Who you are:
You are FY2 in Emergency DepartmentWho the patient is:
Mr. Peter Smith presented with abdominal pain for the past 2 days.What you must do:
Talk to him, take history, and manage him accordingly.
D: Hi my name is Dr. Khalil I am one of the junior doctors in this EMERGENCY department can you please confirm me your name and age please
P: yes dr my name is peter smith I am 30 years old
D: how would you like me to call you ?
P: peter Is fine dr
D: ok peter, What brought you here today?
P: I am having pain in my abdomen .
D: Could you tell me more about it?
P: It’s been happening for the last couple of days and is colicky pain .
SOCRATES
D: Site of pain ?
P: generalized pain in whole abdomen
D: Anything which makes the pain better ?
P: No
D: Is there anything else which makes it worse
P: Dr. its getting worse by its own.
D: Is it radiating some where?
P: no its in my abdomen only.
D: scale your pain 0 to 10
P: 4 or 5 Dr.
D: How are you managing It?
P: I have been taking Ibuprofen for it but its not working .
D: anything else ?
P: I am also having vomiting
FODPARA
D: when it started ?
P: it started one day after the pain in my abdomen
D: how many times per day ?
What is the content of your vomit?
Any blood in vomit? (NSAIDS)
P: 4 to 5 times per day
D: anything making it better
P: no doctor
D: anything making it worse
P: Its getting worse dr.
D: anything else
P: like what dr
D: nausea?
P: no
D: have you passed stools?
P: I haven’t since last few days
When was the last time you passed stools?
D: have you pass wind?
P: no doctor since last day .
How were your bowel habits before this problem? (IBD)
Did you notice any bloating, fullness in your tummy before?
D: fever and flu like symptoms? ( intra abdominal infections )
P: no doctor
D: Loss of weight?
P: no
D: loss of appetite? ( cancer )
P: no
D: lumps and bumps in the body ?
P: No doctor.
Have you noticed any bleeding from your back passage?
D: weather preference , weight gain ( hypothyroidism )
D: Any past history of surgical procedures in your abdomen ? ( adhesion )
P: no doctor
D: rule out IBD as it can lead to narrowing and finally obstruction .
MAFTOSA
D: any past medical history of chronic illness like DM, PERIPHERAL VASCULAR DISEASE ,
P: NO
D: are you taking any medications ? TCA , ANTI DEPRESSANT
( risk factor )
P: no
D: allergic to medications ?
P: no
D: Family history of dvt
P: no
D: are you smoking alcohol ?
P: Yes doctor , 20 cigarettes for the last 10 years
D: are you taking alcohol ?
P: yes dr I am taking alcohol 10 pints for the last 5 years
D: hows your diet ?
P: I am taking a lot of meat in my diet ( less fiber diet ) ( risk factor for constipation )
D: Physical activity ?
P : not that active .
D: Anything else that you would like to share with us
P: That’s it doctor .
D: Do you have any IDEA whats going on with you ?
P: No doctor .
- I would like to check your bp, pulse, RR, temperature , GPE and we will also be doing some blood tests like FBC, U&Es and creatinine as well as a plain abdominal x-ray. We may plan an MRI, ultrasound and CT scan if needed.
- I would also like to examine your abdomen .
- We will also check for blood group and crossmatch in case major surgery is required
- Examiner findings Distended abdomen, tympanic sound on the percussion of the abdomen due to an air-filled stomach and high-pitched bowel sounds
- From our assessment, we are suspecting you may have a condition called intestinal obstruction. It happens when something blocks your bowels, either your large or small intestine.
Treatment
- Uncomplicated obstruction: Management is conservative, including passing an NG tube, fluid resuscitation and monitoring fluid input/output, electrolyte replacement, intestinal decompression and bowel rest.
- When gastrointestinal obstruction results in ischaemia, perforation or peritonitis, then emergency surgery is required. Laparotomy may be required. In view of the risk of perforation and absorption of toxins from ischaemic bowel, prophylactic antibiotics for gut surgery are advised.
D: Do you have any idea of intestinal obstruction ? P: No An intestinal obstruction occurs when your small or large intestine is blocked. The blockage can be partial or total, and it prevents passage of fluids and digested food. If intestinal obstruction happens, food, fluids, gastric acids, and gas build up behind the site of the blockage. D: I would like to inform my seniors and we will ADMIT YOU IN THE HOSPITAL Is that okay ?
D: they may consider doing an X RAY ABDOMEN and ULTRASOUND ABDOMEN and CT SCAN to confirm the diagnosis. P: What are the RISK FACTORS for intestinal obstruction ? D: May be due to adhesions. strangulated hernia malignancy or volvulus. The majority (75%) of small bowel obstructions are attributed to intra-abdominal adhesions from prior operations. Malignancy usually means a tumor of the caecum, as small bowel malignancies are P: How are you going to treat me now?
TREATMENT
I would like to give you some pain killers
I will also inform my seniors to further assess you .
Uncomplicated obstruction management is conservative including
• fluid resuscitation
• electrolyte replacement
• intestinal decompression
• bowel rest.
Complicated obstruction
Surgery can be done in complicated cases to relieve the obstruction
Red flags
Severe unbearable pain
Unconsciousness
Dizziness -Inform the nurses and let us know .
Further information about the operation
In some cases, an operation can be performed to unblock the bowel. This may involve bowel resection, adhesiolysis (release of adhesions)bypass procedure and/or stoma formation. Surgeons may remove the affected part of the bowel and suture (join) the two ends together. If it is not possible to connect the two ends together, they will bring out the end of the bowel through an incision in the abdomen and a stoma bag will collect your stool. Stents Self expanding metal stents (SEMS) are metallic tubes (or stents) used to hold open the bowel if it is obstructed by a tumor so that stools can pass through. 3 They can provide rapid relief of distressing symptoms in patients not considered fit for surgery, or for those who have symptoms of bowel obstruction which need to be treated urgently.