a short clinical course----

2. ACUTE ABDOMEN- acute attack of abdominal
pain that may be sudden or gradual, with
other symptoms
 Denotes an underlying disorder that requires
immediate attention and possibly surgical
intervention
 Careful history and examintaion, early
diagnosis and treatment is crucial

3. INTRA-ABDOMINAL / EXTRA-ABDOMINAL
Intra-abdominal
1) Inflammation- acute appendicitis, acute cholecystitis, acute salpingitis,
amoebic liver abcess, acute pneumoccal peritonitis
2) Perforation- of peptic ulcer, typhoid ulcer, ulcerative colitis
3) Acute Intestinal Obstruction –
A) Mechanical- (i) in the lumen- gallstone, round worms
(ii) in the wall- tubercular stricture, intussception,
growths
(iii) outside the wall- volvulus, external and internal
hernia

4. B)Toxic – paralytic ileus
C) Neurogenic – Hirschsprungs’s
D)Vascular – Occlusion of mesentric vessels by
embolism or thrombosis
4) Haemorrhage – spontaneous rupture of malarial
spleen, rupture of ectopic gestation, ruptured lutein
cyst
5) Tortion of pedicle- twisted of ovarian cyst, spleen
6) Colic – biliary, ureteric, appendicular, intestinal.

5. Extra-Abdominal
1. Parietal conditions: gas gangrene of the abdominal wall,
abscess of the abdominal wall, rupture of rectus
abdominus, superficial cellulitis of the abdominal wall
2. Thoracic conditions: lobar pneumonia, spontaneous
pneumothorax, angina, pericarditis
3. Retro-peritoneal conditions- uremia, pyelitis, dissecting
anwurysm of aorta
4. Diseases of spine, spinal cord, and intercostal nerves:
pott’s disease, acute osteomyelitis, herpes zoster, tabes
dorsalis
5. General diseases: malaria, typhoid, sickle cell anemia,
purpura

6. HISTORY
AND
EXAMINATION

7.  Age
 Sex
 Occupation
 Social status

8. PAIN
 Time of onset: acute appendicitis, peptic ulcer
 Mode of onset:
perforation, colic, torsion - sudden
acute intestinal obstruction- gradual increase
acute appendicitis- sudden increase
 Duration: periodicity, varying intensity
 Site of pain: pointing test
flank- renal
right costal margin- liver or gallbladder
epigastric- perforation, pancreatitis
 Shifting: acute appendicitis- umbilicus to right iliac fossa due to parietal peritonitis
 Radiation: peptic perforation, spreading peritonitis
 Referred pain: epigastrium, around the umbilicus, hypogastrium, shoulder, loin to
groin, scapula
 Character of pain: colicky, constant burning pain, severe agonising pain, throbbing
pain, change in character of pain
 Pressure on pain
 Aggravating and relieving factors: jolting, walking, respiration, micturition (strangury),
lying still, fatty foods, alkalis, stooping, vomiting

9. VOMITING
 Character- projectile/regurgitation
 Vomitus- intestinal obstruction, gastrocolic
fistula, biliary colic, peptic ulcer, peritonitis
and uremia
 Frequency and quantity- frequent/periodical,
nausea characteristic of appendicitis
 With respect to pain: appendicitis,
pancreatitis, colic, in high obstruction

10. BOWEL HABITS
 Constipation-obstruction, appendicitis,
peritonitis
 Tenesmus- pelvic appendicitis, abcess,
rectum
 Diarrhoea- colitis, acute enteritis, ileitis

11. MICTURITION
 Strangury
 Hematuria – retrocaecal appendicitis

12. PERSONAL HISTORY
 Menstrual history
 Smoking alcohol
PAST HISTORY:
 Previous operations
 Jaundice
 Malaena/hematochezia
 Previous episodes of pain
 Drug history
 Family history
 Travel history

13.  Appearance
 Attitude
 Pulse
 Respiration
 Temperature
 tongue

14. - Contour:
- Scaphoid or flat in peptic ulcer
- Distended in ascites or intestinal obstruction
- Visible peristalsis: in a thin or malnourished
patient (with obstruction)-laddar pattern
- Respiration-sluggish in peritonitis
- Pulsating swelling- aneurysm
- Skin discoloration- grey turner’s sign and
Cullen’s sign

17.  Cutaneous hyperaesthesia
Either lift the skin or stimulate the skin with gentle
jabbing with a sterile pin
Indicates a zone of peritoneal irritation
RLQ -- appendicitis
Mid Epigastrium -- peptic ulcer

19.  Tenderness
 Degree and extent
 Bed-shaking test(Bapat)-peritonitis
 Spread
 Appendicular tenderness in left lateral
position

20.  Rebound tenderness
 Apply firm pressure for several seconds to the
abdomen with hand at right angles and
fingers extended
 Quickly release the pressure
 Test away from site where pain is initially
determined

22.  Pain at site is direct rebound tenderness
 Pain at another site is referred rebound
tenderness
 Indicative of peritoneal inflammation

23. Rovsing’s sign
Press in the LLQ evenly for 5 seconds and
note if patient has pain in RLQ – positive-
Gas is pushed through the ileocecal valve thus
distending the cecum-
In acute appendicitis- positive

24.  Cope’s PsoasTest
 Place your hand over the right thigh and push
downward as the patient is trying to raise the
leg, flexing the hip
 Positive RLQ pain associated with a
retrocaecal or perforated appendicitis

26.  ObturatorTest
 Flex the right leg at the hip and knee at a right angle
then rotate the leg internally and externally
 Pain indicative of inflammatory process over
obturator muscle
 Ruptured appendix
 Pelvic abscess

28.  Muscle Guarding
 Use both hands -- one on each rectus
 Check for tensing during expiration
 When positive it is indicative of peritoneal
irritation -- peritonitis

29.  Shifting dullness
 Fluid thrill
 Obliteration of liver dullness

31.  Auscultation
 BS
 > 2min to confirm absent
 High pitched, hyperactive or tinkling
 Bruit in epigastrium
 Noisy abdomen-acute intestinal obstruction
 Silent abdomen- peritonitis