Microsoft PowerPoint - e10 abdominal emergency-1_20151215.ppt []4.
History
History of Present illness Family History Past Medical history Operation history History of drugs taken or Medication eg.
ingestion of certain toxic drugs or Alcohol intake
PAIN The Most Important Symptom
Characteristics of abdominal pain 1. Site 2. Onset – time and mode 3. Severity 4. Nature – colicky, spasm, gripping, dull, vague, sharp,
knife-cut, throbbing, etc. 5. Progression or change of pain – persistent, gradually
improve or worsen, fluctuate, etc. 6. Duration 7. Radiation 8. Movement of pain 9. Aggravating or relieving factors 10. Associated symptoms – bowel or urinary, etc.
Onset of Pain Sudden onset pain which wakes the patient from sleep
eg. perforation or strangulation of bowel Slow insidious Onset
a. Inflammation of visceral peritoneum. b. Contained process such as evolving abscess.
Crampy or colicky pain Biliary colic, Ureteric colic or Intestinal colic
Progression of Pain
To: Sharp, constant & better localized pain indicates involvement of Parietal peritoneum
Associated Symptoms CONSTIPATION
a. Progressive intestinal obstruction from a neoplasm or inflammatory bowel disease
b. Paralytic Ileus c. Post Operative d. Obstructed groin hernia
Associated Symptoms
DIARRHEA Diarrhea with pain is mainly medical. The following are the exceptions:
a. Obstructed Richter's Hernia b. Gall Stone ileus c. Superior mesenteric vascular occlusion d. Intestinal Obstruction associated with
pelvic abscess e. Spurious diarrhea in chronic faecal
impaction
Corticosteroids – mask pain Anticoagulants – can lead to an intramural
haematoma of the gut causing obstruction Oral Contraceptives - rupture of hepatic
adenomas NSAIDs - erosive gastritis & peptic ulcers
NAUSEA & VOMITING
projectile, non-projectile or self-induced (iii) Nature of vomiting: a. Bilious vomiting of small bowel obstruction b. Non-bilious vomiting in obstruction proximal to
ampulla of Vater c. Faeculent vomiting in distal small gut obstruction, large bowel
obstruction , strangulation
NAUSEA & VOMITING
Pain first, followed by Vomiting is usually surgical. The vomiting is due to ‘reflex pylorospasm’ Nausea & vomiting first , followed by pain
is usually due to a medical condition
Vomiting (cont.)
Vomiting is very prominent in a. Mallory-Weiss syndrome. b. Boerhaave syndrome(trans- mural esophageal tear) c. Acute gastritis d. Acute pancreatitis
ANOREXIA
Anorexia or decreased appetite with pain is usually seen in Acute appendicitis
Urinary Symptoms with Pain
adhesions
Past Medical history: Sickle cell disease, Diabetes or Cancer or Renal failure
Menstrual History in females (i) Missed period- ectopic pregnancy (ii) Mid of period-ovulation pain (Mittel- schmerz) (iii) With heavy periods- endometriosis
Family history of colon cancer, any other malignancy or inflammatory bowel disease
Physical Examination General Appearance
a. Anxious Patient lying motionless: (i) Acute appendicitis (ii) Peritonitis
b. Rolling in bed & restless: (i) Ureteric Colic (ii) Intestinal colic
c. Writhing in Pain: Mesenteric Ischemia
Physical Examination (cont.)
e. Jaundiced: CBD obstruction
Physical Examination (cont.)
Vital Charting Temperature, Pulse, BP, Respiratory rate Ruptured AAA or ectopic pregnancy can lead
to -Pallor -Hypotension -Tachycardia -Tachypnea
Physical Examination (cont.)
High grade temp. is seen with - Salpingitis - Abscess
Very High Grade Temp.with increasing lethargy seen in imminent septic shock
- Peritonitis - Acute cholangitis - Pyonephrosis
Systemic Examination
Per Abdomen: Inspection
- Scaphoid or flat in peptic ulcer - Distended in ascites or intestinal
obstruction - Visible peristalsis in a thin or malnourished
patient (with obstruction)
Systemic Examination
Erythema or discolouration a. Peri-umbilical - Cullen sign b. Inguinal – Fox sign c. Flanks - Grey Turner sign
Seen in Hemorrhagic pancreatitis or any other cause of haemoperitoneum
Any Visible masses Any visible cough impulse at hernia site
Systemic Examination Per abdomen:
Palpation Be gentle Start away from site of pathology then towards Check for Hernia sites Tenderness Rebound tenderness Guarding- involuntary spasm of muscles during palpation Rigidity- when abdominal muscles are tense & board-
like. Indicates peritonitis.
Systemic Examination Local Right Iliac Fossa tenderness:
a. Acute appendicitis b. Acute Salpingitis in females c. Amoebiasis of Caecum
Low grade, poorly localized tenderness: Intestinal Obstruction
Tenderness out of proportion to examination: a. Mesenteric Ischemia b. Acute Pancreatitis
Flank Tenderness: a. Perinephric Abscess b. Retrocaecal Appendicitis
Systemic Examination
Rovsing’s Sign in Acute Appendicitis Obturator Sign in Pelvic Appendicitis Psoas Sign
- Retrocaecal appendicitis - Crohn’s Disease - Perinephric Abscess Dunphy’s sign in acute appendicitis
Systemic Examination
Murphy's sign in Acute Cholecystitis Boas’ sign – pain radiates to tip of right scapula
with hyperaesthesia Thumping tenderness over lower ribs in
inflammation of -Diaphragm - liver or spleen
Systemic Examination
Leaking AAA Cutaneous Hyperaesthesia indicates involvement of Parietal Peritoneum
Systemic Examination
Per Rectal Examination: - tenderness - induration - mass (Blumer’s shelf) - frank blood
Systemic Examination
INVESTIGATIONS
Radiology
Upright X ray chest for - Basal Pneumonia - Ruptured Oesophagus - Elevated Hemi diaphragm - Free Gas under diaphragm
Radiology Abdominal X ray film
- Air-Fluid Levels - Stones - Ascites - Eggshell calcification in AAA - Air in Biliary tree. - Obliteration of Psoas Shadow in retro- peritoneal
disease - Right lower quadrant sentinel loops in acute appendicitis
INVESTIGATIONS