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06/15/22 Clinical Clinical Examination Examination of Acute of Acute Abdomen Abdomen

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Page 1: Acute Abdomen FKG

04/21/23

Clinical Examination Clinical Examination of Acute Abdomenof Acute Abdomen

Page 2: Acute Abdomen FKG

Acute Abdomen (acute abdominal pain) “Condition which requires immediate treatment” (FD

Moore, 1977): Surgery? When to perform?

(Buku Ajar Ilmu Bedah, 1997): “Clinical condition which arises from acute critical condition in the abdominal cavity, and usually manifests as pain.

Acute abdominal pain: Chief complaint: acute pain (Nyhus, Vitello, Condon, 1995)

Page 3: Acute Abdomen FKG

Why is it important? Patient with acute abdomen:

Sudden onset Unknown etiology (not clear) Need immediate diagnosis & treatment

Prevent morbidity & mortality

Page 4: Acute Abdomen FKG

Morbidity & Mortality obstruction fluid imbalance

Perforated viscus Peritonitis

infection Sepsis Shock

Bleeding hypovolemic Shock

ischaemia Perforation Peritonitis

Page 5: Acute Abdomen FKG

Acute abdominal pain

Most can be diagnosed clinically

Require accurate and focused history taking

Need meticulous & rationale physical examination

Appropriate special investigations

Page 6: Acute Abdomen FKG

TheDiagnosticProcess

HISTORY

Patient perception of symptoms

Patient description of symptoms

Physician perception

Physician interpretation of symptoms

LABORATORY SYNTHESIS PHYSICALFINDINGS RECORDING EXAM

DECISION

Page 7: Acute Abdomen FKG

History taking 60 - 80% of accurate diagnosis arises from good &

meticulous history taking

Physical diagnosis confirms accurate diagnosis

10 - 15% of accurate diagnosis arise from laboratory & radiological examinations

Page 8: Acute Abdomen FKG

History taking:

May confirm : Suspected diagnosis Possible etiology Disease stages/ complications Differential diagnosis

Page 9: Acute Abdomen FKG

History Taking

Introduction

• Greet the patient, and develop a warm and helpful environment

• Introduce yourself to the patient

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Patient Identity

Ask the patient politely concerning his/her: name age

Record the gender: Male Female

Ask the marital status of the patient (especially for female)

Page 11: Acute Abdomen FKG

Acute abdominal pain in specific groups In children

Acute appendicitis

In the elderly Perforated tumors Bowel obstruction due to tumors

During pregnancy Complicated Ectopic pregnancy

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Chief complaint: Ask the patient regarding why the patient comes to you.

PAINPAIN Site at present

Onset

Radiation

Type

Aggravating /relieving factors

Severity

Duration

Site at onset

Progression

Page 13: Acute Abdomen FKG

Site of pain

Page 14: Acute Abdomen FKG

Upper abdominal pain Peptic or gastric ulcer Acute Cholecystitis, Acute Cholangitis Pancreatitis Early Appendicitis Hepatitis or liver abscess Extra abdominal:

Inferior Pleuritis, lobar pneumonia, pneumothorax Pericarditis, Myocardial infarction, angina

Pyelonephritis, renal colic

Page 15: Acute Abdomen FKG

Central abdominal pain Early appendicitis Bowel obstruction, strangulated Pancreatitis Gastroenteritis Mesenterial Emboli /Thrombosis Dissecting aortic aneurism Mesenteric adenitis Early sigmoid diverticulitis

Page 16: Acute Abdomen FKG

Lower abdominal pain Colonic Gangrene/Obstruction Appendicitis Mesenteric adenitis Diverticulitis Ruptured tubo-ovarial abscess Tuboovarial Torsion Ectopic gestation

Page 17: Acute Abdomen FKG

Onset of pain Sudden onset

Page 18: Acute Abdomen FKG

Onset of pain Gradual pain

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Visceral pain &Parietal pain

Type of pain

Page 20: Acute Abdomen FKG

Type and severity of pain

A. Toothache C. Colicky pain of inflammed hollow organs

A

C

Page 21: Acute Abdomen FKG

Type and severity of pain

Intermittent colicky pain of obstructed hollow organ at early stage.

Page 22: Acute Abdomen FKG

Type and severity of pain

Progressive & Continous colicky pain due to strangulated bowel obstruction (ischemic stage)

Page 23: Acute Abdomen FKG

Other related symptoms:Ask the patient concerning related/concomitant symptoms of

Gastro-intestinal function: Nausea Vomiting Loss of appetite Faintness Previous indigestion (habitual)

Page 24: Acute Abdomen FKG

Other related symptoms:

Jaundice Bowel habit:

constipation? Diarrhoea? Colour of the stool? Presence or absence of blood and mucus

(slime)

Page 25: Acute Abdomen FKG

Other related symptoms:

Urinary function: Micturition: amount of urine, lower abdominal

discomfort, colour of urine

Gynaecological function ( female) Menstrual function Delayed or miss period Abnormal bleeding or discharge (colour, quantity)

Page 26: Acute Abdomen FKG

Previous history of :

similar pain abdominal surgery Major illness: incl. fever, abdominal injury. Drugs Allergies

Page 27: Acute Abdomen FKG

PHYSICAL EXAMINATION Preparation

Check all the equipment required and have a good light:

Examination couchStethoscopeExplain the procedure and its goals to the

patient.Wash your hands with antiseptic soap.Dry and warm your hands with tissues.

Page 28: Acute Abdomen FKG

Implementation:

A General Examination General appearance:Consciousness Mood: distressed? Anxious? Immobile Move cautiously Colour: Pallor? Flushing? Jaundice?

Cyanosis?

Page 29: Acute Abdomen FKG

Implementation: Examine the vital signs:

Temperature Pulse rate Blood Pressure Respiratory rate

Page 30: Acute Abdomen FKG

Implementation:

Perform other systems examination, including cardio-pulmonary system.

Ask the patient politely to expose his/her abdomen.

Page 31: Acute Abdomen FKG

Abdominal Examination: Inspection

Inspect the movement:Respiratory movementVisible bowel peristaltics

Is there any scars on the skin of the abdomen?

Is there any abdominal distention?Flatus ? , Fluid ? , Fetus?

Page 32: Acute Abdomen FKG

Abdominal Examination: Inspection

Is there any rashes and discolouration? Cullen’s sign Gray Turner’s sign Ecchymosis of the abdominal wall

Is there any masses: Tumors? Hernial sites? Masses with pulsation?

Page 33: Acute Abdomen FKG

Cullen Sign Gray-Turner sign

Page 34: Acute Abdomen FKG

Abdominal Examination: Palpation

Ask the patient to locate the site of maximum pain with the tip of a finger.

Using the palmar surface of your fingers, gently palpate the abdomen, starting from a site farthest from the area of maximum pain, move gradually towards it.

Page 35: Acute Abdomen FKG

While palpating, look to the face expression of the patient, and look for any signs of :

Tenderness Rebound tenderness Muscle guarding Rigidity Murphy’s sign

Page 36: Acute Abdomen FKG

While palpating, look to the face expression of the patient, and look for any signs of :

Swelling or masses Rovsing’s sign Expansile pulsation Hernial orifices Scrotum in male

Page 37: Acute Abdomen FKG

Expansile pulsation

Page 38: Acute Abdomen FKG

Specific signs: Rovsing’s sign Obturator sign Psoas sign

Page 39: Acute Abdomen FKG

Abdominal Examination : Percussion Place the palmar aspect of your left hand on the

abdomen, and gently percus its dorsal aspect with the tip of the middle finger of the right hand, moving all around the abdominal region: Is it tymphanitic? Is it Dull ? Is there any shifting dullness? Site of liver dullness ? and is it disappeared ?

Page 40: Acute Abdomen FKG

Auscultation

Using stethoscope, and place it gently on the abdomen, listen to the bowel sounds and bruit at least for one minute: Absent? High pitched and hyperactive? Metallic sound? Vascular bruit?

Page 41: Acute Abdomen FKG

Digital Rectal Examination

Put on surgical hand gloves and ask the patient to expose his/her buttock and anus, and place the patient in lithotomy position.Apply lubricating jelly on to the right index finger.

Page 42: Acute Abdomen FKG

Digital Rectal Examination Gently insert your right index finger into the anus, move toward

the anal canal slowly, and evaluate the followings: Anal margin: piles? Mucosal surface of the anal canal and the ampulla

(collaps?) Sites of any pain elicited Masses or swelling: consistency, location, surface, fixity to

the surroundings. Bowel contents: consistency of faeces? Mucus? Blood?

Page 43: Acute Abdomen FKG

Perform bimanual palpation in female patient to examine the uterus, pelvic cavity and adnexa.

Write up Write up all significant findings in the medical

record. Conclude your diagnosis and differential diagnosis, and order any necessary special investigations

Page 44: Acute Abdomen FKG

Extraperitonealcauses of acute abdomen Cardiothorax Urology Vascular E.t.c

Page 45: Acute Abdomen FKG

Acute peritonitis

Page 46: Acute Abdomen FKG

Patology

Page 47: Acute Abdomen FKG

Degree of peritoneal irritation(Lowenfels, 1975)

bloo

d

Urin

e

bile

pus

Panc

reat

ic ju

ice

Bowe

l bon

tent

Gas

tric

juice

Mild Severe

Page 48: Acute Abdomen FKG

Signs of intrabdominal sepsis

Fever, nausea, vomiting, tachicardia, tachipneu Abdominal pain Peritoneal signs Signs of dehydration Leucositosis Shock, Multiple organ failure

Page 49: Acute Abdomen FKG

Tips > 6 hours: surgically related diseases !!!

Limited movement: peritonitis / ischaemia

persistent pain on morphine : ischaemia

Sense of Crisis

Repeated exams : important

Page 50: Acute Abdomen FKG

Perforated duodenal ulcer

Page 51: Acute Abdomen FKG

GI bleeding

Page 52: Acute Abdomen FKG

Pancreatitis

Page 53: Acute Abdomen FKG

Acute appendicitis

Page 54: Acute Abdomen FKG

Intusucseption

Page 55: Acute Abdomen FKG

sigmoid volvulus

Page 56: Acute Abdomen FKG

Mesenteric thrombosis

Page 57: Acute Abdomen FKG

Mechanical Intestinal obstruction

Page 58: Acute Abdomen FKG

Obstetrics & gynecological causes

Obstetrics Ectopic gestation Abdominal pregnancy Rupture of the uterus Mola Destruen

gynecology Ruptured ovarial cyst Ovarial Torsion, Myoma Ruptured abscess Perforated Uterus

Page 59: Acute Abdomen FKG

Ruptured

organ

Content

PusMaterials :• sebum• meconeum

Blood

Acute

abdomen

torsion

Strangulation

distentionischaemia

Abdominal pain inObgyn

Page 60: Acute Abdomen FKG

A Good Diagnosticianis not Born, but is Developed