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Nurhayat Usman, dr Sp.B-KBD
* 07/16/96 Acute Abdomen Nurhayat Usman, dr Sp.B-KBD 11/7/2018 *
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Acute Abdomen (acute abdominal pain)
* 07/16/96 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) *
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Why is it important ? Patient with acute abdomen: Sudden onset
* 07/16/96 Why is it important ? Patient with acute abdomen: Sudden onset Unknown etiology (not clear) Need immediate diagnosis & treatment Prevent morbidity & mortality *
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Morbidity & Mortality Death Obstruction Fluid imbalance
* 07/16/96 Morbidity & Mortality Obstruction Fluid imbalance Perforated viscus Peritonitis Infection Sepsis Shock Bleeding Hypovolemic Shock Ischaemia Perforation Peritonitis Death *
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Acute abdominal pain Most can be diagnosed clinically
* 07/16/96 Acute abdominal pain Most can be diagnosed clinically Require accurate and focused history taking Need meticulous & rationale physical examination Appropriate special investigations *
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The Diagnostic Process
* 07/16/96 HISTORY Patient perception of symptoms Patient description of symptoms Physician perception Physician interpretation of symptoms LABORATORY SYNTHESIS PHYSICAL FINDINGS RECORDING EXAM DECISION The Diagnostic Process *
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* 07/16/96 History Taking % of accurate diagnosis arises from good & meticulous history taking Physical diagnosis confirms accurate diagnosis % of accurate diagnosis arise from laboratory & radiological examinations *
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History Taking May confirm : Suspected diagnosis Possible etiology
* 07/16/96 History Taking May confirm : Suspected diagnosis Possible etiology Disease stages/ complications Differential diagnosis *
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History Taking Introduction
* 07/16/96 History Taking Introduction Greet the patient, and develop a warm and helpful environment Introduce yourself to the patient *
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* 07/16/96 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) *
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Acute abdominal pain in specific groups
* 07/16/96 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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* 07/16/96 Chief complaint: Ask the patient regarding why the patient comes to you. Onset Site at onset Radiation PAIN Site at present Type Progression Severity Duration Aggravating /relieving factors *
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* 07/16/96 Site of pain *
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Upper abdominal pain Peptic or gastric ulcer
* 07/16/96 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 *
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Central abdominal pain
* 07/16/96 Central abdominal pain Early appendicitis Bowel obstruction, strangulated Pancreatitis Gastroenteritis Mesenterial Emboli /Thrombosis Dissecting aortic aneurism Mesenteric adenitis Early sigmoid diverticulitis *
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Lower abdominal pain Colonic Gangrene/Obstruction Appendicitis
* 07/16/96 Lower abdominal pain Colonic Gangrene/Obstruction Appendicitis Mesenteric adenitis Diverticulitis Ruptured tubo-ovarial abscess Tuboovarial Torsion Ectopic gestation *
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* 07/16/96 Onset of pain Sudden onset *
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* 07/16/96 Onset of pain Gradual pain *
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* 07/16/96 Type of pain Visceral pain & Parietal pain *
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Type and severity of pain
* 07/16/96 Type and severity of pain A C A. Toothache C. Colicky pain of inflammed hollow organs *
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Type and severity of pain
* 07/16/96 Type and severity of pain Intermittent colicky pain of obstructed hollow organ at early stage. *
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Type and severity of pain
* 07/16/96 Type and severity of pain Progressive & Continous colicky pain due to strangulated bowel obstruction (ischemic stage) *
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* 07/16/96 Other related symptoms: Ask the patient concerning related/concomitant symptoms of Gastro-intestinal function: Nausea Vomiting Loss of appetite Faintness Previous indigestion (habitual) *
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Other related symptoms:
* 07/16/96 Other related symptoms: Jaundice Bowel habit: Constipation? Diarrhoea? Colour of the stool? Presence or absence of blood and mucus (slime) *
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Other related symptoms:
* 07/16/96 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) *
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Previous history Similar pain Abdominal surgery
* 07/16/96 Previous history Similar pain Abdominal surgery Major illness: incl. fever, abdominal injury. Drugs Allergies *
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PHYSICAL EXAMINATION Preparation
* 07/16/96 PHYSICAL EXAMINATION Preparation Check all the equipment required and have a good light: Examination couch Stethoscope Explain the procedure and its goals to the patient. Wash your hands with antiseptic soap. Dry and warm your hands with tissues. *
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Implementation: A General Examination
* 07/16/96 Implementation: A General Examination General appearance : Consciousness Mood : Distressed? Anxious? Immobile Move cautiously Colour : Pallor? Flushing? Jaundice? Cyanosis? *
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Implementation: Examine the vital signs: Temperature Pulse rate
* 07/16/96 Implementation: Examine the vital signs: Temperature Pulse rate Blood Pressure Respiratory rate *
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* 07/16/96 Implementation: Perform other systems examination, including cardio-pulmonary system. Ask the patient politely to expose his/her abdomen. *
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Abdominal Examination: Inspection
* 07/16/96 Abdominal Examination: Inspection Inspect the movement: Respiratory movement Visible bowel peristaltics Is there any scars on the skin of the abdomen? Is there any abdominal distention? Flatus ? , Fluid ? , Fetus? *
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Abdominal Examination: Inspection
* 07/16/96 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? *
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Gray-Turner Sign Cullen Sign
* 07/16/96 Gray-Turner Sign Cullen Sign *
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Abdominal Examination: Palpation
* 07/16/96 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. *
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* 07/16/96 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 *
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* 07/16/96 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 *
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* 07/16/96 Expansile pulsation *
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* 07/16/96 Specific signs Rovsing’s sign Obturator sign Psoas sign *
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Abdominal Examination : Percussion
* 07/16/96 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 ? *
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* 07/16/96 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 ? *
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Digital Rectal Examination
* 07/16/96 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. *
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Digital Rectal Examination
* 07/16/96 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? *
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* 07/16/96 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 *
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Extra peritoneal causes of acute abdomen
* 07/16/96 Extra peritoneal causes of acute abdomen Cardiothorax Urology Vascular E.t.c *
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* 07/16/96 Acute peritonitis *
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* 07/16/96 Patology *
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Degree of peritoneal irritation
* 07/16/96 Degree of peritoneal irritation (Lowenfels, 1975) Pancreatic juice Bowel bontent Gastric juice pus Urine blood bile Mild Severe *
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Signs of Intrabdominal Sepsis
* 07/16/96 Signs of Intrabdominal Sepsis Fever, nausea, vomiting, tachicardia, tachipneu Abdominal pain Peritoneal signs Signs of dehydration Leucositosis Shock, Multiple organ failure *
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Tips Sense of Crisis > 6 hours: surgically related diseases !!!
* 07/16/96 Tips > 6 hours: surgically related diseases !!! Limited movement: peritonitis / ischaemia Persistent pain on morphine : ischaemia Sense of Crisis Repeated exams : Very important *
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Perforated duodenal ulcer
* 07/16/96 Perforated duodenal ulcer *
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Perforasi Ulkus Ventrikuli
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* 07/16/96 GI bleeding *
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* 07/16/96 Pancreatitis *
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* 07/16/96 Acute appendicitis *
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* 07/16/96 Intusucseption *
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* 07/16/96 Sigmoid volvulus *
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Mesenteric thrombosis
* 07/16/96 Mesenteric thrombosis *
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Iskemi Usus, Thrombosis Mesenterial
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Mechanical Intestinal Obstruction
* 07/16/96 Mechanical Intestinal Obstruction *
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Obstetrics & gynecological causes
* 07/16/96 Obstetrics & gynecological causes gynecology Ruptured ovarial cyst Ovarial Torsion, Myoma Ruptured abscess Perforated Uterus Obstetrics Ectopic gestation Abdominal pregnancy Rupture of the uterus Mola Destruen *
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Abdominal pain in Obgyn
* 07/16/96 Ruptured organ Content Pus Materials : sebum meconeum Blood Acute abdomen torsion Strangulation distention ischaemia Abdominal pain in Obgyn *
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A Good Diagnostician is not Born, but is Developed
* 07/16/96 A Good Diagnostician is not Born, but is Developed *
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