Abdo exam & acute abdo (more OSCE related)

Question 1

What are the 3 main types of abdo pain ?

Answer 1

1. Visceral pain
2. Parietal pain
3. Referred pain

Question 2

What causes visceral type abdo pain and how is it percieved?

Answer 2

Distension, inflammation or ischaemia of the abdo organs results in dull, poorly localised pain

Question 3

Where would visceral pain from the foregut, midgut and hindgut be felt ?

Answer 3

• Foregut felt in the middle (stomach, pancreas)
• Midgut felt in suprapubic (small intestine)
• Hindgut - lower abdomen (colon)

Question 4

What causes parietal type abdo pain and how is it percieved?

Answer 4

• Inflammation, stretching or tearing of the parietal peritoneum, the muscle or the skin
• This pain is characterised by sharp, more intense and more localised sensation
• Movement may aggravate pain so patient very often lay still

Question 5

What causes referred pain and how is it percieved?

Answer 5

• It is well localised but felt in distant areas of the same cutaneous dermatome as the effected organ
• It occurs when organs share common nerve pathway
• For example - gall bladder pain may be felt in the right shoulder tip

Question 6

For OSCE if someone mentions pain just SOCRATES the shit out of it

Question 7

What questions should you cover in your history taking of someone with an acute abdomen ?

Answer 7

Present illness:

• Pain - SOCRATES
• Associated symptoms; Nausea, vomiting, weight loss, urinary habits, bowel habit

PMH: previous operations, recent hospitalisation

Social history: alcohol, smoking, illicit drugs, work history

Family history

Menstrual and contraceptive history - pregnant?

Question 8

What general things should be done on abdo exammination prior to the specific abdo part ?

Answer 8

1. Anaemia, Cyanosis, Jaundice & Lymph Nodes
2. Check for Diabetes, Hypertension, Peripheral Pulses
3. Examine Chest

Question 9

In terms of examining an acute abdomen following (IPPA) what should you do on inspection ?

Answer 9

• Patient with peritonitis will be motionless, in fetal position, shallow respiration
• Observe abdomen: previous surgery, distension, masses, hernias, organomegaly, discoloration, stigmata of liver disease, pulsatile mass
• Ask them to cough & stand up

Question 10

On ascultation of an acute abdomen what should you be listening for & how long ?

Answer 10

• Need to listen for at least 2 minutes
• Normal to hear 4-8 bowel sounds over 2 minutes, wide normal variations
• Listen for bruits
• Quiet abdomen generally means sick abdomen
• High pitched ”tinkles” indicative mechanical obstruction

Question 11

What should be done on percussion of the abdo ?

Answer 11

• For organs
• Over mass – fluid, solid?
• Ascites - shifting dullness

Question 12

What should you do when palpating the abdomen ?

Answer 12

• Do it sitting
• Gentle, 2 – hand technique, use tips of the fingers
• Palpate pathological quadrant last
• Palpate for specific organs – liver, kidneys, spleen
• Hernia orifices
• PR examination

Question 13

What is meant be guarding, rigidity & rebound tenderness when palpating an abdomen ?

Answer 13

Guarding:

• Voluntarily: patient tightness muscles to avoid pain
• Involuntary: spasm of abdominal muscles due to peritonitis

Rigidity = involuntarily guarding

Rebound tenderness:

• Gentle and slow pressure applied to abdomen followed by quick release of the examining hand
• Studies have shown 85% sensitivity to peritonitis

Question 14

If you find a mass on abdo exam what should be done to describe it ?

Answer 14

• Tender
• Fixed
• Hard
• Smooth edge
• Moves on respiration
• Pulsatile

Question 15

What are abdo CT scans done with ?

Answer 15

Oral/ IV contrast

Question 16

What 2 investigations are mandatory for patients with upper abdo pain with an unknown aetiology ?

Answer 16

ECG & Erect CXR

Question 17

How do patients who require urgent surgical intervention usually present ?

Answer 17

Usually febrile, leukocytic, rigid abdomen