Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are currently an emergency department doctor. Your next patient is a 56-year-old gentleman (Adam Sadler) coming in due to vomiting. Please take a history and perform a relevant examination.
Patient History:
Your name is Adam Sadler – You are currently 56-year-old – retired, and used to work as an accountant.
Since yesterday you have been vomiting, and it is only worsening – you also noticed you were starting to vomit green stuff today, which looked horrible and shocked you! Vomit doesn't contain any blood/faecal matter. You have been struggling to keep food down. You have a poor appetite. You feel weak and tired. You haven't had a good sleep since yesterday.
You also started to develop sudden, intermittent excruciating tummy pain throughout your tummy, which is widespread. No radiation. Pain score 9/10. You tried to take paracetamol and Oramorph, but it didn't help. Any movement only makes the pain worse, so you try to stay still as much as possible. You also feel your tummy has gotten a little bigger than usual. You do not feel well at all. You feel feverish with some chills.
You have not been passing bowel content/wind in the past week. No diarrhoea or bloody stool recently. No weight loss. No night sweats. No recent infection / surgery/ admission. No recent weight loss.
Ideas, Concerns, Expectations:
You are not sure what is going on. You don't think you have eaten anything abnormal lately. Maybe you have some constipation. You are concerned that the pain is now getting worse today. You hope to find out what is going on and receive some medications to help control your pain!
Past Medical History:
Hypothyroidism, type 2 diabetes, appendectomy, cholecystectomy, previous inguinal hernia operation, paroxysmal atrial fibrillation
Drug History:
Levothyroxine NKDA, metformin, apixaban
NKDA
Family History:
Bowel cancel >60 years old, diverticular disease
Social History:
You smoke 10 cigarettes/ day for the last 20 years.
You drink about 1-2 pints of beer every week.
You use oramorph recreationally, but you haven't been taking this last week until the pain started.
You live in a house with your partner currently.
Examination Findings:
Patient looks uncomfortable. Generalised abdominal tenderness – worst at the umbilical region. Voluntary guarding suggesting peritonitis. Bowel sound is absent. Abdominal distension with hyper-resonant on percussion. No palpable mass/lump. Previous surgical scars are present.
Signs of dehydration might include prolonged capillary refill time, tachycardia, reduced skin turgor, and dry mouth.
Differentials:
Bowel obstruction secondary to e.g. adhesions (due to extensive history of abdominal surgeries), strangulated hernia, malignancy, volvulus…etc.
Need to rule out bowel perforation
Bowel ischemia
Diverticular disease
Gastroenteritis
Acute pancreatitis
Constipation e.g. secondary to opioid use/ dehydration / hypothyroidism
Investigations:
Bedside:
ABCDE assessment
Observation (tachycardia, hypotension / pyrexia may indicate perforation/ infarction)
ECG (tachycardia/ rule out arrhythmias)
ABG (metabolic alkalosis/electrolyte imbalance due to vomiting + raised lactate if bowel ischaemia)
Fluid charts for input/out monitoring/ consider catheterisation (may show signs of dehydration e.g. oliguria)
BM /ketones (DKA/HHS)
Urinalysis (rule out UTI cause of abdominal pain / may show high ketones for DKA)
Admit all patients with bowel obstruction/ perforation
Urinalysis
Serum hCG in women of childbearing age.
Bloods:
FBC(high WCC/neutrophilia, low haematorcrit or hb indicates blood loss), CRP, LFTs, U&Es (electrolyts imbalance from vomiting/ reduced kidney function from dehydration/ pseudoobstruction), Bone Profile, Amylase, Lactate, Cross-match / cross match (for surgery / plan for blood transfusion), serum/urine osmolality (HHS), blood culture (for suspected infection)
Imaging:
Supine and erect XR Abdomen (rule out gas in peritoneum/ bowel dilatation / may show fluid level)
Barium swallow (can also be therapeutic)
Erect CXR (rule out referred pain from pneumonia/ gas under diaphragm)
Consider water-soluble contrast enema XR for diagnosis
CT scan (rule out obstruction + perforation or other causes of abdominal pathology/plan for surgery)
Consider MRI / US for diagnosing bowel obstruction or other causes.
Special Test:
Consider endoscopy e.g. flexible sigmoidoscopy/colonoscopy (can be diagnostic/therapeutic e.g. stenting) Care should be taken due to the risk of perforation / exacerbating complications. Should be in the absence of sepsis/ ischaemia/ perforation/ peritonitis/ closed loop obstruction/ abscesses/ distal rectal lesions/ persistent coagulopathy, dilated caecum more than 9cm.
Management: