Question

Question 3: Based on Mr. Sawyer's chief complaint describe your physical assessment. Be thorough & detailed in your answer. (15 points) Question 4: Based on Mr. Sawyer's chief complaint what additional physical exam techniques / tests would you want to include in your physical assessment of him? Be thorough & detailed in your description. (20 points)

Answer 1

                      In this scenario, Patient presented with complaint of severe Abdominal pain which is radiating to his back and right shoulder with pain score of 10/10, Poor appetite and Fatigue and Vomiting. On Initial examination the BP reading are high. Patient is having high body temperature of 99.6 degree celcius which indicates that patient is having fever.

Physical Examination Techniques to be conducted for the patient includes:

                  A fundamental part of physical examination of an abdomen consist of four methods-Inspection, Palpation, Percussion and Auscultation.

Inspection

              Inspection of an Abdomen can be done by positioning the patient supine on an examining table or bed. The head and knees should be supported with small pillows or folded sheets for comfort and to relax the abdominal wall musculature. The patient's arms should be at the sides and not folded behind the head, as this tenses the abdominal wall.

                 The abdominal wall skin should be inspected carefully for abnormalities. Any areas of discoloration should be noted, such as the bluish discoloration of the umbilicus or flanks .The skin should be inspected for striae, or "stretch marks," and surgical scars.

                  Next, the abdomen should be inspected for masses. This should be performed from several angles. It is important to differentiate abdominal wall from intra-abdominal masses.

              Finally, the abdominal wall should be observed for motion with respiration. Normally, the abdominal wall moves posteriorly in a symmetrical fashion with inspiration. With peritonitis, there may be localized rigidity of the abdominal wall so that this motion is absent.

Palpation

            Performing   palpation may stimulate bowel activity and thus falsely increase bowel sounds if performed before auscultation. Palpation is directed primarily to the localization of tenderness, the identification of peritonitis, and the detection of certain enlargements such as the abdominal aorta.

            On deep palpation, the examiner is testing for any organomegaly (enlarged organs) and is looking for enlargement of the liver and spleen or abnormal masses in the intestines. Sometimes the physician looks for the kidney and uterus as well.

               When abdominal masses are palpated, the first consideration is whether the mass is intra-abdominal or within the abdominal wall. This can be determined by having the patient raise his or her head or feet from the examining table.

Percussion

                   Abdominal percussion is used most frequently to determine whether free peritoneal fluid, namely, ascites, is present, especially if there is abdominal distension. Percussion may include assessment of the liver and spleen size and a search for pulsatile or other masses and an assessment of the quality of femoral pulses.

Percussion is a useful technique for:

• Evaluating the size of the liver and sometimes the spleen.
• Evaluating gas in the abdomen versus solid or fluid-filled structures.
• Evaluating for focal areas of tenderness and peritoneal irritation.
• Evaluating for the presence of ascites.

                     Percussion is a useful tool for evaluating abdominal tenderness. Lightly percuss the abdomen to determine the location of the pain. Localized pain is suggestive of peritoneal or intra-abdominal inflammation.

Auscultation

                    Auscultation of the abdomen can be used to assess bowel motility and evaluate for vascular disease.

                    The patient is positioned comfortably in the supine position. The stethoscope is used to listen over several areas of the abdomen for several minutes for the presence of bowel sounds. The diaphragm of the stethoscope should be applied to the abdominal wall with firm but gentle pressure. It is often helpful to warm the diaphragm in the examiner's hands before application, particularly in ticklish patients.

                   Bowel sounds are widely transmitted so listening in one area generally suffices unless no bowel sounds are heard. In patients with hypertension, listen several centimeters to the right and left of the umbilicus as well as in the flanks near the costo-vertebral angles, noting any bruits that might suggest the presence of renal artery stenosis.

              By performing the above mentioned four techniques of physical assessment, the physician can determine the presence of any abnormalities in the abdomen as a cause for mentioned symptoms.

Additional Physical assessment Technique/Tests

               In addition to the above mentioned abdominal assessments, there are some tests which can provide a detailed information regarding the patient condition.

The tests Include:

• The rectal examination

                               Rectal and pelvic examinations are recommended in patients with lower abdominal and pelvic pain. A rectal examination may reveal fecal impaction, a palpable mass, or occult blood in the stool.The diagnostic value of a rectal examination in the evaluation of acute abdominal pain use in detecting intestinal ischemia, late intussusception, or colon cancer. The exam’s utility is likely to increase with the patient’s age. The use of the rectal examination in other age groups should be targeted to diagnoses in which it may yield important information.

Laboratory Studies

• Complete Blood Count (CBC)

                    A complete blood count, or CBC, is a blood test that can help determine if an infection is present in the body. Certain types of blood cells increase when an infection is present, and the presence of infection can help determine the nature of the problem.

• Liver Enzymes/Hepatic Function Test

                         Liver enzymes are tests that, when elevated, indicate a problem with the function of the liver. Other liver tests can indicate whether the liver is successfully doing its job removing harmful toxins from the body. The liver can be damaged in many ways, including taking too much medication that is harmful to the liver, drinking too much alcohol, or by a natural disease process—and these conditions are often painful.

• Urinalysis

                       Urine test was performed to determine if blood or infection is present in the urinary tract. A urinary tract infection can cause pain in the kidneys, ureters, bladder or urethra, or a combination of all four. This can lead to pain that is felt in the back, the abdomen or pelvis.

• Amylase and Lipase

              These blood tests look at enzyme levels produced by the pancreas. Elevated levels can indicate an infection or inflammation in the pancreas called pancreatitis, which can be extremely painful .

• Occult Stool/Hemoccult Test

                          This is a test that looks for blood in the stool, which is not a normal finding. Blood in the stool that cannot be seen with the naked eye can indicate a problem in the upper digestive tract.

• Imaging Studies for Abdominal Pain
• Computed Tomography Scan

                      This test is non-invasive, looking at the inside of the human body without even touching the body. This test uses many X-ray type images to create an image of the inside of the human body, which can then be read by a skilled radiologist. The test images may be enhanced by the use of contrast, which can provide more detailed images

• Magnetic Resonance Imaging

                               This test uses magnetic fields to produce images of the inside of the human body. An MRI cannot be performed on a person with certain types of metal in their body, as the test uses very strong magnets that can be harmful to patients with some implants.

• Upper Endoscopy

                                This test is used to inspect the upper digestive tract from the inside. Using a lighted endoscope with a camera, the endoscope is inserted into the mouth so that the inside of the esophagus, stomach, and duodenum can be inspected. This test will help determine if stomach pain is being caused by acid reflux or stomach ulcers.

• Colonoscopy

                      This is a test that allows a physician to inspect the inside of the large intestine with an instrument that has both a light and a camera, with the images shown on a monitor. During this test, the examiner can inspect the entire large intestine for sources of pain or even bleeding, and can also take biopsy samples and perform other minor procedures during the examination.

• Ultrasound

                       This test uses sound waves that are higher than the human ear can detect to create images of the inside of the human body. The ultrasound can be used to examine the abdomen and determine if there are issues present with the tissues and organs there.

            By following these techniques and methods the physician can identify the actual cause for the patient condition and can provide effective treatment as per the clinical condition.