| | Abdominal
pain
Prof J.H. van Bockel, S.
Eggermont, drs P.M. Bloemendaal
After a short conversation with
your assistant, mister Biesheuvel requested an immediate appointment with you as
his general practitioner.
He woke from his sleep several times last night
because of a terrible pain in his abdominal region, until eventually he couldn't
catch sleep anymore. He phoned your assistant first thing this morning. Mister
Biesheuvel would like you to find the cause of this pain and treat it, if
possible.
05/09/2001 10:50 Location of your patient:
General practitioner
Age
Your patient is 50 years
old.
Allergies
No known allergies.
No hay fever In particular
and no allergic reactions to domestic animals or dust.
How are
you?
The pain in my stomach is irritating me, could you tell me what is
causing it?
Over-sensitiveness
Not hypersensitive to medication,
antibiotics, iodine or sticking plaster
Shivers
No
shivers.
Weight
Your patient is not overweight and has not lost or
gained weight during the last months.
Previous history
At the age
of twelve the patient moved back from Indonesia to the Netherlands.
Never had
any venereal diseases and was never admitted to hospital or operated on. At the
age of twenty he broke his wrist, no complications.
Upon questioning, he
answers that he has suffered from the same pain in the past. It was on a
Saturday and he did not consult a physician. Luckily the pain went away then
after a few hours.
During the last few weeks he has felt this pain again now
and then.
Defecation
Normally patient passes stool once a day.
Today this has not ocurred yet, yesterday the patient didn't pay any attention
to it, he hasn't noticed anything special.
Diet
"This pain has
caused me to lose my appetite. Normally I am not on a
diet."
Flatulence
The patient has no complaints of
flatulence.
Gall-bladder related problems
"I never had colorless
defecation."
"I have had this pain before. That time it only lasted for a few
hours and I didn't bother to visit my family
physician."
Intolerances
"As far as I know I am not allergic to
anything"
Last meal
"My wife and me had lasagna for diner last
night. It was a bit heavy on the stomach, but I only fell ill during the night.
It hasn't caused her any digestive problems."
"This morning I had only one
dry slice of toast."
Nausea
"I am pretty nauseous. I have got this
strange sensation in my stomach, as if I have eaten something bad, but I don't
think that's it.."
Stomach acid
The patient never has any
complaints of stomach acid.
Swallowing
"Swallowing is normally not
painful, but I couldn't swallow any food just this moment because I am
nauseous."
Vomiting
"No, I don't have to throw up."
Weight
changes
The patient has kept his normal weight during the last
years.
Pain
The patient describes the pain of last night as cramps
in upper part of the abdomen, as if he had eaten something bad. The cramps are
now coming more rapidly one after the other.
Pain location
"This morning the pain started around my stomach, that
is why I thought I had eaten something bad. Now my whole upper abdomen
hurts."
Pain radiation
"The pain is in the right upper
part of my abdomen most of the time, but I can feel it radiate to the side
sometimes."
Inspection abdomen
No visible swelling of the groin when
pressing.
No scars, symmetric breathing pattern. Abdomen seems to be a bit
swollen.
Auscultation abdomen
Normal lively peristalsis.
Percussion abdomen
Percussion is
unpleasant and particularly painful in the upper right region of the abdomen.
Tympanic sounds differ through different parts of the abdomen.
Palpation
abdomen
Palpation of the abdomen is painful, particularly on the right.
Muscular resistance complicates examination. The liver is not palpable.
Murphys syndrome
You make your patient sit upright and place your
fingers in the right abdomen, just beneath the thorax. You ask your patient to
breath in deeply.
Result: Pain shows from mister Biesheuvel's face.
Pain on release
The patient does not complain of pain on release
after palpation.
Inspection anus
No skin defects.
Rectal
examination
Normal sphincter tension. Ampoule filled with soft feces,
brown feces on the glove, no blood or mucus present.
05/09/2001 11:03 Buscopan 10 mg
Buscopan tablets 10 mg \s 3-5 times a day 1-2 tables.
Ultrasound abdomen is requested.
Blood Leucocytes is requested.
Plasma Alkaline phosphatase is requested.
Plasma Bilirubin is requested.
05/09/2001 11:16
Appointment for tomorrow
Mister Biesheuvel
returns the next day.
Your requests of 05/09/2001
11:16:
06/09/2001 11:44 Blood
Leucocytes
9.9 10e9/l (normal: 4,3 - 10,0 10e9/l)
06/09/2001 11:44 Plasma Bilirubin
17.0 µmol/l (normal: tot 17,0 µmol/l)
06/09/2001 11:44 Plasma
Alkaline phosphatase
79.2 U/l (normal: 15 - 60
U/l)
06/09/2001 11:44 Ultrasound abdomen
The wall of the
gallbladder is slightly expanded. Cross-section of the gallbladder is estimated
at 5 cm. Visible sludge and concretes in the gallbladder, generating cast
shadow.
No visible expansion of the bile ducts.
No abnormalities in the
kidney region. No hydronephrosis.
Ultrasound abdomen
06 Sep 2001 11:44:35
| 06 Sep 2001 11:46
seggermont () |
Dear colleague,
I refer to you mister Biesheuvel.
Ultrasound shows gallbladder stones. Possible obstruction of the bile
ducts.
Request for further examination. |
Location of your patient: First aid
Mister
Biesheuvel hands over a note from his family physician .
You are now
performing the role of assistant-surgeon and are responsible for further
diagnostics and treatment of mister Biesheuvel.
Your patient is already in
hospital.
ERCP is requested.
Your request of 06/09/2001
12:21:
06/09/2001 14:02 ERCP
ERCP
The scope is brought in through the esophagus, the stomach and the
papilla duodeni major into the bile ducts. A contrast fluid is injected. The
gallbladder does not become visible. The hepatopancreatic duct does not show
signs of obstruction.
Conclusion: No sings of obstruction of the
hepatopancreatic duct, obstruction in de gallbladder or the cystic duct cannot
be excluded.
EKG is requested.
X-ray thorax cito is requested.
Your requests of 06/09/2001
14:02:
06/09/2001 14:20 X-ray thorax cito
X-ray can
be well judged, good inspiration, good lighting.Sinuses clear, sharp
diaphragm lines. Hart normal size. No signs for any abnormality to hart or
lungs.
X-ray thorax cito
X-ray thorax cito
06/09/2001 14:20 EKG
The EKG does not show any abnormalities,
no signs of an infarction or irregular rhythm.
EKG
Your patient is on the waiting list for a Laparoscopic
cholecystectomy.
Your request of 06/09/2001
14:20:
06/09/2001 17:21 Laparoscopic
cholecystectomy
Operation report.
Introduction
of the first trocar through open method of approach of fascia and peritoneum.
Insufflation of the abdomen. The other trocars are brought to
view. Inspection of the abdomen. No abnormalities. Next step is hooking of
the gallbladder. This is complicated by the inflammatory character of the
gallbladder. Stretching of the gallbladder, opening of the serosa over the
cystic duct. Preparing the cystic duct, clipping, preparing the cystic arteria,
clipping. The cystic duct as well as the cystic arteria are cut through.
Retrograde removal of the gallbladder through subserous removal from the
liverbed. The gallbladder is removed through the trocar at the navel. There is
nog leakage of gall or loss of stones. Control on hemostasis. Retraction of the
trocars, desufflation of the abdomen. Closure of the incisions. The simulation has been stopped.
In this case the patient was suffering from gallstones that were
trapped in the cystic duct. Clinical representation
was first that of gallbladder colic pain and switched to acute cholecystitis
within a week.
The family physician should come to the right diagnose and refer the patient to
hospital for further examination.
The physician at the first aid can affirm the diagnose by additional research
such as an ERCP and should schedule the patient for operation.
Your score
Positive actions:
 | Defecation : 5
| Weight changes : 2
| Nausea : 2
| Last meal : 2
| Gall-bladder related problems : 5
| Diet : 2
| Pain : 5
| Pain location : 5
| Rectal examination : 2
| Percussion abdomen : 2
| Murphys syndrome : 5
| Pain on release : 2
| Palpation abdomen : 2
| Inspection abdomen : 2
| Auscultation abdomen : 2
| Buscopan 10 mg : 10
| Ultrasound abdomen : 10
| Plasma Alkaline phosphatase : 5
| Plasma Bilirubin : 5
| Blood Leucocytes : 5
| ERCP : 10
| EKG : 5
| X-ray thorax cito : 5
| Laparoscopic cholecystectomy : 30 |
| | | | | | | | | | | | | | | | | | | | | | |
For this case it is perfect to retrieve 115 points, while you may loose a
maximum of 100 points.
You scored 130 points and lost 0 points.
Your total score until now: 10.0
Here are the costs of your actions:
| Buscopan 10 mg : 4
| Ultrasound abdomen : 54
| Plasma Alkaline phosphatase : 3.2
| Plasma Bilirubin : 2.6
| Blood Leucocytes : 2.6
| ERCP : 45
| EKG : 27
| X-ray thorax cito : 35
| Laparoscopic cholecystectomy : 450 |
| | | | | | | |
Total costs: 623.4
You forgot the following items according to the author of this case:
Refer to hospital points: 10
This action would have had the
following effect: Comments of the author: If a patient is suspected for a
disease that requires short term operation, you have to refer the patient to
the hospital.
Temperature ear points: 5
This measurement of lab result would
give the following value (at this time): 37.1 ° Celsius
Comments of the
author: Raised temperature can point to an inflammatory process.
Plasma Bilirubin conjugated points: 5 costs: 2.6
This
measurement of lab result would give the following value (at this time): 4.2
µmol/l (normal: tot 4,0 µmol/l)
Skin color points: 2
The result at this moment of Skin color:
The skin color is normal.
Comments of the author: Liver pathology can
cause yellow discoloring of the skin
Shoulder pain points: 2
The result at this moment of Shoulder
pain: No pain in the shoulder.
Comments of the author: Radiation of pain to the shoulder region can point to pathology of the gall bladder.
Comment page
Comment on Defecation
Colorless defecation can be prove of the absence of substances from the
gallbladder
Comment on Diet
A patient's diet gives information about intolerances or limitations to
nutritional components.
Comment on Gall-bladder related problems
Gallstone related colic can sometimes cause pain that will subside
spontaneously. When the pain persists, operation might be necessary to prevent
cholecystitis.
Comment on Last meal
The patient's last meal does not seem to have caused the current problems.
Comment on Nausea
Complaints of nausea seem
not related to the feeding pattern of this patient.
Comment on Weight changes
Persisting pathology of the digestive tract can cause weight loss.
Comment on Pain
Important aspects in pain:
| onset, location, transfer.
| sudden or sliding onset
| colic attacks or continues pain
| vomiting, defecation, flatulence. |
| | |
Comment on Inspection abdomen
Pay attention to swelling in the
groin region, scars of operating procedures and general swelling of the abdomen.
Comment on Auscultation abdomen
Visceral pain can cause stillness of the
bowels
Comment on Percussion abdomen
Percussion can bring abnormal accumulation of gas and sensitivity of the
abdomen.
Comment on Palpation abdomen
Pay attention to pain with and resistance to palpation and the presence of
abnormal swellings.
Comment on Murphys syndrome
Positive findings for this test point to sensitivity of the liver or gall bladder.
Comment on Pain on release
Internal movements of the abdominal organs can cause pain on
release.
Comment on Rectal examination
Rectal examination should always be part of a thorough abdominal
examination.
Comment on Buscopan 10 mg
If the pain is caused by spasms of the digestive tract, effect can be
expected within hours.
Comment on Ultrasound abdomen
An abdominal ultrasound is the
least invasive technique to obtain supplementary information about pathology in
the abdomen.
In the diagnoses of gall bladder stones the accuracy is about 99
%.
Comment on ERCP
Negative findings in ERCP do not exclude pathology of the bile ducts.
Comment on EKG
If your patient has to undergo surgery it is sensible to make an EKG and a
thoracic x-ray to bring possible underlying hart conditions to light.
Comment on X-ray thorax cito
If your patient has to undergo surgery it is sensible to make an EKG and a
thoracic x-ray to bring possible
underlying hart conditions to light.
Comment on Laparoscopic cholecystectomy
Acute cholecystitis requires operation within 72 hours after the onset of the
pain.
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