• Right shoulder tip / right scapula — biliary / diaphragmatic
• Mid-back / periscapular — pancreatitis
• Loin to groin — ureteric colic
• Interscapular — aortic dissection

Associated features

• Nausea / Vomiting (projectile vs non-projectile; content — bilious, blood, undigested food)
• Fever, rigors — infection (cholangitis, appendicitis, peritonitis)
• Jaundice — hepatobiliary
• Change in bowel habits
• Distension
• Haematemesis / Melaena / Haematochezia

Timing & duration

• Constant vs colicky (intermittent, crampy = hollow viscus obstruction)
• Duration of each episode
• Diurnal variation: Peptic ulcer — hunger pain / nocturnal pain

Severity (VAS 1–10)

• Effect on daily activity / sleep

Aggravating and Relieving factors

• Food: Pain worsened by eating → gastric ulcer, mesenteric ischaemia; Pain relieved by food/antacids → duodenal ulcer
• Posture: Leaning forward relieves pancreatitis pain
• Defaecation relieves — IBS, colonic pathology
• Menstrual cycle — endometriosis, ovarian pathology

Previous episodes

• Similar episodes in the past? Treatment received? Investigations done?

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B. DYSPHAGIA / ODYNOPHAGIA

"Patients almost invariably recognize accurately the locus and consequence of oropharyngeal dysphagia; they mistakenly identify the neck as the locus of bolus hang-up with esophageal dysphagia about 30% of the time." — Yamada's Textbook of Gastroenterology, 7th Ed.

Localisation

• Oropharyngeal dysphagia: Difficulty initiating swallow, coughing, choking, nasopharyngeal regurgitation, drooling, aspiration → Neurological/muscular cause (CVA, MND, myasthenia)
• Esophageal dysphagia: Sensation of food sticking after swallowing → Structural or motility disorder

Nature

• Solids only → progressing to liquids: Mechanical obstruction (carcinoma oesophagus, peptic stricture, Schatzki ring)
• Solids AND liquids from onset: Motility disorder (achalasia, oesophageal spasm)
• Liquids > Solids: Neuromuscular (oropharyngeal)
• Intermittent: Motility disorder, Schatzki ring
• Progressive: Carcinoma (red flag)

Associated symptoms

• Odynophagia (painful swallowing): Oesophageal ulcer, infective oesophagitis (Candida, CMV, HSV), eosinophilic oesophagitis
• Regurgitation of undigested food: Pharyngeal pouch (Zenker's diverticulum), achalasia
• Heartburn / Acid reflux (GERD → peptic stricture)
• Weight loss (malignancy — red flag)
• Hoarseness (recurrent laryngeal nerve involvement by tumour)
• Hiccups (diaphragmatic/mediastinal involvement)
• Respiratory symptoms: Aspiration pneumonia, nocturnal cough

Globus Sensation

• Painless lump/foreign body sensation in throat between meals (unlike dysphagia which occurs only during swallowing)
• Associated with GERD, motility disorder, anxiety

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C. HEARTBURN / GASTRO-OESOPHAGEAL REFLUX

• Burning sensation: Retrosternal / epigastric, radiating upward to throat / mouth
• Timing: Post-prandial, on bending forward, on lying down, nocturnal
• Aggravated by: Fatty food, chocolate, coffee, alcohol, smoking, NSAIDs, large meals
• Relieved by: Antacids, sitting up, water
• Regurgitation: Sour / bitter fluid, "water brash" (excess salivation)
• Chronic cough, hoarseness, throat clearing (extra-oesophageal GERD)
• Dysphagia superimposed: Suggests peptic stricture or Barrett's (red flag)

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D. NAUSEA AND VOMITING

• Onset: Sudden vs gradual
• Timing: Morning (pregnancy, alcoholic gastritis, raised ICP), post-prandial (pyloric obstruction), projective
• Content:
  • Undigested food: Oesophageal/gastric cause
  • Partially digested + bile: Duodenal/intestinal
  • Faeculant (faecal smell): Low intestinal obstruction
  • Blood (haematemesis): See below
• Volume and frequency
• Relationship to pain: Vomiting relieves pain of SBO; does not relieve pancreatitis/appendicitis
• Associated features: Vertigo (labyrinthine), headache/photophobia (migraine), diarrhoea (gastroenteritis)
• Dehydration assessment: Thirst, decreased urine output, sunken eyes

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E. HAEMATEMESIS AND MELAENA (Upper GI Bleed)

• Haematemesis: Vomiting of blood
  • Fresh red blood: Active arterial bleed (varices, Mallory-Weiss tear)
  • Coffee-ground material: Altered blood (PUD, gastric erosions)
• Melaena: Black, tarry, offensive-smelling stools — blood from proximal GIT (>50 mL)
• Haematochezia: Bright red blood per rectum (LGIB or massive UGIB)

History for UGI Bleed:

• Peptic ulcer: Previous PUD history, NSAIDs use, aspirin, steroids, H. pylori (dyspepsia, epigastric pain)
• Varices: Liver disease history (alcohol, hepatitis, jaundice, previous variceal bleed, cirrhosis)
• Mallory-Weiss tear: Forceful vomiting preceding haematemesis
• Malignancy: Weight loss, anorexia, dysphagia
• Anticoagulants / Antiplatelets: Warfarin, aspirin, clopidogrel, NSAIDs
• Quantity of blood: Teaspoon / Cup / Bowl estimate; associated dizziness/syncope (haemodynamic compromise)
• Previous similar episodes

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F. HAEMATOCHEZIA / RECTAL BLEEDING (Lower GI Bleed)

• Nature of blood:
  • Blood mixed with stool: Colonic source (carcinoma, IBD, diverticular)
  • Blood on surface of stool / on toilet paper: Anorectal (haemorrhoids, fissure)
  • Blood separate from stool: Polyp, angiodysplasia
  • Mucus + blood: IBD (ulcerative colitis), infective colitis, carcinoma
• Associated features: Tenesmus, urgency, change in bowel habit, weight loss
• Anal symptoms: Pain on defaecation (fissure), prolapse, pruritus ani

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G. DIARRHOEA

• Duration: Acute (<2 weeks) vs Chronic (>4 weeks)
• Stool characteristics:
  • Watery (large volume, no blood): Secretory/osmotic, small intestinal origin
  • Bloody (small volume + mucus + urgency): Inflammatory, large intestinal origin
  • Fatty / Oily / Frothy / Foul-smelling (floats): Steatorrhoea — malabsorption
  • Pale/clay-coloured: Obstructive jaundice / Exocrine pancreatic insufficiency
• Frequency (per day) and volume per episode
• Nocturnal diarrhoea: Organic (IBD, diabetic autonomic neuropathy) — rules out IBS
• Associated symptoms: Abdominal cramps, urgency, tenesmus, fever, weight loss
• Food history: Dietary triggers (osmotic); onset after specific meal (infective)
• Contact history / Travel history: Infective gastroenteritis, tropical sprue
• ETOH use: Alcoholic pancreatitis, exocrine insufficiency
• Medications: Antibiotics (C. difficile), metformin, laxatives, PPI

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H. CONSTIPATION

• Definition: <3 stools/week or hard/straining/incomplete evacuation
• Duration: Acute (obstruction, colonic carcinoma) vs Chronic (IBS, functional)
• Onset: Sudden change (red flag — colonic malignancy)
• Stool calibre: Ribbon-like (rectal carcinoma)
• Associated symptoms: Bloating, abdominal distension, overflow diarrhoea
• Straining, incomplete evacuation, manual disimpaction required
• Rectal bleeding / Mucus: Carcinoma, solitary rectal ulcer
• Systemic causes: Hypothyroidism, hypercalcaemia, Parkinson's, opiate use, anticholinergics
• Dietary: Low fibre intake, inadequate fluids
• Alternating constipation and diarrhoea: IBS, carcinoma of colon

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I. JAUNDICE

• Onset: Sudden vs gradual
• Duration
• Type by history:

• Dark urine (cola/tea-coloured): Conjugated bilirubin — hepatic or post-hepatic
• Pale/clay stools: Obstruction of biliary outflow
• Pruritus: Bile salt deposition in skin (cholestasis)
• Risk factors:
  • Viral hepatitis: Contaminated food/water (HAV, HEV), blood/sexual exposure (HBV, HCV, HDV)
  • Alcohol history (alcoholic hepatitis)
  • Blood transfusions, IV drug use, tattoos, unprotected sexual intercourse
  • Travel to endemic area
  • Family history of liver disease / jaundice
  • Medications (paracetamol, isoniazid, rifampicin, statins, oral contraceptives)
  • Auto-immune history

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J. ASCITES / ABDOMINAL DISTENSION

• Duration and progression
• Associated features: Bilateral leg oedema, breathlessness (large ascites / hepatic hydrothorax), scrotal oedema
• Causes by history:
  • Cirrhosis: Alcohol, viral hepatitis, NASH — previous liver disease, jaundice, haematemesis
  • Malignancy: Wasting, prior cancer, lymphadenopathy
  • Cardiac: Bilateral oedema, exertional dyspnoea, orthopnoea (congestive heart failure)
  • Renal: Frothy urine, facial puffiness, nephrotic syndrome
  • Tuberculosis: Fever, night sweats, weight loss, cough, contact
• SAAG (Serum-Ascites Albumin Gradient): ≥1.1 g/dL = portal hypertension related

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K. WEIGHT LOSS AND ANOREXIA

• Quantity and time period: kg lost over months
• Unintentional vs intentional
• Appetite: Decreased (malignancy, malabsorption, depression) vs maintained (malabsorption, hyperthyroidism)
• Food intake: Change in dietary habits
• Associated symptoms: Diarrhoea (malabsorption), dysphagia (oesophageal Ca), jaundice (pancreatic Ca), night sweats, fever (malignancy, TB)
• RED FLAGS for GI malignancy:
  • Age >50, unintentional weight loss, progressive dysphagia
  • Haematemesis, melaena, haematochezia
  • Persistent vomiting, iron-deficiency anaemia
  • Palpable mass, organomegaly
  • New onset dyspepsia in >55 years

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L. DYSPEPSIA AND PEPTIC ULCER DISEASE

• Epigastric pain / discomfort:
  • Duodenal ulcer: Hunger pain 2–4 hours post-meal, relieved by food/antacids, nocturnal pain (2–4 AM)
  • Gastric ulcer: Pain immediately/shortly after eating, not relieved by food
• Bloating, early satiety (delayed gastric emptying)
• NSAID/aspirin use: Dose, duration, with or without food
• H. pylori risk: Socioeconomic status, household contacts with peptic ulcer
• Alcohol and smoking: Impair mucosal defence
• Acid regurgitation, belching

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SECTION 4 — PAST HISTORY

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SECTION 5 — FAMILY HISTORY

• Peptic ulcer disease / H. pylori infection
• Colorectal carcinoma (first-degree relative <50 years — FAP, HNPCC/Lynch syndrome)
• Inflammatory bowel disease (genetic predisposition)
• Pancreatitis (hereditary)
• Viral hepatitis (HBV — vertical transmission)
• Liver disease, cirrhosis
• Coeliac disease (HLA-DQ2/DQ8 association)
• Polyp syndromes (FAP, Peutz-Jeghers, juvenile polyposis)
• Haemochromatosis, Wilson's disease (autosomal recessive)

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SECTION 6 — PERSONAL HISTORY

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SECTION 7 — TREATMENT HISTORY

• Current medications (NSAIDs, aspirin, steroids, antibiotics, PPIs, anticoagulants, immunosuppressants)
• Hepatotoxic drugs (paracetamol, isoniazid, rifampicin, methotrexate, statins, OCPs)
• Previous endoscopy / colonoscopy results
• Prior surgeries and outcomes
• Traditional / Herbal medicines (hepatotoxic)

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SECTION 8 — MENSTRUAL HISTORY (Females)

• Last menstrual period (LMP) — rule out ectopic pregnancy in RLQ/LLQ pain
• Cycle regularity
• Dysmenorrhoea / Dyspareunia — endometriosis
• Amenorrhoea — pregnancy, ovarian cyst torsion
• Vaginal discharge / Pelvic inflammatory disease

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SECTION 9 — GENERAL PHYSICAL EXAMINATION

Vitals

General Examination

• Built and nourishment: Wasted (malignancy, malabsorption, IBD, cirrhosis) / Obese (NAFLD, gallstones)
• Pallor: Iron deficiency anaemia (chronic GI blood loss), haemolysis (haemolytic jaundice)
• Icterus / Jaundice: Scleral icterus (earliest sign at bilirubin >2.5 mg/dL)
• Clubbing: Liver cirrhosis, Crohn's disease, GI lymphoma, coeliac disease
• Leukonychia (white nails): Hypoalbuminaemia (cirrhosis)
• Palmar erythema: Liver disease, pregnancy
• Dupuytren's contracture: Alcoholic liver disease
• Spider naevi (>5 = pathological): Liver disease; look in SVC drainage area (face, neck, chest, arms)
• Parotid enlargement: Alcoholism
• Gynaecomastia / Testicular atrophy: Cirrhosis (hyperoestrogenaemia)
• Asterixis (liver flap / flapping tremor): Hepatic encephalopathy — ask patient to dorsiflex wrists for 15 seconds
• Lymphadenopathy:
  • Virchow's node (left supraclavicular) — gastric carcinoma (Troisier's sign)
  • Periumbilical — Sister Mary Joseph nodule (intra-abdominal malignancy)
  • Axillary — Irish's node (gastric carcinoma)
• Peripheral oedema: Bilateral pitting — hypoalbuminaemia (cirrhosis, malabsorption, nephrotic syndrome), CCF
• Skin:
  • Jaundice
  • Scratch marks (pruritus of cholestasis)
  • Xanthelasma / Xanthomata (primary biliary cholangitis, hyperlipidaemia)
  • Erythema nodosum / Pyoderma gangrenosum (IBD)
  • Dermatitis herpetiformis (coeliac disease)
  • Peutz-Jeghers pigmentation (perioral, buccal mucosa, digits)
  • Acanthosis nigricans (GI malignancy, insulin resistance)
  • Bronze pigmentation (haemochromatosis)
  • Kayser-Fleischer rings in eyes (Wilson's disease)
• Fetor hepaticus: Sweet musty breath (liver failure / portosystemic shunting)

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SECTION 10 — ABDOMINAL EXAMINATION

Surface Anatomy Reference

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INSPECTION

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PALPATION

Superficial Palpation

• Guarding (voluntary / involuntary)
• Rigidity (board-like = perforated viscus / peritonitis)
• Tenderness: Site, severity, local vs diffuse

Deep Palpation

• Masses: Site, size, shape, surface, consistency, margins, mobility, pulsatility, tenderness, plane
• Hepatomegaly (see below)
• Splenomegaly (see below)

LIVER EXAMINATION

• Technique: Start from RIF, move towards RUQ; percuss upper border first
• Size: Span (normal <12.5 cm in MCL); measure in cm below costal margin at MCL
• Surface: Smooth (hepatitis, CCF, fatty liver) / Nodular (cirrhosis, metastases)
• Consistency: Soft / Firm / Hard
• Tenderness: Tender — hepatitis, CCF, acute amoebic abscess; Non-tender — cirrhosis, malignancy
• Edge: Rounded (CCF, fatty liver) / Sharp and firm (cirrhosis)
• Pulsatility: Pulsatile — tricuspid regurgitation
• Hepatic rub: Hepatocellular carcinoma over the surface

SPLENOMEGALY EXAMINATION

• Technique: Start from RIF, move to LUQ; cannot "get above it"; moves with respiration; notch medially; dull on percussion; not ballottable
• Grades:
  • Grade I (mild): Palpable only on deep inspiration
  • Grade II (moderate): Extends to umbilical line
  • Grade III (massive): Below umbilicus / to RIF (malaria, myelofibrosis, CML, kala-azar, Gaucher's)

KIDNEY / RENAL EXAMINATION

• Ballottement: Place one hand behind loin (posteriorly), push upward; palpate anteriorly
• Distinguishing kidney from spleen: Ballottable, no notch, resonant on percussion (gas-filled bowel anterior), can get above it

ASCITES EXAMINATION

• Shifting dullness: Percuss from umbilicus to flank until dull → keep finger there → roll patient 45° away → re-percuss (becomes resonant if shifting = ascites ≥1.5 L)
• Fluid thrill: One hand on flank, flick opposite flank — felt if large ascites (place other hand/assistant's hand on midline to damp transmission through fat)
• Dipping (ballottement): Large ascites — quick, jabbing palpation to feel organ through fluid

SPECIAL SIGNS

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PERCUSSION

• General percussion: Dullness (organomegaly, mass, ascites) / Resonance (gas-filled bowel)
• Liver dullness: Upper border (5th IC space MCL) to lower border
• Traube's space: 6th rib above, MAL laterally, costal margin below — normally resonant (gastric air bubble); Dull = splenomegaly / pleural effusion
• Bladder: Suprapubic dullness (retention)

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AUSCULTATION

• Bowel sounds:
  • Normal: 5–10/min, low-pitched
  • Increased (high-pitched, tinkling): Intestinal obstruction ("borborygmi")
  • Absent (silent abdomen): Paralytic ileus, peritonitis
• Succussion splash: Large fluid-gas level in stomach — pyloric stenosis / gastric outlet obstruction (>4 hours post-meal)
• Bruits:
  • Epigastric: Renal artery stenosis (renovascular hypertension), aortic aneurysm
  • Hepatic bruit: Hepatocellular carcinoma, hepatic AVM, alcoholic hepatitis
  • Splenic friction rub: Splenic infarct, perisplenitis

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RECTAL EXAMINATION (PR)

• Inspection: Haemorrhoids (grade), fistula, fissure, skin tags, condylomata
• Tone: Reduced (spinal cord lesion), increased (fissure)
• Contents: Faecal impaction, blood (glove)
• Masses: Rectal carcinoma (shelf of rock-hard tissue), polyp
• Prostate (males): Size, surface, consistency, median sulcus
• Uterus / Cervix (females)
• Pelvic peritoneum: Boggy, tender (pelvic abscess — "pelvic peritonitis to feel by PR")
• After PR — inspect glove: Blood / Melaena / Mucus / Pale stools / Pus

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SECTION 11 — SYSTEMIC EXAMINATION

Cardiovascular:

• AF (mesenteric ischaemia, portal vein thrombosis)
• Murmurs (carcinoid — pulmonary/tricuspid)
• JVP elevation (congestive hepatopathy)

Respiratory:

• Pleural effusion (pancreatitis — left side; massive ascites — hepatic hydrothorax)
• Consolidation (aspiration, pneumonia mimicking acute abdomen)
• Lung metastases (colonic carcinoma)

Musculoskeletal:

• Arthritis (IBD — enteropathic arthritis; Whipple's disease; reactive arthritis)
• Clubbing (IBD, cirrhosis)

Neurological:

• Hepatic encephalopathy: Asterixis, altered GCS, fetor hepaticus
• Peripheral neuropathy: Vitamin B12/B1 deficiency (malabsorption, alcoholism)
• Proximal myopathy: IBD, malabsorption (Vitamin D)

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SECTION 12 — PROVISIONAL DIAGNOSIS & DIFFERENTIAL DIAGNOSIS

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SECTION 13 — INVESTIGATIONS

Routine Blood Tests

• CBC (anaemia, leucocytosis, thrombocytopenia in hypersplenism)
• ESR / CRP (inflammation, IBD, malignancy)
• Blood glucose, HbA1c (diabetes → gastroparesis, NAFLD)
• LFTs: Total/direct/indirect bilirubin, AST, ALT, ALP, GGT, total protein, albumin
• Renal function tests + electrolytes (dehydration, hepatorenal syndrome, prerenal AKI)
• Coagulation: PT, INR (liver synthetic function)
• Amylase / Lipase (pancreatitis — lipase more specific)
• Lipid profile (gallstones, NAFLD)
• Thyroid function tests (TSH — constipation/diarrhoea)

Liver Disease Panel

• Hepatitis B surface antigen (HBsAg), Anti-HBs, Anti-HBc (IgM/IgG), HBeAg
• Anti-HCV antibody + HCV RNA (PCR)
• Anti-HAV IgM / Anti-HEV IgM
• Serum ferritin + transferrin saturation (haemochromatosis)
• Serum ceruloplasmin + 24h urine copper (Wilson's disease)
• ANA, Anti-smooth muscle antibody (ASMA), AMA (autoimmune hepatitis / PBC)
• AFP (alpha-fetoprotein) — HCC screening
• Child-Pugh score + MELD score (cirrhosis staging)

Stool Examination

• Routine: Colour, consistency, mucus, blood, parasites
• Microscopy: Ova, cysts, trophozoites, fat globules (malabsorption)
• Culture + sensitivity
• C. difficile toxin (pseudomembranous colitis)
• Faecal occult blood (FOBT) — colon cancer screening
• Faecal calprotectin (IBD vs IBS — elevated in IBD)
• Sudan staining for fat (steatorrhoea)

Urine

• Bilirubin (conjugated jaundice)
• Urobilinogen (absent in complete obstruction; increased in haemolysis/hepatitis)

Radiology

• X-ray Abdomen (Erect + Supine):
  • Air under diaphragm (erect) — perforated viscus
  • Dilated bowel loops + air-fluid levels — obstruction (SBO vs LBO)
  • Gallstones (10% radio-opaque), renal calculi, pancreatic calcification
  • Absent psoas shadow (retroperitoneal pathology)
• Ultrasound Abdomen:
  • Gallstones, biliary dilatation (CBD >6 mm)
  • Liver: Size, echogenicity, nodularity, portal vein diameter (>13 mm = PH)
  • Spleen size, ascites (free fluid), lymph nodes, masses
  • Pancreas
• CT Abdomen with contrast:
  • Pancreatitis severity (Balthazar score)
  • Abdominal mass characterisation
  • IBD extent (Crohn's complications — fistulae, abscess)
  • Staging of GI malignancy
• MRI / MRCP: Biliary and pancreatic ductal anatomy (choledocholithiasis, PSC, chronic pancreatitis)
• CECT/Angiography: GI bleed localisation, mesenteric ischaemia

Endoscopy

• Upper GI Endoscopy (OGD): Oesophageal varices, PUD, gastric Ca, oesophageal Ca, GERD, mucosal biopsy
• Colonoscopy: IBD, CRC screening, polyps, diverticular disease, biopsy
• Flexible Sigmoidoscopy: Distal colonic pathology
• ERCP: Therapeutic: Stone removal, stenting; Diagnostic: Biliary/pancreatic ductal disease
• Endoscopic Ultrasound (EUS): Pancreatic masses, submucosal lesions, biliary pathology

Special Investigations (targeted)

Ascitic Fluid Analysis

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SECTION 14 — MANAGEMENT PLAN

• Haemodynamic resuscitation: IV access (2 large bore) → IV fluids / blood products
• NBM in GI bleed / surgical abdomen
• IV PPI (omeprazole/pantoprazole) in UGIB
• Endoscopy (urgent OGD within 24h in UGIB)
• Surgical consult if: Peritonitis, perforation, obstruction

• Disease-specific: Antibiotics (cholangitis, SBP, infective colitis), antivirals (hepatitis B/C), immunosuppressants (IBD), PPIs (H. pylori triple therapy)
• Nutritional support: High-protein diet (unless hepatic encephalopathy), vitamins
• Alcohol cessation (counselling, thiamine, benzodiazepines for withdrawal)
• Diuretics (spironolactone + frusemide for ascites)
• Beta-blockers (propranolol — variceal prophylaxis)

• Surveillance endoscopy (Barrett's, varices, cirrhosis — HCC screening USG 6-monthly + AFP)
• Colonoscopy surveillance (IBD, CRC after polyp removal)
• Dietary modifications (low-salt for ascites, high-fibre for constipation, gluten-free for coeliac)
• Rehabilitation (alcohol, nutritional)

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SECTION 15 — PROGNOSIS & DISCUSSION

• Natural history of the condition
• Complications anticipated
• Scoring systems used (Child-Pugh, MELD, Ranson's/APACHE for pancreatitis, Harvey-Bradshaw for Crohn's, Mayo score for UC)
• Correlation of clinical findings with investigations
• Discussion with supervisor

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QUICK LOCALISATION & DIAGNOSIS GUIDE

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• "The history is the most important part" — Sir Zachary Cope's dictum still holds for acute abdomen
• Always check SAAG in ascites (≥1.1 = portal hypertension related)
• Courvoisier's Law: Palpable painless GB with jaundice = NOT gallstones = malignancy
• Melaena vs Haematochezia: Melaena = upper GI source; fresh red blood (haematochezia) in massive UGIB can also occur
• Red flags in GI: Age >50, weight loss, progressive dysphagia, rectal bleeding, new-onset dyspepsia >55 years, palpable mass, iron-deficiency anaemia — warrant urgent investigation
• In jaundice, always check for stigmata of chronic liver disease before ascribing a cause
• Child-Pugh score (bilirubin, albumin, INR, ascites, encephalopathy) — classify cirrhosis A/B/C