Marleen, a 20-year-old student, has called an out-of-hours general practice. She has had abdominal pain for the last 12 hours. The pain is becoming worse and she feels increasingly ill.<\/span><\/p>\n She presents one hour later. She took a taxi because cycling was too painful. Even the taxi ride was uncomfortable. She felt every speed bump in her abdomen. In addition, she cannot walk fully upright due to the abdominal pain.<\/span><\/p>\n When she woke up this morning, Marleen was already feeling ill. She had a vague pain around her navel and felt slightly nauseous. She therefore decided not to go to class. She thought she may have eaten something the day before that disagreed with her.<\/span><\/p>\n Throughout the afternoon, the pain became worse and sharper. The pain was now located more in the lower right abdomen. The pain did not radiate.<\/span><\/p>\n In the evening, the pain caused mild cramping, but has since become persistent. The pain is just bearable as long as it doesn\u2019t get any worse. It doesn\u2019t feel right. Lying still, slightly hunched, is the most comfortable position. Walking and the movement in the taxi were very unpleasant.<\/span><\/p>\n The patient has mild nausea. She vomited once today. The vomit looked normal – tea and toast that she had eaten one hour earlier. Over the course of the day, she became increasingly ill. She is shivering and thinks she may have a fever.<\/span><\/p>\n She has no other symptoms. She claims that she is rarely sick, and has no pain when urinating. Sometimes she feels the urge to urinate, but finds she does not need to. The urine looks normal. Her period is always normal, her last period started seven days ago and just ended. She has had a new serious boyfriend for the last five months, and has used a contraceptive pill for the last two months. She has no vaginal discharge and no pain during sexual intercourse.<\/span><\/p>\n Initially, the abdominal pain had characteristics of visceral pain. Because it was localised around the navel, mid-abdominal disorders were suspected (small intestine, appendix and caecum<\/em>). Then later, more intense pain is parietal pain. The pain during transit is also consistent with parietal pain. The cause of the pain lies at the site of the pain. In this case, it may be the appendix, the distal part of the small intestine (terminal ileum<\/em>), or the caecum. The right ovary and fallopian tube should also be considered. The acute onset, fever and malaise suggest inflammation.<\/span><\/p>\n Based on the patient history, acute appendicitis takes priority in the differential diagnosis, but it could also be a case of inflammation of the ileum or the right ovary and fallopian tube.<\/span><\/p>\n Marleen is moderately ill with a pulse of 88 beats per minute. Her rectal temperature is 38.2 degrees Celsius.<\/span><\/p>\n Coughing produced pain in the lower right abdomen. If coughing causes pain, always ask where the pain occurs. This \u2018confirms<\/em>\u2019 the pain upon transit or moving.<\/span><\/p>\n Auscultation reveals scant peristaltic action.<\/span><\/p>\n During palpation of the lower right abdomen, even light palpation was painful. Abdominal muscle tone was greater in the lower right abdomen than elsewhere in the abdomen.<\/span><\/p>\n Deeper palpation of the lower left abdomen also caused pain in the lower right abdomen. This phenomenon is referred to as contralateral tenderness and suggests peritoneal irritation at the pain site. The increase in pain after (abrupt<\/em>) release after palpation is referred to as rebound tenderness (ipsilateral: pain on the palpated side, contralateral: pain on the side opposite the palpated side<\/em>). This also indicates peritoneal irritation.<\/span><\/p>\n The abdominal examination is concluded with a vaginal examination to check for signs of inflammation in the extreme lower abdomen (the lesser pelvis<\/em>) or to check for the presence of a palpable mass deep in the abdomen.<\/span><\/p>\n There appears to be cervical motion tenderness on the right side. More resistance is found in the lower right abdomen, but there is no clearly palpable mass; palpation of the left side is normal.<\/span><\/p>\n These findings support the diagnosis of acute appendicitis.<\/span><\/p>\n Additional examination will consist of general blood work-up (leucocytes and assessment of acute-phase proteins<\/em>) and urinalysis (with particular attention to the sediment to rule out a urinary tract infection<\/em>).<\/span><\/p>\n Surgical removal of the inflamed appendix should occur in a timely manner. If too much time passes, the infected appendix will burst (perforation<\/em>), leading to generalised peritonitis – a severe, life-threatening complication.<\/span><\/p>\n <\/p>\n","protected":false},"excerpt":{"rendered":" Marleen, a 20-year-old student, has called an out-of-hours general practice. She has had abdominal pain for the last 12 hours. The pain is becoming worse and she feels increasingly ill. She presents one hour later. She took a taxi because cycling was too painful. Even the taxi ride was uncomfortable. She felt every speed bump […]<\/p>\n","protected":false},"author":83,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[24],"tags":[126],"class_list":["post-981","post","type-post","status-publish","format-standard","hentry","category-the-abdominal-examination-in-a-clinical-context","tag-the-examination-of-the-abdomen"],"acf":[],"yoast_head":"\n
\nHistory-Taking<\/strong><\/span><\/h3>\n
\nExplanation<\/strong><\/span><\/h3>\n
\nFindings and Explanation<\/strong><\/span><\/h3>\n
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