Learning objectives:
At the end of this session, the student shall be familiar with:
1. The approach to a patient with an acute abdomen
a. Conduct an orderly and thorough history and physical examination
b. Establish a probable cause of the acute abdomen
2. The presenting pattern of the most common causes of an acute abdomen
a. Formulate working diagnosis
b. List down probable differential diagnosis
3. The supplementary laboratory and radiologic examinations to establish the diagnosis
4. Disposition of patients diagnosed with acute abdomen
Suggested Reading Materials
1. Current Diagnosis and Treatment Surgery 14th Ed. Chapter 21: The Acute Abdomen
Supplemental Learning Materials
1. Emergency Severity Index Score
2. Clinical Practice Guideline on Acute Appendicitis (PCS)
3. Noori, I. F., Jabbar, A. S., & Noori, A. F. (2023). Clinical scores (Alvarado and AIR scores)
versus imaging (ultrasound and CT scan) in the diagnosis of equivocal cases of acute
appendicitis: a randomized controlled study. Annals of medicine and surgery
(2012), 85(4), 676–683. https://doi.org/10.1097/MS9.0000000000000270
CASE
A 23-year-old male patient presented to the emergency department due to right lower
abdominal pain for 2 days. He describes the pain initially as dull non localizing pain at the
epigastric area radiating to the back then migrated to the right lower quadrant region during the
day. It is associated with repeated vomiting, and 3 episodes of diarrhea.
On physical examination, BP 123/76 mmHg, PR 98 bpm, temp 38.5°C RR 18cpm O2 99%.
Abdomen: soft, non-distended with tenderness at RLQ region, (+) voluntary guarding at the RLQ
region (+) cough tenderness, (+) Rovsing’s sign (+) CVA tenderness Right
Hgb (g/L)
139
120-160
WBC
Neutrophil
18.8
0.84
4.5-10.0
0.56 - 0.66
PLT
Creatinine (mg/dL)
201
0.64
140 - 440
0.6 - 1.3
Na (mEq/L)
140
138 - 146
K (mEq/L)
3.5
3.5 – 4.9
PT (Seconds)
12.3
12.0 – 14.0
aPTT (Seconds)
29.0
28.0 – 37.0
Lipase (U/L)
158
23.0 – 300.0
URINALYSIS
Color
Transparency
Ph
Sp. Gravity
Blood
Glucose
Protein
Leucocytes
Red Cells
White Cells
Epithelial Cells
Casts
Bacteria
Dark Yellow
Clear
6.0
1.009
Negative
Negative
Negative
Negative
4
5
1
0
10
0-2/hpf
0-3/hpf
0-3/hpf
0-3/hpf
0-50/hpf
Whole abdominal CT scan with IV contrast: The is a diffuse inflammatory process at the
ileocecal area, appendix dilated at 1.0cm with periappendiceal fat stranding and with free fluid
in the abdomen. No urolithiases seen, bilateral kidneys normal. Pancreas normal.
Guide Questions
1. How would you triage this patient using the Emergency Severity Index
2. Conduct a thorough history of this patient
a. Characterize the pain
b. What additional questions are you going to ask the patient?
i. Are there other associated symptoms?
ii. What are other relevant aspects of the history?
3. Conduct a systemic Physical Examination of this patient
a. What are the steps in performing abdominal PE?
i. What are you trying to observe or elicit from each of the steps and its
clinical significance?
ii. Demonstrate the following special maneuvers and its clinical significance
1. Iliopsoas Sign
2. Obturator Sign
3. Rovsing’s Sign
4. Murphy’s Sign
5. CVA tenderness
4. Identify the salient features of the case and establish differential diagnoses for the case
a. What is your working impression?
b. What is your differential diagnosis?
5. What is an equivocal score for appendicitis using Alvarado Score?
6. What investigative studies will help you establish your working impression?
a. Laboratory Investigations
i. Enumerate requested laboratory investigations and their clinical
significance
b. Imaging Studies
i. What imaging modalities will you request?
ii. Is CT scan recommended for this case?
7. What is your disposition for this case?
a. What would be your management for this case?
i. Is surgery warranted for this case?
ii. What will be your antibiotic of choice?