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Acute abdomenal pain H istory

Acute abdomenal pain H istory . Station 1. Onset Duration Site, radiation Severity Progression: continuous or ON&OFF, constant or increasing severity Nature: burning, dull, sharp, colicky Precipitating, aggravating, relieving factors

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Acute abdomenal pain H istory

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  1. Acute abdomenal pain History Station 1

  2. Onset • Duration • Site, radiation • Severity • Progression: continuous or ON&OFF, constant or increasing severity • Nature: burning, dull, sharp, colicky • Precipitating, aggravating, relieving factors • Associated symptoms: nausea, vomiting, anorexia, heartburn, change in bowel habit, GI bleeding, jaundice, fever, wt loss • Risk factors: Hx of peptic ulcer disease (endoscopy, H.pylori Rx), IBD (colonoscopy), Gastroenteritis (eating outdoor), previous abdominal operation (adhesions causing intestinal obs.)

  3. Station 2 Q.Describe what you see? Q.Give 3 causes? Q.What are the investigations? Q.Howwould you prepare the jaundiced patient for surgery?

  4. Describe? yellowish discoloration of the sclera (jaundice) • Mention 3 causes: • pre-hepatic: hemolytic disease • Hepatic: hepatitis, cirrhosis • Post-hepatic: CBD obstruction by stone, carcinoma of head of pancreas, cholangiocarcinoma

  5. Investigation : • CBC, U&E, LFT, Coagulation, Hepatitis • Remember Macrocytosis as a sign of alcoholism • In obstructive jaundice, the Alkaline Phosphatase will rise out of proportion to the transaminases (These may be slightly up), and the bilirubin is conjugated. • Hepatocellular jaundice is characterised by marked transaminase rise, and a mix of conjugated and unconjugatedbilirubin. • Prehepatic Jaundice is unconjugated (so not present in urine) • Ultrasound: if the CBD dilated the obs is extrahepatic, if not dilated the obs is intrahepatic

  6. How would you prepare the jaundiced patient for surgery? • Basically this means correcting any coagulation abn with FFP and/or Vitamin K, and giving perioperative IV fluids to maintain a good urine output (Hepatorenal syndrome more likely in the dehydrated)

  7. Station 3 Jaundiced patient: Q.Take a history ? Q.what are the Finding on Examination?

  8. Hx: PD: age, gender, origin (for belharzia) • Onset, duration, how did the pt notice, previous episode • Associated symptoms: RUQ pain, nausea, vomiting, fever, rigors, steatorrhea, dark urine, pale stool, itching, wt loss, anorexia, cirrhosis (hematemesis, melena, ascitis), anemia (fatigue, palpitations, SOB) • Risk factors: hepatitis (IV drug abuse, BT, contact with jaundiced pt, recent travel, alcohol), GallBladder (previous Hx of stones, fertility, DM, crohn’s, ERCP, cholecystectomy), hemolytic disease (known blood disorder, we already asked abt BT), pancreatic CA (smoking) • Medications: antiTB, OCPs, herbal • Family Hx: blood disorder, hepatitis, gall stones, malignancies

  9. Jaundice P/E • Hands: Finger clubbing, Leukonechia, Palmarerythema, Dupuytren’s, Asterixis • Skin: Bruising, Spider Naevi, itching • Face & Head: Jaundiced sclera. Constructional apraxia, Foetor hepaticus. • Chest:Gynaecomastia • Abdomen: Enlarged liver or spleen, Ascites, Caput Medusae. Remember to ascertain the nature of the liver edge, consistency, tenderness. Bruits etc astronomically rare. • Legs: Peripheral pitting oedema from hypoalbuminaemia.

  10. What are the DDxof RUQ pain? Station 4

  11. Liver: Hepatitis, Liver abscess, Hepatocellular carcinoma (stretching liver capsule) • Gallstone disease: biliarycolick, cholecystitis, cholangitis • Basal pneumonia (rt lower lobe) • pyelonephritis • Peptic ulcer disease • Pancreatitis • Colitis of hepatic flexure

  12. Mention 4 symptoms in patient with acute pancreatitis? Station 5

  13. Epigastric pain, radiating through to the back, releived by leaning forward • Vomiting, nausea • Fever • Palpitations • fatigue

  14. CholecystitisHxExRx Station 6

  15. The pt will present with RUQ pain, so: • Onset, duration, site, radiation (Rt shoulder or inter-scapular region), aggravating (fatty food, coffee, tea), relieving factors (analgesics), associated symptoms (fever, rigors, nausea, vomiting, usually no jaundice bcoz no CBD obstruction, if yes dark urine & pale stool & itching), nature (usually constant not colicky), severity • Previous Hx of biliarycolick, DM, blood disorder • Risk factors: female, 40’s, fatty, fertile, +ve family Hx, hemolytic disease, ileal disease (Crohn’s) or resection • Exclude other DDx: hepatitis (IV drug abuse, BT, contact with jaundiced pt, recent travel, alcohol, antiTB), basal pneumonia (cough,sputum), pyelonephritis (flank pain, dysuria, heamaturia), PUD (heartburn, epigastric pain, endoscopy), pancreatitis (pattern of pain, ERCP) • Family Hx: blood disorder, hepatitis, gall stones

  16. Physical examination usually only shows subcostal tenderness and murphy’s sign. Rarely palpable. 5 F’s • The investigation of cholecystitis is essentially the investigation of upper abdominal pain: CBC, U&E, AMYLASE, LFT’s, Erect Chest X-ray abdominal film, US abdomen, endoscopy. • Treatment: admitssion, NPO, IVF, Abx (Cefuroxime), analgesics • Lap Cholecystectomy: if pt present within 72 hrs do it, if present after 72 hrs do it after 6 wks (including 2 wks of Abx & spasmolytics) • Cholangitis is Jaundice, Fever /Rigors, RUQ pain (Charcot’s triad).

  17. What are the causes of Cirrhosis? Station 7

  18. Alcohol and viral Hepatitis are the first things to say If pressed: Primary Biliary Cirrhosis Autoimmune hepatitis Haemochromatosis and Wilson’s disease Drugs egMethotrexate Budd-Chiari syndrome (Hen’s tooth), Congestive Cardiac failure. Alpha-1-antitrypsin deficiency

  19. Station 8 57 yr female , was treated by surgical inscesion of adenoCA in her rectum :a) what are the exact operation?b) name the insecion?c) 4 complications ?d)What does the arrow show?

  20. a) the exact operation :colostomy b) name the insecion : midline c) 4 complications ? d) the arrow shows :the stoma.

  21. DDx of upper abdominal pain Station 9

  22. Epigastric:Upper GI: Gastritis, Oesophageal reflux, Peptic Ulcer, Perforation of gastric or duodenal ulcer.Hepatobiliary: Biliary Colic, PancreatitisREMEMBER MYOCARDIAL INFARCTION • Right HypochondriumHepatobiliary: Biliary Colic, Cholecystitis, Cholangitis, Hepatitis, Pancreatitis, Fitz-Hugh-Curtis syndrome.Upper GI: Peptic Ulcer, Perforation of UlcerOther Abdominal:Subphrenic abscess, Appendicitis, Renal ColicExtra-Abdominal: Right lower lobe pneumonia, Pulmonary embolus

  23. Chronic vomiting Hxواضحة ان شاء الله Station 10

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