SMALL GROUP SESSION 18A
January 20th or January 22nd
Abdominal Pain Case and Abdominal Examination Workshop
Suggested Readings: Complete the abdominal exam module on the POM-1 web-site
Optional: http://medicine.ucsd.edu/clinicalmed/abdomen.htm
Mentors: Bring pads, cleaning supplies, gowns, and hand washing gel.
Prepare by: Wearing clothing that will allow for examination of the abdomen: two-piece outfits; bringing your stethoscope.
A group member should bring anatomy text or notes and atlas.
Hand in your hospital interview write ups from last week
Brief Outline: Section 1 Touch base (20 minutes)
Section 2 Abdominal pain case (60 minutes)
Section 3 Abdominal examination (90 minutes)
Section 4 Evaluation (10 minutes)
Objectives for Session 18
By the end of this session, students will able to:
· Apply knowledge of anatomy of the abdomen to a patient with abdominal pain.
· Perform a physical examination of the abdomen
Section 1: Touch base (20 minutes)
Are you well adjusted to the workload in medical school yet? Share how you cope with your peers.
Section 2: Case discussion (60 minutes)
Logistics:
A student interviews the mentor, who plays the patient in the case.
Then mentors hand out or view the case on the projector and discuss.
Pick a scribe to record discussion, and then choose learning objectives.
We suggest that you write findings or questions in several columns:
· History
· Physical findings
· Anatomy
· Issues (physician, patient, ethical)
· Diagnostic possibilities
· Laboratory and test findings, if any
Case discussion, Part 1 (patient history)
Patient: you are a 40 year old and are coming to the doctor for abdominal pain that started 4 days ago. The pain started gradually in your upper abdomen. The pain was initially mild, but is now severe, and is radiating to the middle of your back. The pain, while continuously present, has a crampy quality, building up to greater intensity and then declining. You took several tablets of tums, with no response. For the last hour you have had nausea with occasional vomiting. You don’t know if you have a fever, but you have had chills for the past half-hour. You have not had diarrhea or other change in bowel habits. You deny any urinary symptoms. You have been feeling well, apart from the pain.
Your past history is significant for high cholesterol, for which you take a medication, zocor; and reflux
If a woman, you have 2 children, ages 10 and 12, and have had a tubal ligation. Your last period was 2 weeks ago.
Social history; married, work at Lowe’s; current tobacco use (1 pack per day for 20 years. You drink at least 2 cans of beer every night (though your responses to the CAGE questions are negative)
Family history: Your father (a smoker) died of lung cancer, and your mother died of stomach cancer.
1. What are the important history findings? What could they mean?
2. What organs are located in the upper abdomen?
3. What are some diagnostic possibilities?
(After the interview, mentors hand out or project the rest of the case)
Physical examination:
Physician: On exam, the patient appears uncomfortable, and is rocking back and forth holding his/her abdomen. T is 37.9, P 108, R 18, BP 140/90. Lung and heart exam are normal.
Abdominal exam shows the abdomen is flat, with decreased, but present, bowel sounds. There are no bruits. There is slight tenderness to percussion in the epigastric region. The liver span measures 7 cm to percussion. There is moderate tenderness to palpation in the epigastrium, and the patient has guarding upon deeper palpation. There is no CVA tenderness. There is no rebound tenderness.
4. What have you learned from the physical examination? What could cause these findings?
Suggested learning objectives (if needed):
1. What organs/problems can cause pain in this area (epigastrium)?
2. What do guarding and rebound tenderness mean?
3. What is the reason pain is felt in his/her back?
4. What is the relationship between the past medical/social history and his/her current condition?
Section 3: Examination of the abdomen (90 minutes)
Use the OSCE sheets for abdominal exam as a guide for this section. (Attached in this session)
· Inspection: for distension, scars, hernias, asymmetry, etc.
· Auscultation: (before you touch the abdomen):
o For normal bowel sounds: in all four quadrants
o For bruits: over the aorta, renal arteries and iliac arteries
· Percussion:
o Of the liver: estimate liver size by percussing up from the abdomen and down from the chest, both at the right midclavicular line
o Of the spleen: look for enlarged spleen by percussing just above the lowest rib in the left anterior axillary line, first at rest, then in the same location while patient takes and holds a deep breath
o Of all four quadrants, listening for changes in pitch or quality
· Palpation:
o Of liver edge by deep palpation, starting low in the abdomen and moving up to the right costal margin at the midaxillary line
o For enlarged spleen, holding rib cage up from below with your left hand while pressing inward with the right hand, starting at the left lower quadrant
o For aortic pulsation, using palmar surface of fingers of both hands, or thumb and forefinger of one hand in the upper abdomen, just left of midline
o For masses and tenderness: once lightly and once deeply
Percussion of kidneys for CVA tenderness: just under the lowest rib posteriorly on both sides
Section 4: Evaluation (10 minutes)
How did this small group go? What could make it work better in the future?
Abdominal
A = Attempted Satisfactory B = Attempted Below Satisfactory C = Did Not Attempt
Procedure A B C Comments
1. INSPECTION: Ex should inspect abdomen for color, contour, symmetry, movement, scars.(Ex should state what they are inspecting for.)2. AUSCULTATION: Ex should listen to ALL FOUR QUADRANTS of the abdomen: right upper, left upper, right lower, and left lower. The ex MUST auscultate before palpating or percussing.
Ex should listen to the AORTIC artery (located in the middle of the abdomen above the umbilicus), the RENAL arteries (located above the umbilicus), the ILIAC arteries (located below the umbilicus, bilaterally)
3. LIVER PERCUSSION: Ex should begin percussing the liver in the right midclavicular line at the level between the lower right chest and the umbilicus and proceed superiorly. Then, Ex should begin in the right midclavicular line over the lung and proceed inferiorly.
4. SPLEEN PERCUSSION: Ex percusses just above lowest rib on the left anterior axillary line and then repeats while Pt holds a deep breath.
5. LIGHT PALPATION TECHNIQUE: Ex should first palpate all four quadrants and the epigastrium LIGHTLY while using the palmar surface of the fingers to identify any masses or areas of tenderness.
6. DEEP PALPATION TECHNIQUE: Ex should palpate all four quadrants and the epigastrium more DEEPLY while using the palmar surface of the fingers.
7. LIVER – RIGHT COSTAL MARGIN: Ex should place his/her hand on the lower right quadrant of Pt’s abdomen and gently press in and upward. Ex should ask Pt to take a deep breath and then exhale while Ex moves his/her hand upward toward the right.
8. SPLEEN – LEFT COSTAL MARGIN: Ex should place his/her left hand around Pt’s left lower rib cage and gently press upwards against back. Ex’s right hand is placed below the left costal margin and pressed inward toward the spleen. Ex should start in the lower left quadrant and work up towards the upper left quadrant.
9. AORTIC PULSE: Ex should use opposing thumb and finger or palmar surface of fingers and palpate the aortic pulsation located in the upper abdomen slightly to the left of midline.
10. CVA TENDERNESS: Ex should use his/her fist and percuss the kidneys just under the lowest rib posteriorly on both sides.
5
ãUniversity of Virginia 2009
O:\Practice of Medicine1\2008-2009\Handbook\Spring 2009\Session 18\SESSION 18A(Mentor) abdominal case and exam spring 2009_101208.doc