Pick ‘n’ Mix Week 1 February 2023
We are really grateful to Trudie Pestell for sharing this fabulous education initiative that she has been producing for University Hospital Southampton Emergency Department for a while.
Each week we will bring you some clinical pearls to add in to your knowledge and understanding with links to other resources as well as an OSCE of the week. This week has an abdominal theme.
The case of runner’s tummy pain
The beginning:
A 40 year old female, who is a keen runner, attends your ED with a day history of increasing abdominal pain and nausea which started after her half marathon yesterday. She has now started vomiting and complains of increased distension.
Her observations are currently all within the normal range.
As she hasn’t passed faltus for some time and her abdomen is distended an abdominal Xray was performed
Use this to practise your abdominal examination. Remember there are resources for lots more system examinations here.
Script
Introduction
“”Hello, my name is Phil I am one of the medical students.”
“Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”
“Are you comfortable? Do you need any pain relief or a drink?”
“I have been asked to examine your gastrointestinal system. This will involve looking at your hands and face and chest, then examining your abdomen. Is this ok with you?”
“Would you like a chaperone present?”
“Please can you take your top off?”
“I will ensure the bed is at 45 degrees”
“I will talk out loud as we go”
“If at any time you want me to stop or you are in pain, let me know”
Brief history
“Can you briefly tell me why you have come to hospital?”
General inspection
“I am looking at the…”
Patient’s
- comfort level
- jaundice
- abdominal distension
- abdominal drains or scars
- spider naevi; caput medusa and gynaecomastia
- anasarca
Environment
- drains
Hands and other observations
“I am feeling for…”
- warmth
- clamminess
- the pulse (rate; rhythm; quality)
“I am looking for…”
- clubbing
- leucknoycia
- palmar erythema
- Dupuytren’s contractures
- liver flap
Other observations
- Blood Pressure
- Respiratory Rate
- Oxygen saturations
- Temperature
- Blood glucose
Face
“I am looking for evidence of…”
- conjunctival pallor (“Please look up I will gently lower your bottom eye lids.”)
- cngular stomatitis of lips
- cral ulcers (Please open your mouth and stick out your tongue.”)
- lymph nodes (“I need to feel your neck for any swellings. I will stand behind you to do this.”)
- Virchow’s node can be found in the left supraclavicular fossa and may be a sign of intraabdomminal malignancy
Abdomen
“Now I need to examine your abdomen. Are you ok to lie flat? If at any time you are in pain or want me to stop let me know.”
“I will examine the patient from their right side; at their level; looking at the patient for any signs of discomfort.”
Inspection
- Closer inspection (don’t forget the left flank)
Palpation
- Light then deep all quadrants for: guarding; rigidity; etc
- Organs: liver; spleen; kidney; bladder
- Aorta
Percussion
- Organs: liver; spleen; bladder
- Ascites (shifting dullness)
Auscultation
- Bowel sounds
- Femoral bruits
Close
“Thank you. That is the end of the examination”
“Do you need any help getting dressed?”
“In summary my working differential diagnosis is…”
“To complete my examination (scenario dependent) I would like to:
- Examine the the axilla; groin; the hernial orifices; perform a rectal examination and testicular exam (male patients)
- Obtain a
- urinalysis
- chest x-ray/abdominal x-ray/CT scan
- blood tests (state which ones)
“Does that sound reasonable to you? Do you have any questions or concerns?”
