Acute Abdominal Pain – OSCE Case

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Introduction

A 35-year-old woman is referred to the surgical assessment unit with acute abdominal pain. Work through the case to reach a diagnosis.

UK Medical Licensing Assessment (UKMLA)

This clinical case maps to the following UKMLA presentations:

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History

Presenting complaint

“My stomach is killing me.”

History of presenting complaint

Where is the pain?

β€œAt first it was everywhere, but now it is in my lower tummy on the right-hand side”

When did the pain start?

β€œAround two days ago”

Did it come on suddenly?

β€œYes”

How would you describe the pain?

β€œA sharp pain”

How bad is the pain out of 10?

β€œ8/10 at the moment”

Does the pain go anywhere else?

β€œNo”

Does the pain follow any pattern?

β€œNo, it’s just constant and there all the time”

Does anything help the pain?

β€œNot moving! I took some paracetamol and that helped a little”

Does anything make the pain worse?

β€œMoving around”

Have you had any nausea or vomiting?

β€œMainly nausea, but I did vomit a couple of times when the pain started”

How is your appetite?

β€œYes, I’ve not really eaten since it started”

Any change in weight?

β€œNo”

Have you had a fever?

β€œNot really, I think the highest I’ve measured has been 37.8C”

Have you had a change in bowel habit?

β€œNo”

Have you noticed any blood in your stools?

β€œNo”

Any change in the amount you are passing urine?

β€œNo”

Is it painful to pass urine?

β€œNo”

Have you had any illnesses recently?

β€œI had a cold last week”

Have you been feeling more tired than usual?

β€œNo”

Have you noticed any skin changes?

β€œNo”

Have you noticed any abnormal vaginal bleeding?

β€œNo”

Have you noticed any abnormal vaginal discharge?

β€œNo”

When was your last menstrual period?

β€œIt started 2 weeks ago and lasted 4 days”


Clinical examination

Examination findings

Basic observations:

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

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

Investigations

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


Diagnosis

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

Investigation results

Some of the results of the patient’s investigations are shown below.

Bedside tests:

  • Urine pregnancy test: negative
  • Urinalysis: negative for blood, nitrites, and leukocytes
  • Blood glucose: 4.7 mmol/L

Blood tests:

  • Hb 120 g/L
  • WCC 12.7 x 109/L
  • Platelets 234 x 109/L
  • Na+ 138 mmol/L
  • K+ 4.2 mmol/L
  • Urea 8.2 mmol/L
  • Creatinine 84 ΞΌmol/ L
  • CRP 48 mg/L

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.


Management

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

Complications

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

Editor

Dr Jess Speller


References

  1. Patient UK.Β Abdominal Pain. January 2023. Available from: [LINK]
  2. Patient UK.Β Acute Abdomen. August 2019. Available from: [LINK]
  3. Tavakkoli A, Szasz P. Acute appendicitis. BMJ Best Practice. 2020. Available from: [LINK]
  4. NICE CKS.Β Appendicitis. May 2021.Β Available from: [LINK]

 

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