Professional Documents
Culture Documents
which arises from acute critical condition in the abdominal cavity, and usually manifests as pain.
Acute abdominal pain: Chief complaint: acute pain
Why is it important ?
Patient with acute abdomen:
Sudden onset Unknown etiology (not clear) Need immediate diagnosis & treatment
Perforated viscus
Infection Bleeding Sepsis
Peritonitis
Shock
Ischaemia Perforation
HISTORY Patient perception of symptoms Patient description of symptoms Physician perception Physician interpretation of symptoms
LABORATORY FINDINGS
SYNTHESIS RECORDING
PHYSICAL EXAM
DECISION
History Taking
60 - 80% of accurate diagnosis arises from good &
History Taking
May confirm :
Suspected
History Taking
Introduction
Greet the patient, and develop a warm and helpful environment Introduce yourself to the patient
Patient Identity
Ask the patient politely concerning his/her :
name age Record the gender : Male Female Ask the marital status of the patient (especially for female)
Acute appendicitis
In the elderly
During pregnancy
Chief complaint:
PAIN
Duration
Site at present
Progression
Severity
Aggravating /relieving factors
Site of pain
Pancreatitis
Early Appendicitis Hepatitis or liver abscess Extra abdominal:
Inferior Pleuritis, lobar pneumonia, pneumothorax Pericarditis, Myocardial infarction, angina Pyelonephritis, renal colic
Pancreatitis
Gastroenteritis Mesenterial Emboli /Thrombosis Dissecting aortic aneurism Mesenteric adenitis Early sigmoid diverticulitis
Mesenteric adenitis
Diverticulitis Ruptured tubo-ovarial abscess Tuboovarial Torsion Ectopic gestation
Onset of pain
Sudden onset
Onset of pain
Gradual pain
Type of pain
early stage.
Menstrual function Delayed or miss period Abnormal bleeding or discharge (colour, quantity)
Previous history
Similar pain Abdominal surgery Major illness: incl. fever, abdominal
PHYSICAL EXAMINATION
Preparation
Check all the equipment required and have a good light: Examination couch Stethoscope Explain the procedure and its goals to the patient. Wash your hands with antiseptic soap. Dry and warm your hands with tissues.
Implementation:
A General Examination
General
appearance : Consciousness Mood : Distressed? Anxious? Immobile Move cautiously Colour : Pallor? Flushing? Jaundice? Cyanosis?
Implementation:
Examine the vital signs:
Temperature Pulse
Implementation:
Perform other systems examination, including
cardio-pulmonary system.
Ask the patient politely to expose his/her
abdomen.
Abdominal Examination:
Inspection
Inspect the movement: Respiratory movement Visible bowel peristaltics Is there any scars on the skin of the abdomen? Is there any abdominal distention? Flatus ? , Fluid ? , Fetus?
Abdominal Examination:
Inspection
Cullens sign Gray Turners sign Ecchymosis of the abdominal wall Is there any masses: Tumors? Hernial sites? Masses with pulsation?
Cullen Sign
Gray-Turner Sign
gently palpate the abdomen, starting from a site farthest from the area of maximum pain, move gradually towards it.
While palpating, look to the face expression of the patient, and look for any signs of :
While palpating, look to the face expression of the patient, and look for any signs of :
Swelling
Expansile pulsation
Specific signs
Rovsings sign Obturator sign
Psoas sign
abdomen, and gently percus its dorsal aspect with the tip of the middle finger of the right hand, moving all around the abdominal region: Is it tymphanitic ? Is it dull ? Is there any shifting dullness? Site of liver dullness ? and is it disappeared ?
Auscultation
Using stethoscope, and place it gently on the
abdomen, listen to the bowel sounds and bruit at least for one minute: Absent ? High pitched and hyperactive ? Metallic sound ? Vascular bruit ?
gloves and ask the patient to expose his/her buttock and anus, and place the patient in lithotomy position.Apply lubricating jelly on to the right index finger.
toward the anal canal slowly, and evaluate the followings: Anal margin: piles? Mucosal surface of the anal canal and the ampulla (collaps?) Sites of any pain elicited Masses or swelling: consistency, location, surface, fixity to the surroundings. Bowel contents: consistency of faeces? Mucus? Blood?
Write up all significant findings in the medical record. Conclude your diagnosis and differential diagnosis, and order any necessary special investigations
Acute peritonitis
Patology
(Lowenfels, 1975)
Mild
blood Urine bile
pus
Pancreatic juice Bowel bontent Gastric juice Severe
Abdominal pain
Peritoneal signs Signs of dehydration Leucositosis Shock, Multiple organ failure
Tips
> 6 hours: surgically related diseases !!!
Sense of Crisis
Repeated exams : Very important
GI bleeding
Pancreatitis
Acute appendicitis
Intusucseption
Sigmoid volvulus
Mesenteric thrombosis
Ruptured organ
Content
Pus Materials : sebum meconeum
Blood
Acute abdomen
ischaemia
Strangulation
distention
torsion
A Good Diagnostician
is not Born,
but is Developed