Acute Abdominal Pain – OSCE Case

Where is the pain?

“At first it was everywhere, but now it is in my lower tummy on the right-hand side”

When did the pain start?

“Around two days ago”

Did it come on suddenly?

“Yes”

How would you describe the pain?

“A sharp pain”

How bad is the pain out of 10?

“8/10 at the moment”

Does the pain go anywhere else?

“No”

Does the pain follow any pattern?

“No, it’s just constant and there all the time”

Does anything help the pain?

“Not moving! I took some paracetamol and that helped a little”

Does anything make the pain worse?

“Moving around”

Have you had any nausea or vomiting?

“Mainly nausea, but I did vomit a couple of times when the pain started”

How is your appetite?

“Yes, I’ve not really eaten since it started”

Any change in weight?

“No”

Have you had a fever?

“Not really, I think the highest I’ve measured has been 37.8C”

Have you had a change in bowel habit?

“No”

Have you noticed any blood in your stools?

“No”

Any change in the amount you are passing urine?

“No”

Is it painful to pass urine?

“No”

Have you had any illnesses recently?

“I had a cold last week”

Have you been feeling more tired than usual?

“No”

Have you noticed any skin changes?

“No”

Have you noticed any abnormal vaginal bleeding?

“No”

Have you noticed any abnormal vaginal discharge?

“No”

When was your last menstrual period?

“It started 2 weeks ago and lasted 4 days”

• Basic observations
• Abdominal examination
• Vaginal examination

Examination findings

Basic observations:

• HR 108, RR 20, BP 106/62, Oxygen saturation 96% on air, Temperature 37.9^oC

Abdominal examination:

• Generally tender abdomen, maximal tenderness in the right iliac fossa (RIF)
• Voluntary guarding present
• Bowel sounds normal
• No organomegaly

Vaginal examination:

• Vulva appears normal
• No evidence of vaginal prolapse
• Cervix appears normal
• No cervical motion tenderness
• Uterus is of normal size and is anteverted
• No palpable masses

• Rovsing’s sign: palpation of the left iliac fossa (LIF) causes RIF pain
• Psoas sign: extension of the right thigh, in the left lateral position, causes RIF pain
• Obturator sign: internal rotation of the flexed right thigh causes pain
• Hop test: hopping or jumping causes abdominal pain

A urine pregnancy testis one of the most important initial investigations in a woman of childbearing age presenting with abdominal pain.

• Blood glucose
• Urinalysis

• Full blood count
• Urea and electrolytes
• CRP
• Coagulation profile: in case surgery is needed
• Group and save: in case a blood transfusion is needed

Vascular: mesenteric ischaemia, upper gastrointestinal bleed, ovarian torsion

Inflammatory & infectious: acute appendicitis, gastroenteritis, urinary tract infection, pelvic inflammatory disease, ruptured ovarian cyst

Neoplastic: intra-abdominal malignancy

Degenerative: diverticulitis

Idiopathic:

Congenital:

Autoimmune: inflammatory bowel disease

Traumatic:

Endocrine: ectopic pregnancy, endometriosis, diabetic ketoacidosis

The most likely diagnosis in this patient is acute appendicitis.

They have presented with typical symptoms of migratory abdominal pain (beginning generally and localising to the RIF), nausea and vomiting, and anorexia. The combination of RIF pain, nausea and vomiting, and low-grade fever is known as Murphy’s triad and is commonly seen in appendicitis.

• Intravenous fluids
• Analgesia
• Antiemetics
• Antipyretics

Laparoscopic appendicectomy

This operation removes the inflamed appendix carried out under general anaesthetic. Generally, a laparoscopic approach is preferred. However, an open procedure may be required if the appendix has burst, the patient has a history of abdominal surgery or has from peritonitis.

• Group and save (+/- crossmatch)
• Ensure the patient is nil by mouth
• Consent patient for surgery
• Anaesthetic assessment
• Prescribe any regular medications
• Venous thromboembolism (VTE) risk assessment
• Prescribe VTE prophylaxis
• Inform theatres

• Perforation: leading to generalised peritonitis
• Abscess formation: generally requiring drainage
• Sepsis