Abdo Flashcards
Please examine this lady
Hello my name is Lydia I’m a final year medical student Can I check your full name and date of birth please?
WASH HANDS
I’ve been asked to examine you today, this will involve me looking at your hands, face and examining your tummy, would that be ok?
Are you in any pain at the moment?
Great, if you could lie on the bed for me.
Would you be ok to pull your top up and roll your trousers down slightly (I’d ideally expose the patient from nipple to knees)
I’ll have a look at the hands and the nails
In the nails I am looking for clubbing, leukonychia, koilonychia
In the hands I am looking for palmar erythema, dupuytren’s contracture
If you could put your arms out in front of you, cock your wrists back and close your eyes
I’ll have a feel of the pulse
I’d like to take a BP measurement
If I could look at your eyes, could you pull the lower lids down for me? (looking for conjunctival pallor, scleral jaundice)
I’d ideally examine the mouth for ulcers, stomatitis and glossitis
Would you be able to sit up and forward for me, I’ll have a feel of the glands in the neck.
Ok I’d like to examine your chest and abdomen now, would you mind removing your top. Are you happy to lie flat?
Looking first at the chest, could you lift your arms up like this for me? (spider naevi, gynaecomastia, acanthosis nigricans)
Looking at the tummy (distension, scars, striae, stomas)
I’m going to press lightly on your tummy now, tell me if you have any pain
Ok I’m going to press a bit harder this time
Take some deep breaths in and out for me LIVER SPLEEN AAA Renal angle tenderness
I'm going to have a tap on your tummy LIVER SPLEEN BLADDER ASCITES Could you turn onto your right side for me? That's fine, turn back for me
And I’ll have a quick listen
To finish up I’m just going to feel the lower legs, any pain there?
Ok that’s all from me, thank you for your time. Do you need any help getting redressed? Ok thank you again.
After the patient had recovered i would consider a delayed colonoscopy
Please present your examination
I performed a abdominal exam on this elderly lady. On initial inspection the patient was alert and there were no signs of respiratory distress. The pulse was regular at x bpm. There were no stigmata of gastrointestinal disease in the eyes and I would like to inspect the hands and mouth.There were no signs on the chest or abdomen. There was tenderness on light and deep palpation in the RLQ (with no rebound tenderness and negative Rovsing sign), otherwise the abdomen was soft and nontender with no organomegaly, masses or ascites. Bowel sounds were present with no detectable bruits. There was no cervical lymphadenopathy and no peripheral oedema.
In summary this was a normal abdominal exam/is a patient with RLQ tenderness and a soft abdomen.
For completeness I would ideally examine the hernial orifices, the external genitalia, and perform a DRE exam.
My top differential would be x I would also consider xyz
I would investigate this patient with bedside tests, bloods, imaging.
Bedside - urine dip, +/- stool sample
Bloods - FBC, U&Es, LFTs, clotting, amylase, VBG for lactate
To manage this patient I would take an A to E approach including IV fluids, analgesia and antibiotics.
Imaging - After consulting with my senior I would consider advanced imaging such as CT abdo pelvis.
What would your differentials be for this patient with RLQ pain?
Causes of RLQ pain include inflammation, infection and malignancy. A common cause is appendicitis, and I would also consider ruptured ectopic, ovarian torsion, terminal ileitis.
To investigate I would like to start with bedside tests such as urine for dipstick and bHCG (+a stool sample). I would also take bloods for to look for signs of inflammation or infection (FBC, U&Es, CRP, LFTs, clotting, G&S, amylase, VBG). For imaging I would consider an USS and discuss with a senior the role of further tests i.e. CTAP
What’s your approach to appendicitis?
Appendicitis most commonly presents with Murphy’s triad of nausea and vomiting, low-grade fever and RIF pain and is a clinical diagnosis.
I would initially manage the patient with a A to E approach, and follow hospital protocol for suspected appendicitis including IV fluids, analgesia, keeping the pt NBM and referral to the general surgeons for laparoscopic appendectomy. Surgery can be delayed in favour of antibiotics and active observation.
Complications include perforation and abscess formation in delayed presentations, as well as bleeding and surgical wound infection.
What’s your approach to diverticulitis?
Diverticulitis is complication of diverticulosis, outpouchings of colonic mucosa that become obstructed and infected, initially localised & as the disease progresses, fistulae, abscess, obstruction and perforation can develop.
I would initially manage the patient with a A to E approach, and follow hospital protocol for suspected diverticulitis including IV fluids, analgesia, IV Abx. If the patient is showing any signs of complications i.e. perforation, haemorrhage or abscess formation I’d consider referral to general surgeons. CT is gold standard for Dx.
Rx depends on the severity of the illness (NBM, IV fluids, analgesia, Abx, drip+suck), but surgical management may be necessary in the case of perforation i.e. emergency Hartmann’s procedure.
What’s your approach to cholecystitis?
This is caused by a blockage in the cystic duct or neck of the gallbladder, typically gallstones (also biliary injury, tumours, stricture). This leads to inflammation and possible infection, complications including gallbladder necrosis and abscess formation.
I would initially manage the patient with a A to E approach, and follow hospital protocol for suspected cholecystitis including keeping the pt NBM, IV fluids, analgesia, IV Abx and referral to the general surgeons for consideration for laparoscopic cholecystectomy. USS will help guide Rx.
CHOLANGITIS - Ascending infection of the biliary 2* to an obstruction.
(Charcot’s triad) - fever, RUQ pain, jaundice (Reynold’s Pentad) + confusion + hypotension.
Rx: Abx, ERCP within 48 hours
Stoma
Stoma - artificial opening into a hollow organ
Stoma in the LLQ/RLQ
Spouted/flush to the skin
Pink and healthy/grey in appearance
Active and producing faeces & green/yellow liquid
On closer inspection there is no obvious herniation or retraction and there appears to be 1/2 lumens
This would be consistent with a (end/defunctioning loop) ileostomy/colostomy
The potential indications for this include:
Colostomy - rectosigmoid cancer, diverticulitis or IBD. Hartmann’s - Immediate anastomosis not safe, can go back later to reverse the stoma with an anastomosis
~ perforated diverticula
Defunctioning ileostomy - anterior resection, ileoanal pouch
End ileostomy - panproctocolectomy - UC, FAP
Complications of stomas can be early or late. Early - ABD --> BIP High output (electrolyte)/obstruction Ischaemia/necrosis Late - stenosis Retraction/prolapse/parastomal hernia Dermatitis
Scars
Well-healed/newly formed (clips/sutures) 10cm oblique/transverse/vertical scar
in the xyz
Midline scars - open laparotomy (emergency/elective)
Oblique/transverse scar in RLQ - appendectomy
Hockey stick shaped scar in the LLQ - renal transplant
Transverse loin scar - renal surgery i.e. nephrectomy
Right subcostal scar (Kocher’s) - gallbladder i.e. open chole, liver, bile duct
Subcostal scar (Rooftop) - pancreas i.e. Whipple’s, stomach, liver
Mercedes benz (vertical extension of the rooftop) - liver transplant
Transverse scar in the suprapubic area - Pfannenstiel incision - CS, bladder, uterus
Oblique inguinal scar - hernia repair
Renal patient with renal replacement therapy
- Haemodialysis – via tunnelled line, AV fistula
- Peritoneal dialysis – different types
- Transplant
Mature AV fistula with overlying bruising - suggesting it has been needled recently *Is it working? - Listen for thrill, feel for bruit
Complications: Bleeding, infection (don’t needle), thrombosis.
Possible causes - DM, HTN, GN, PCKD (look for signs)
I would like to perform a systemic examination, enquire about risk factors and dipstick the urine (glucose + blood)
Indications for RRT
- Uraemia with complications
- Refractory pulm oedema
- Refractory hyperkalaemia
- Refractory metabolic acidosis
- Drug overdoses
RRT assessment - fluid status, uraemic, electrolyte imbalances, pulmonary oedema
What’s your approach to a IBD flare?
Initially, resus using A-E appraoch. Admit, fluids, analgesia, antiemetic.
Need steroids such as iv hydrocortisone (pr if UC). If Crohns, then antibiotics like metronidazole.
Thromboprophylaxis and dietician review
Need regular monitoring- vitals, bloods, stool chart
When better, switch to oral prednisolone.
Monitor for acute complications such as perforation, bleeding, VTE and if UC, toxic megacolon— these may need surgical intervention.
Induce remission with 5 ASA’s like sulfasalazine in UC and azathioprine in Crohns.
What would your differentials be for this patient with LLQ mass?
Transplanted kidney Infection, inflammation and malignancy - loaded sigmoid - abscess or cyst - Crohn's flare, diverticulitis - lymphadenopathy, hernia - colorectal or gynaecological malignancy
What would your differentials be for this patient with RLQ mass?
Transplanted kidney Infection, inflammation and malignancy - abscess or cyst - Crohn's flare - lymphadenopathy, hernia - colorectal or gynaecological malignancy
What’s your approach to suspected colorectal carcinoma?
Risk factors
Genetic- FAP, HNPCC
Diet- Low fibre
Inflammatory bowel disease
Can present with CBH, anaemia/wt loss, PR bleed
FIT test stool
Bloods - + CEA
Imaging - flexi sig/colonoscopy + biopsy, CT AP
Supports Duke’s staging
Complications include obstruction and perforation
Tx: referral to cancer MDT, surgical elective bowel resection +/- chemoradiation
Chronic liver disease
Common causes: alcohol, NASH, viral hepatitis, autoimmune, metabolic disease (Wilson’s, haemochromatosis)
Ix: GGT, hep B/C, lipids, autoimmune screen, ceruloplasmin, iron studies, alpha-1-antitrypsin. +/- liver biopsy, MRCP if ?PSC —– CHILD PUGH ABCDE
Signs of CLD -
Hands – clubbing, leukonychia, Dupuytren’s, palmar erythema, bruising
Chest – spider naevi, gynaecomastia, hair loss.
Abdo – testicular atrophy.
Signs of P.HTN - SAVE
- Decompensation = Jaundice, hepatic encephalopathy (incl asterixis), ascites
Causes - infection (SBP/sepsis), bleeding, dehydration, constipation, drugs (sedatives)
Rx: Rx any ppt, lactulose +/- thiamine - SBP
- Hepatorenal syndrome
- Coag/hypoglycemia
Long term Rx: MDT, dietician, alcohol liaison support
Treat causes, treat Sx (cholestyramine)
Screen for complications - aFP, USS abdo, endoscopy
Renal transplant
- signs of complications of drugs if transplant
- is transplant working correctly if transplant
