Case Study #1:
A 37 year old female with a BMI of 30 has abdominal pain with the following:
- RUQ
- steady and severe
- nausea/vomiting
- diminished appetite, worse with fatty food
- 1+ hr after meal, prolonged > 4-6 hrs).
- Unremarkable medical history.
Cholecystitis:
- RUQ pain with contraction of gallbladder against stone in the cystic duct
- colicky pain after fatty intake
- no signs of obstruction or infection
- fear of perforation of gallbladder
- Cannot maintain PO intake
- Pain not adequately controlled
- Charcot's triad (fever, jaundice, RUQ pain)
- Reynolds pentad (triad plus shock and altered mental status)
Case Study #2:
A 25 year old male complains of discomfort and bulge in the abdominal wall.
- Heaviness and dull discomfort
- History of open appendectomy
- Located at scar
- Cosmetic concern
- Appearance and discomfort worsened with coughing or straining
- Distinguish hernia from ischemic pain
Rational clinical abdominal exam:
- Murphy's signs: cessation of inspiration when pressure applied over gallbladder
- Rovsing's signs: pain in RLQ with deep palpation of LLQ
- Psoas sign: pain with passive/ active extension and flexion at hip, lie on side and grab leg, flex/extend at hip joint and check for discomfort. Bring leg in and kick out to move core muscles, see if anything on the peritoneal muscles inflamed.
- Obturator sign: pain with adduction and external rotation at hip
- Peritoneal signs:
- rebound: increase in pain with quick withdrawal of hand from deep palpation
- guarding: tensing of the abdominal muscles at initiation of palpation
- tap tenderness: pt reacts when percussing
Other Surgery in Clinic:
- Scratch test (hepatomegaly)
- Assessing size of liver, for hepatitis
- Used instead of percussing.
- Drains from surgery such as a mastectomy. If red, swollen, warm, tender skin, it could be fluid or an infection.
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