Acute Abdomen Flashcards
26 year old woman presents with her male partner to the ED with a 2/7 Hx of R-sided abdominal pain
What do you want to know?
Site
Quality
Severity
Time course (onset, offset, temporal profile and progression)
Context
Aggravating and relieving factors
Associated features (e.g. N+V, urinary or bowel changes, jaundice, pruritis)
Menstrual Hx: LMP, normal cycle, changes in cycle (menorrhagia, dysmenorrhoea, amenorrhoea), contraception (OCP or barrier), vaginal discharge, dyspareunia
+/- sexual Hx if at risk
26 year old woman presents with her male partner to the ED with a 2/7 Hx of R-sided abdominal pain
Pain began suddenly 2/7 ago while at the gym (which she had to leave); had been well before pain started
It has always been on the R hand side, low down, and is constant and does not radiate; worse when she coughs and “sort of” when she moves but she is able to walk around
Since it came on, it has stayed the same and just not gone away; she is here today because she is worried it is something serious
No N+V, anorexia (has been eating normally)
Has not had any previous similar episodes
DDx?
Muscular strain (came on with exercise)
Ovarian pathology (can tort, bleed or rupture; sudden onset, constant pain in RLQ is consistent)
Ectopic pregnancy or pregnancy complication
Acute appendicitis (not a classic Hx!)
No systemic “yuck” that would be consistent with bowel pathology
26 year old woman presents with her male partner to the ED with a 2/7 Hx of R-sided abdominal pain
Also describes dysuria but no burning and stinging pain
Bowels have been fine, no gastro risks
Regular periods, currently day 16
She says she has had the same sexual partner for 2 year and they use condoms all of the time
Not on OCP
Denies any vaginal discharge different to usual
Is your sexual Hx complete? Are there any outstanding issues?
Yes, need to know about any other sexual partners (including past partners) so may need to ask partner to leave
Ask about PHx of STIs or sexual problems
26 year old woman presents with her male partner to the ED with a 2/7 Hx of R-sided abdominal pain
Rx: none, no allergies
FHx: none
ROS: nil of note
Her partner leaves the room and you have the opportunity to chat to her alone; she tells you that over the last few months she has had another sexual partner and they do not use protection, but as far as she knows her long-term partner has been faithful to her
She has never had a pelvic examination and denies Sx of an STI
What issues are important and how (and when) do you deal with them?
Discuss Ix for STIs (explain that some STIs can be asymptomatic but may cause other problems)
Consider pregnancy
May discuss telling her partner, as he may be at risk
Acknowledge the difficulty she has faced in telling you!
26 year old woman presents with her male partner to the ED with a 2/7 Hx of R-sided abdominal pain
O/E: sitting up in bed comfortably, does not look unwell, happily moves to lying position when you ask her to
Vitals and general: temp 37.8, HR 80, BP 110/60, RR 12, SaO2 98% RA, no fetor, no jaundice or pallor, no lymphadenopathy, moist tongue, JVP normal
Cardiorespiratory exam otherwise unremarkable
Abdomen: winces when you ask her to cough (muscle pain can cause this) and points to the RLQ when you ask where she feels the pain, moves normally with respiration, does not look distended, no scars, no asymmetry, soft, no guarding, tenderness on percussion and to light palpation in the RLQ but rest of abdomen is non-tender, Rovsings and Psoas signs are negative, no masses, no organomegaly, no hernias, no groin lymphadenopathy
Are pelvic and rectal examinations appropriate?
Pelvic is relevant; looking at this picture (isolated fever with no obvious abdominal pathology), suggestive of PID or some other gynaecological pathology
PR exam probably not necessary
26 year old woman presents with her male partner to the ED with a 2/7 Hx of R-sided abdominal pain
O/E: sitting up in bed comfortably, does not look unwell, happily moves to lying position when you ask her to
Vitals and general: temp 37.8, HR 80, BP 110/60, RR 12, SaO2 98% RA, no fetor, no jaundice or pallor, no lymphadenopathy, moist tongue, JVP normal
Cardiorespiratory exam otherwise unremarkable
Abdomen: winces when you ask her to cough and points to the RLQ when you ask where she feels the pain, moves normally with respiration, does not look distended, no scars, no asymmetry, soft, no guarding, tenderness on percussion and to light palpation in the RLQ but rest of abdomen is non-tender, Rovsings and Psoas signs are negative, no masses, no organomegaly, no hernias, no groin lymphadenopathy
Pelvic: no signs of warts or other STIs on inspection, no masses palpable, no vaginal discharge, no cervical excitation, endocervical swabs and cervical smears taken, PR examination deferred as not felt to be contributory
DDx?
Surgical: appendicitis, Merkel’s diverticulum, Crohn’s disease, complicated inguinal herniae
Gynaecological: physiologic or pathologic ovarian, endometriosis (probably not - more of a chronic condition), PID/salpingitis, pregnancy-related
Medical: mesenteric adenitis, IBS, UTI or sepsis/pyelonephritis, inguinal lymphadenopathy
Muscle strain
Rovsing’s sign
Palpation in LLQ induces pain in RLQ
“Do you feel pain? Where do you feel it?”
Psoas sign
Active flexion of R hip (or passive extension with patient lying on side)
Consistent with psoas irritation, e.g. from appendicitis (with retrocaecal appendix) or psoas abscess
26 year old woman presents with her male partner to the ED with a 2/7 Hx of R-sided abdominal pain
After a thorough Hx and examination, a list of potential surgical, gynaecological and medical causes are identified
Surgical: appendicitis, Merkel’s diverticulum, Crohn’s disease, complicated inguinal herniae
Gynaecological: physiologic or pathologic ovarian, endometriosis (probably not - more of a chronic condition), PID/salpingitis, pregnancy-related
Medical: mesenteric adenitis, IBS, UTI or sepsis/pyelonephritis, inguinal lymphadenopathy
Also consider muscle strain
Ix?
Basic panel for abdo pain: FBE (look at WCC), UEC, LFTs, consider CRP and lipase
Urine B-hCG
Swab for chlamydia and gonorrhoea
MSU
Summarise the findings
FBE: evidence of inflammation, Hb higher than expected (may be due to dehydration)
CRP: increased
UEC: normal
Serum B-hCG: negative (but presumed last ovulation was 2 days ago, usually takes 5-10 days for pregnancy to occur so will need follow-up to confirm)
MSU: normal
Endocervical swabs: negative for chlamydia and gonorrhoea
Pelvic U/S: non-specific free fluid in pelvis (could be consistent with ruptured cyst, PID, etc)
ISBAR
Identification
Situation
Background
Assessment
Response
Identification
Your name and role
Patient’s name, age and gender
+/- social situation (e.g. employment)
+/- health situation (e.g. previously well, patient known to renal transplant unit, etc)
Situation
Where, when, why, how
Background
Relevant medical history
Relevant psychosocial setting
Assessment
Identify likely diagnosis or provide DDx (common and serious causes)
Hx and examination results
Which of these are consistent with possible diagnoses
Any current test results
Test results still pending
