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PHYSICAL EXAMINATION
INSPECTION
- inspect patient (1st) then inspect abdomen
(2nd)
- peritonitis Px avoids movements
- flexed hip reduce abs pressure
- check for scars, cyanosis, pallor, diaphoresis
- check for hernias upon palpation
- erythema or edema cellulitis
- Ecchymosis deep necrosis
AUSCULTATION
- quiet ileus
- hyperactive enteritis
- high pitch mechanical obstruction
- echoes lumen distention
- bruits turbulent blood flow (present in
fistula and stenosis)
PERCUSSION
- hyper resonance/ tympany gas filled
Ileus tympany in all except RUQ
- dull abdominal mass
- lateral pressure ascites waves to other
side
false(+) to obese px by using
ulnar surface of examiners hand
in the midline then make wave
- pressure peritonitis excruciating pain
PALPATION (final major step)
- begin gently and away from the pain
- guarding is obvious even before palpation
- involuntary guarding by peritonitis
To assess vol and invol guarding,
apply a constant pressure in the
area away from pain then ask the
patient to take a slow deep
breath. Voluntary will relax,
involuntary will remain rigid.
AAron
Chandelier
Cruveihier
Edward
(vampire)
McBurneys
Acute
pressure epigastricAppendicitis
pain
Cervix mvt lower Pelvic inflam Dse
abs
and pelvic pain
Caput medusa
Portal HPN
Periumbilical
Hemoperitoneum
bruising
Abdominal mass
pain
LLQ pressure
Mcburneys pain
Acute
appendicitis
PERITONEAL LAVAGE
a. Mild supportive tx
b. ModerateCT
c. Severe
i. No shock CT
ii. Shock respiratory failure
peritoneal lavage
b. Fever, cholangitis antibiotics, ERCP
FEMALE
Gynecologic, UTI, appendicitis CT
a. Appendicitis laparotomy
b. No appendicitis CTDT
MALE
Consistent appendicitis OR laparotomy
Equivocal presentation CTCTDT
PERITONITISCT
a. Abscess AB, lavage resection
b. Perforation laparotomy
NO PERITONITIS
a. Diverticulitis AB
b. Equivocal CT CTDT
CASE 1
- 78 y.o. man, Hx of CABG, severe abdominal
pain began 6hrs ago, confused and disoriented,
pain is excruciating
- tenesmus
- digoxin, pindolol, ASA, Nitrate patch
- cool ashen skin, pulse rate = 120, BP = 85/50,
RR = 28, Temp = 36.5C, liquid stool (hematest
+), distended intestine, no bowel sound, no
guarding, no abdominal scar, tenderness difficult
to evaluate.
CASE 2
-18 y.o., M, periumbilical
pain, anorexia, &
***EVALUATION***
nausea
Generally irregular vital Stat
-later
the day
pain moved to RLQ
Bloodyinstool
bleeding
-Medications
unable to eat,
are vomiting
for atrial fibrillation
- Pain worsens
when
But (ASA,
NO)walking
bleeding
-BleedingO
RLQ tenderness,
involuntary
guarding, 38.3 C
(thats why!)
2 & BP
(fever),
Ischemia bleeding
WBC = 12,500 w/ 80% PMN lymphocytes
***MANAGEMENT***
***EVALUATION***
Resucitation STAT
Differentials:
Angiogram & thrombolytic therapy if there is no
Mesenteric
lymphadenitis,
UTI,
Gastritis,
peritonitis
Appendicitis
Blood transfusion
Appendicitis must be (+) Rovsings, Obturator
and Psoas signs and in rectal exam (precaution
with heart Px)
Visceral (vague) parietal (localized) pain
Pain is cresendo
***MANAGEMENT***
Appendectomy empty stomach <8hrs
CASE 3
- 59 y.o. M lower abdominal pain, fever, difficulty
when walking, intermittent cramps & changing
bowel habits over the past 2 months,
constipated with occasional diarrhea
- in the past 18 hrs, constant severe pain &
soreness in the LLQ, no apetite but thirsty
- 135/85 mmHg, pulse=100, 39 C
- lying supine, leg flexed at the hip and doesnt
want to move
-involuntary guarding & tenderness in LLQ, no
bowel sound
- tenderness on the left side of the upper rectum
- small brown bloody stools
***EVALUATION***
Inflammation
If female, consider gynecologic uterus ovary
problem
Consider tumor CA
Consider TB (GI manifestation)
Most likely, acute diverticulitis
***MANAGEMENT***
Needs further evaluation (SUBACUTE/OBSERVE)
CT scan for inflamed sigmoid
DONT USE!
colonoscopy perforate air sacs
barium enemabarium peritonitis
Antibiotic first,