Week 5 - Abdominal pain

Question 1

Mr. J.K. is a 65-year-old cane farmer from Ingham. “The pain in my gut just won’t go away.”

Take a history of this patient.

HPC:
• Worsening abdominal pain. Since 4 weeks.
• All day everyday* started 1/10 now 4/10 (started mild, gradually worsening). Epigastric, no radiation, paracetamol and antacids no help. No relation to food - what if? (Difference between pain before food and pain after food).
• Nausea but no vomiting, no appetite, 3kg weight loss, tired.
• P/H: lots of heart burn, stress at work, bowel, urine normal.
• Chronic smoker (25/day 50 years).

Answer 1

HPC:
• Site - where is the pain?
• Onset - when did it start? i.e. acute or chronic.
• Character - describe the pain i.e. colicky or constant.
• Localised or radiating?
• Alleviating factors? i.e. antacids/paracetamol, vomiting/defecation, movement.
• Timing - experienced it before? Constant or intermittent? How long does it last/worse at a particular time?
• Exacerbating factors? i.e. food, movement.
• Severity?
• Associated symptoms? i.e. nausea, vomiting, loss of weight, change in bowel movement (diarrhoea, constipation, blood), bleeding, dysphagia, heartburn, satiety, indigestion, jaundice, fatigue.
• Effect on lifestyle?

• Weight loss, fatigue, loss of appetite?
• Dysphagia?
• Haematemesis, melaena?
• Dyspepsia?
• Past GI bleeds?
• Pain related to food, known ulcers?
• Fever, recent illness?

PMHx:
• Past history of heartburn, ulcers, GI problems, cancer etc?

PSHx:
• Past surgeries?

Medications:
• Any regular medications? i.e. NSAIDs.

Allergies:
• Agent, reaction, treatment?

Immunisations:
• E.g. Fluvax, pneumococcal?

FHx:
• Family history of heartburn, ulcers, GI problems, cancer etc?

SHx:
• Background? 
• Occupation?
• Education?
• Religion?
• Living arrangements?
• Smoking?
• Nutrition?
• Alcohol/recreational drugs? 
• Physical activity?

Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, indigestion, dysphagia, change in bowel habit, abdominal pain?
• UG - dysuria, polyuria, nocturia, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?

Question 2

Perform a physical examination on this patient.

Answer 2

1. Introduction, explanation, consent, wash hands. Patient properly positioned lying flat, chest and abdomen exposed.
2. General inspection: consciousness, orientation, distressed/in pain, habitus, colour (jaundice, pallor), skin pigmentation.

3. Vital signs:
• HR
• RR
• BP 
• Temp
• O2 sats, BGL, BMI.

4. Hands/arms:
   • Warm/cool, dry/sweaty, pallor.
   • CRT, clubbing.
   • Bruising, acanthosis nigricans in axilla.
5. Face:
   • Eyes - conjunctival pallor, scleral jaundice.
   • Mouth - peripheral/central cyanosis, angular stomatitis, brown black lesions around the mouth and in buccal mucosa in Peutz-Jeghers syndrome (harmatomas/polyps in GIT), glossitis, hydration.
6. Neck/chest:
   • Shrug shoulders - supraclavicular lymph nodes - enlarged left supraclavicular node (Virchow’s node) secondary to gastric malignancy.
7. Abdomen:
   • Inspection - scars, skin lesions, abdominal distension, prominent veins, visible masses/pulsations, visible peristalsis.
   • Palpation - light and deep (tenderness - rebound, guarding, rigidity), hepatomegaly (liver mets), splenomegaly, paraortic lymph nodes, inguinal lymph nodes.
   • Percussion - ascites.
   • Auscultation - bowel sounds.

8. Legs:
• Bruising/muscle wasting.
• Oedema.
• Clubbing, CRT.
• Peripheral pulses.

9. CVS/RS:
   • Auscultation.

Question 3

What is your provisional diagnosis and differential diagnoses?

Answer 3

• Provisional diagnosis: Gastric cancer.
• DDx:
- Oesophagitis, GORD, cancer (oesophageal/gastric), peptic ulcer, gastric ulcer.
- Chronic pancreatitis, cholecystitis, cholelithiasis, liver (expanding liver mass - mets, abscess).
- Pain of pleura, pericardiac, cardiac origin?
- AAA (not for weeks - more of an acute presentation).

Question 4

What investigations would you carry out on this patient?

Answer 4

• FBC - Hb (anaemia), WCC (infection - cholecystitis, pancreatitis, gallstones).
• U+Es - renal function, electrolytes.
• LFTs.
• Lipase, amylase.
• USS abdomen (gallstones).
• CXR (RLL pneumonia causing epigastric pain, air under diaphragm due to perforated ulcer).
• Urea breath test.
• Endoscopy.

Question 5

What treatment does this patient require?

Answer 5

Gastric cancer:
• Partial/total gastrectomy.
• Combination chemotherapy.
• Palliative care.