Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a doctor working in the emergency department. Your next patient is 64-year-old Harry Wilson complaining of abdominal discomfort. Please take a history and perform a relevant examination.
Patient History:
You are Harry Wilson - a 64-year-old male - retired construction worker.
You've had some vague aching pain in the middle part of your upper abdomen which comes and goes. Not worsened by eating/moving. It is gradually getting worse. It radiates to the back. You'd rate the pain 4/10 but has got worse. Sometimes you feel lightheaded upon standing.
Bowels are normal, no urinary symptoms, no vomiting, no heartburn. Never had screening tests. No fever, no weight loss, no blood in stool, no loss of consciousness.
You haven't had any fevers, weight loss or black stool. You sometimes feel a bit faint, especially when standing up. No collapse. No loss of consciousness.
Ideas, Concerns, Expectations:
You have no idea what this is - possibly maybe reflux. You're not really worried about it, but you hope to just find out what is going on - as told by your wife.
Past Medical History:
Hypertension
High cholesterol
Angina
Type 2 diabetes.
Drug History:
Amlodipine, ramipril, GTN spray, bisoprolol, insulin, atorvastatin
NKDA
Family History:
Your father died of bowel cancer at the age of 70.
Your mother has diabetes.
Social History:
You live at home with your wife and frequently take care of your mother.
You've smoked 20 cigarettes a day since you were 15.
You used to binge drink when you were younger, but nowadays, you'll drink the occasional six or so cans of lager at night.
You're a retired construction worker.
Examination Findings:
Observations are normal
Overweight body habitus
Nicotine staining on right hand
Corneal arcus
Epigastric tenderness
No organomegaly
Strong Pulsatile and expansile central abdominal mass
Differentials:
Abdominal aortic aneurysm - Central abdominal pain, pulsatile mass, male, age, radiates to back, vascular history, smoker.
Pancreatitis (alcohol history) - Epigastric pain, but may have indication of exocrine dysfunction (E.g. steatorrhoea), and it wouldn't be pulsatile
GORD - Would have retrosternal burning pain, worse with classic triggers.
Constipation/obstruction - May be faecal mass (but wouldn't be pulsatile) Passed stool today, no change in bowel habit
Diverticulitis - Usually LLQ pain, fever, no pulsatile masses
Investigations:
Bedside:
Observations (hypotension and tachycardia in rupture)
ECG (cardiovascular co-morbidities)
Bloods:
FBC, U&E, CRP, LFT
Amylase - Assess for acute pancreatitis
Coagulation screen - Risk of bleeding
Imaging:
Abdo USS (diagnostic for AAA and look for gallstones / dilated biliary tree)
CT angiogram (guides elective surgery for repair for AAA and to diagnose/exclude ruptured AAA in haemodynamically stable patients)
CT Abdomen (pancreatitis)
Specialist Test:
Consider OGD (if suspecting upper GI cause)
Data Interpretation: