Clinical Signs in Abdominal Examination

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Questions and Answers

Which sign is associated with retroperitoneal hemorrhage?

Grey-Turner's sign (correct)

Kehr's sign

McBurney's sign

Chandelier sign

What is indicated by tenderness located 2/3 distance from the anterior iliac spine to the umbilicus on the right side?

Mesenteric ischemia

Ectopic pregnancy rupture

Acute pancreatitis

Appendicitis (correct)

Which examination finding involves an abrupt interruption of inspiration upon palpation of the right upper quadrant?

Iliopsoas sign

Obturator's sign

Rovsing's sign

Murphy's sign (correct)

What condition is indicated by flank tenderness?

Perinephric abscess Signup and view all the answers

What is the significance of a hyperextension of the right hip causing abdominal pain?

Iliopsoas sign Signup and view all the answers

Which sign is characterized by severe left shoulder pain?

Kehr's sign Signup and view all the answers

What is the misconception regarding rebound tenderness as a clinical indicator of peritonitis?

It has a high false negative rate. Signup and view all the answers

Which of the following findings is associated with the manipulation of the cervix lifting the buttocks off the table?

Chandelier sign Signup and view all the answers

What should be the initial management step for a patient presenting as 'ill'?

Initiate resuscitation and analgesia Signup and view all the answers

Which investigation is NOT typically prioritized for patients with acute abdominal pain (AAP)?

Plain X-rays Signup and view all the answers

In which scenario would a pregnancy test be most relevant?

When suspecting gynae pathology Signup and view all the answers

Why might FBC (Full Blood Count) not have significant clinical utility?

25% of patients have similar outcomes regardless of WCC levels Signup and view all the answers

What is the first-line imaging modality for patients with acute appendicitis?

CT scan Signup and view all the answers

What is a key benefit of performing urinalysis?

It is a cheap and readily available test with high yield Signup and view all the answers

Which of the following statements about the use of CT in diagnosing AAP is true?

CT scanning delays necessary treatment Signup and view all the answers

Which investigation is commonly used but has a limitation in its clinical utility?

FBC for determining specific outcomes Signup and view all the answers

What is one advantage of early diagnostic laparoscopy in managing acute abdominal pain?

Enhances diagnostic accuracy Signup and view all the answers

How does multi-detector computer tomography (MDCT) improve diagnostic processes?

By enhancing diagnostic accuracy with faster scanning Signup and view all the answers

What aspect of treatment does early diagnostic laparoscopy aim to improve?

Prompt and efficient management of acute abdominal pain Signup and view all the answers

What is one outcome of unnecessary laparotomy addressed by early diagnostic laparoscopy?

Decreased rates of unnecessary laparotomy Signup and view all the answers

What potential diagnostic dilemma can early laparoscopy help resolve?

Non-specific abdominal pain (NSAP) Signup and view all the answers

Which of the following is NOT a commonly recognized cause of acute abdominal pain?

Chronic gastritis Signup and view all the answers

What percentage of acute abdominal pain cases have an inaccurate initial diagnosis?

50-65% Signup and view all the answers

Visceral pain in acute abdominal pain is specifically associated with which of the following conditions?

Distention in hollow viscous organs Signup and view all the answers

In acute abdominal pain, referred pain is characterized by which of the following?

Produces symptoms but not signs Signup and view all the answers

Which embryological origin corresponds to pain localized to the epigastrium?

Forgut Signup and view all the answers

Which condition is least likely to cause right upper quadrant (RUQ) pain?

Spontaneous splenic rupture Signup and view all the answers

What type of pain is primarily characterized as 'colicky'?

Renal stones pain Signup and view all the answers

What is a common symptom associated with both acute pancreatitis and peptic ulcer disease (PUD)?

Abdominal tenderness Signup and view all the answers

Which of the following conditions is most frequently associated with suprapubic pain?

Acute urinary retention Signup and view all the answers

What pain type is described as 'gnawing'?

Pancreatitis Signup and view all the answers

In which abdominal examination observation might you see visible peristalsis?

Distended abdomen Signup and view all the answers

What is a common associated symptom of pancreatitis?

Genitourinary symptoms Signup and view all the answers

Which option is a key point to note in a medical history for abdominal pain?

Associated medications Signup and view all the answers

Study Notes

Acute Abdominal Pain

Acute abdominal pain (AAP) is the presentation of previously undiagnosed abdominal pain lasting 1/52 or prior to a clinical encounter in 1° or 2° care.

Introduction

Over 1000 causes exist for acute abdominal pain.
Non-specific acute abdominal pain (SAP) accounts for 34% of cases.
Acute appendicitis accounts for 28%.
Acute cholecystitis represents 10% of cases.
Other causes include small bowel obstruction (SBO), perforated peptic ulcer, pancreatitis, diverticular disease, and others (13%).
Admission rates vary from 20-40%.
Initial diagnosis is inaccurate in 50-65% of cases.

Pathophysiology

Visceral pain arises from distension, inflammation, or ischemia in hollow or solid organs.
Visceral pain location is related to the embryonic origin of the organ.
Forgut organs cause pain in the epigastrium.
Midgut organs cause pain in the umbilicus.
Hindgut organs cause pain in the hypogastric region.
Parietal pain is localized to the dermatome above the stimulus and can produce symptoms like tenderness, but not signs.

Generalized AP

Perforation
AAA
Acute pancreatitis
Diabetes Mellitus (DM)
Bilateral pleurisy

Central AP

Early appendicitis
Small bowel obstruction (SBO)
Acute gastritis
Acute pancreatitis
Ruptured AAA
Mesenteric thrombosis

Epigastric Pain

Peptic ulcer disease (PUD)
Oesophagitis
Acute pancreatitis
AAA

RUQ Pain

Gallbladder disease
Peptic ulcer disease (PUD)
Acute pancreatitis
Pneumonia
Subphrenic abscess

LUQ Pain

Genitourinary issues
Pneumonia
Acute pancreatitis
Spontaneous splenic rupture
Acute perinephritis
Subphrenic abscess

Suprapubic Pain

Acute urinary retention
Urinary tract infections (UTIs)
Cystitis
Pelvic inflammatory disease (PID)
Ectopic pregnancy
Diverticulitis

RIF Pain

Acute appendicitis
Mesenteric adenitis (in younger patients)
Perforated peptic ulcer (PUD)
Diverticulitis
Pelvic inflammatory disease (PID)
Salpingitis
Ureteric colic
Meckel's diverticulum
Ectopic pregnancy
Crohn's disease
Biliary colic (low-lying gall bladder)

Loin Pain

Muscle strain
Urinary tract infections (UTIs)
Renal stones
Pyelonephritis

LIF Pain

Diverticulitis
Constipation
Irritable bowel syndrome (IBS)
Pelvic inflammatory disease (PID)
Rectal cancer (Ca)
Ulcerative colitis (UC)
Ectopic pregnancy

Limitations

Overlying tenderness can mask underlying surgical disease.
35% of intraoperative diagnoses have atypical presentations.

Key Points on History

Site
Nature and character of pain
Duration of pain
Intensity of pain
Precipitating and relieving factors
Associated symptoms

Classification by Nature

Colicky pain: Baseline of no pain in true colic. IBS and bowel obstruction are examples.
Nagging and grumbling pain: Biliary colic, cholecystitis, PID, and UTIs
Stabbing pain: AAA
Burning or boring pain: PUD and oesophagitis
Gnawing pain: Pancreatitis or pancreatic cancer (Ca)

Associated Symptoms

Fever
Genitourinary issues
Gynaecological issues
Vascular issues

PMSH (Past Medical Surgical History)

Previous episodes of abdominal pain (AP)
Investigations
Operations
Chronic disease
Immunosuppression
Medications (NSAIDs)

Physical Examination

Observations (OBS) are important
Observations:
- Bending forward: Chronic pancreatitis
- Jaundice: Common bile duct (CBD) obstruction
- Dehydration: Peritonitis or small bowel obstruction
Inspection:
- Scaphoid or flat in peptic ulcer disease (PUD)
- Distended in ascites or intestinal obstruction
- Visible peristalsis in thin/malnourished patients (with obstruction)
Palpation:
- Check for hernia sites
- Tenderness
- Rebound tenderness
- Guarding (involuntary muscle spasm during palpation)
- Rigidity (abdominal muscles tense and board-like): Indicates peritonitis

Local Right Iliac Fossa (RIF) Tenderness:

- Acute appendicitis
- Acute salpingitis (in females)

Low-grade, Poorly Localized Tenderness:

- Intestinal obstruction

Tenderness out of Proportion to Examination:

- Mesenteric ischemia
- Acute pancreatitis

Flank Tenderness:

- Perinephric abscess
- Retrocaecal appendicitis

Important Signs in Patients with Abdominal Pain

Provided a list of signs and associated findings.

Physical Examination (continued)

Auscultation:
- Bowel sounds (BS): Absent for >2 minutes, high-pitched, hyperactive, or tinkling indicates possible bowel obstruction.
- Bruit in epigastrium
PR Examination:
- Tenderness
- Induration
- Mass
- Frank blood
PV Examination:
- Bleeding
- Discharge
- Cervical motion tenderness
- Adnexal masses or tenderness
- Uterine size or contour

Surgical Myths

Rebound tenderness has a high (25%) false-negative rate for peritonitis.
Rigidity, referred tenderness, and cough pain are not sufficient evidence for peritonitis.
Administering analgesics before surgery does not obscure the diagnosis, instead improves accuracy.

Initial Management

First 20 seconds: Only 3 diagnoses are possible (very ill, going to die, reasonably well).
Very ill: Identify the situation and act accordingly if life-threatening.
Ill: Urgent investigations and initial management.
Reasonably well: Investigations as appropriate with diagnosis formulation.
ABCDE approach is crucial.
Resuscitation & analgesia (opioid IV)
Full monitoring (including urine output)
Low threshold for seeking senior help if needed.

Investigations

Full blood count (FBC), hemoglobin (Hb), and white blood cell count (WCC)
Amylase (for pancreatitis)
Urea and electrolytes (U&Es), liver function tests (LFTs)
Clotting profile (for acute pancreatitis, sepsis, disseminated intravascular coagulation (DIC), or liver disease)
Blood glucose (BM)
Group and save (G&S), cross-match if necessary
Arterial blood gas (ABG)
Electrocardiogram (ECG)
Cardiac enzymes (if appropriate)
Be mindful of WCC as a screening test; 25% of patients with elevated WCC don't have outcomes different from those with normal WCC. FBC has limited clinical utility.
Urine analysis (URINALYSIS) - cheap & readily available, high yield when results correlate with the clinical scenario.
MSU (mid-stream urine)
Pregnancy test
Radiology, Including
- Erect and supine chest X-rays (CXR),
- ultrasonography (USS),
- CT KUB/IVU
Plain X-rays have limited utility in acute abdominal pain (AAP); low yield, high misleading findings; exception: bowel obstruction or perforation

CT Scanning

No significant advantage in diagnosing AAP with CT.
Delay in necessary treatment.
Routine use not justified.
History, physical examination are crucial basis of correct diagnosis.
CT is now a first-line for AAP.
Multidetector CT (MDCT) is faster with thinner slices and offers higher diagnostic accuracy.

Laparoscopy

Early diagnostic laparoscopy can offer accurate, prompt, and efficient management of acute abdominal pain (AAP).
Reduces unnecessary laparotomy rates.
Improves diagnostic accuracy and might resolve diagnostic dilemmas for non-specific acute abdominal pain (NSAP).

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Description

Test your knowledge on clinical signs associated with abdominal examination, including retroperitoneal hemorrhage and other key findings. This quiz will help reinforce your understanding of abdominal assessment techniques and the significance of various signs and symptoms. Ideal for medical students and healthcare professionals.