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ODESSA NATIONAL MEDICAL UNIVERSITY Department of Internal Medicine №4 ODESSA NATIONAL MEDICAL UNIVERSITY Department of Internal Medicine №4 METHODICAL ELABORATION for students of the 6th year of the Medical Faculty: Theme 44. “Management of patients with acute abdominal pain. Supervision of the patient with gastrointestinal bleeding’. (The specialty: general medicine) “APPROVED” At methodical chair’s meeting 27.08.2020 y. Protocol N 1. The chief of the Department of Internal Medicine №4 Professor N.A. Zolotaryova, MD, PhD “__________________________” ODESSA D:\home\e231282mla\Одеський національний медичний університет\Методичні матеріали - Documents\Методичні Сторінка: 1 з 10 матеріали\Міжнародний, English\Аудиторна СРС, eng\44-Acute abdominal pain.docx, версія: 70 від 31.03.2021 13:21:00 Дата друку: 31 березня 2021 р. Theme № 44. Management of patient with acute abdominal pain. Management of patient with gastrointestinal bleeding Кафедра внутрішньої медицини №4 ОНМедУ Emergency conditions in the clinic of Internal Medicine Theme № 44. Management of patient with acute abdominal pain. Management of patient with gastrointestinal bleeding. Control questions 1. Give the definition to acute abdominal syndrome. 2. List main groups of causes that determine the development of acute pain instomach: 3. What aspects should you pay attention to during the questioning of a patient with acute abdominal pain? 4.What abdominal pain features do you know? 5. What information can be obtained on the physical examination of the patient? 6. Due to which diseases an acute abdominal pain in combination withblood pressure decrease (BP)is most frequently observed? 7. Give the definition to“acute” abdomen syndrome. 8. What diseases are characterized by the development of “acute” abdomen? 9. List the indications for urgent hospitalization. 10. What basic principles of treatment of patients with “acute” abdominal syndrome on prehospital stage? 11. What main groups of gastro-intestinal bleeding causes do you know? 12. What diseases are the most often to give rise to gastro-intestinal bleeding? 13.Characterize clinical manifestations of gastro-intestinal bleeding, depending on the level of their occurrence. 14. What are the main clinical syndromes of posthemorrhagic anemia. 15. What are the severity stages of hemorrhagic shock do you know? 16. List the basic principles of gastro-intestinal bleeding diagnosing 17. What are the basic principles of gastrointestinal bleeding treatment? 18. Describe the main methods of stopping the bleeding. 19. What steps should be taken to restore hemodynamics and oxygen transport? 20.What is the treatment of refractory shock? D:\home\e231282mla\Одеський національний медичний університет\Методичні матеріали - Documents\Методичні Сторінка: 2 з 10 матеріали\Міжнародний, English\Аудиторна СРС, eng\44-Acute abdominal pain.docx, версія: 70 від 31.03.2021 13:21:00 Дата друку: 31 березня 2021 р. Theme № 44. Management of patient with acute abdominal pain. Management of patient with gastrointestinal bleeding Кафедра внутрішньої медицини №4 ОНМедУ Tests 1. A young man,18 years old, was delivered to the hospital Admission Room with complaints of pain attacks in the right half of the abdomen with irradiation in the scrotum, nausea, vomiting. Acutely got sick for the first time. On palpation: muscle strain in the right half of the abdomen. Shchetkin- Blumberg’ssymptom is questionable. Pasternatskiy’ssymptom is weakly positive from the right side, there is urinary retention. The temperature - 37,7 o C, Leuk. = 8.0 x 10^9 /L. In the analysis of urine collected from catheter, 10-15 fresh erythrocytes in the area of vision. Which of the following diagnoses is most likely? A. Renal colic. B. Acute appendicitis. C. Acute cholecystitis. D. Ileus. E. Perforated duodenal ulcer. 2. Patient, aged 47, with IHD went to a doctor complaining about intense pain in the epigastric region for 2 hours, which occurred suddenly after physical exertion, not relieved by nitroglycerin and analgesics. On examination - the state of moderate severity, skin pale and covered with cold sweat. BP 90/60 mm Hg., Heart rate - 110 per minute. On auscultation - vesicular breathing, heart sounds are rhythmical, muffled. Abdomen is soft on palpation, symptoms of peritoneal irritation are absent. The ECG - sinus rhythm, left axis deviation, ST segment elevation in II, III, and AVF. Which of the following diagnoses is the most likely? A. Stomach ulcer. B. Diaphragmatic hernia. C. Acute cholecystitis. D. Acute coronary syndrome. E. Spontaneous pneumothorax. 3. Male 39 years old, working as a stevedore, after a sharp lifting felt an intense pain in the left hypochondrium. Objective: diffuse cyanosis, increased intercostal spaces. On percussion – tympanitis from the left, on auscultation - prominent weakening of the respiratory noises. Borders of the heart are displaced to the right. Pulse 120 per minute., BP 90/60 mmHg. Abdomen palpation is soft and painless. The most reliable preliminary diagnosis is: A. Perforated duodenal ulcer. B. Diaphragmatic hernia. C. Myocardial infarction. D. Exudative pleurisy. E. Spontaneous pneumothorax 4. Female 35 years old, after an injection of nonsteroidal anti-inflammatory drugs for radicular syndrome felt sharp pain in the epigastric region, nausea. Patient's condition quickly deteriorated: skin is pale, covered with cold sweat. BP 80/50 mmHg. HR 120 per minute. Abdomen is soft on palpation; symptoms of peritoneal irritation are absent. Which of the following diagnoses is most likely? A. Cardiogenic shock. B. Diaphragmatic hernia. C. Anaphylactic shock, abdominal form. D. Perforated duodenal ulcer. E. Spontaneous pneumothorax. 5. A 45 y.o. woman complains of severe pain in the right abdominal side irradiating in the right supraclavicular area, fever, dryness and bitterness in the mouth. There were multiple vomitings without relief. Patient relates the onset of pain to the taking of fat and fried food. Physical examination: the D:\home\e231282mla\Одеський національний медичний університет\Методичні матеріали - Documents\Методичні Сторінка: 3 з 10 матеріали\Міжнародний, English\Аудиторна СРС, eng\44-Acute abdominal pain.docx, версія: 70 від 31.03.2021 13:21:00 Дата друку: 31 березня 2021 р. Theme № 44. Management of patient with acute abdominal pain. Management of patient with gastrointestinal bleeding Кафедра внутрішньої медицини №4 ОНМедУ patient lies on the right side, pale, dry tongue, tachycardia. Right side of abdomen is painful during palpation and somewhat tense in right hypochondrium. What is the most likely diagnosis? A. Acute cholecystitis B. Perforative ulcer C. Acute bowel obstruction D. Acute appendicitis E. Right-sided renal colic 6. Female 55 years old, overweight, felt a sharp pain in the right abdomen after the birthday party. Pain was accompanied by nausea, vomiting, feeling of bitterness in the mouth. On examination – general condition of moderate severity. BP =140/90 mm Hg, HR 110 per minute. Heart sounds are muffled, rhythmic activity. Vesicular breathing. On palpation of abdomen patient feels sharp pain in right hypochondrium. Positive Ortner’s, Courvoisier’s symptoms. Your preliminary diagnosis: A. Acute pancreatitis. B. Biliary colic. C. Acute appendicitis. D. Duodenum ulcer perforation. E. Acute pancreatitis. 7. The patient, 62 years old, went to the hospital with complaints about intensive pain in the right side of the abdomen, which is intensified on deep breathing and coughing, dry cough and fever to 39oC. A patient is sick for 4 days. On examination: pale skin, acrocyanosis, RR - 32 per minute, BP 100/70 mm Hg., heart rate - 110 per minute. Under the right scapula - dull percussion sounds, on auscultation - crackling. Palpation revealed pain in the projection of the gallbladder. Liver on the edge of the costal arch. What method of research is needed in this case? A. Ultrasonography of the abdominal cavity. B. Retrograde cholecystography. C. Radiography of the chest. D. EFGDS. E. Diagnostic laparoscopy. 8. Male, 44 years old, after alcohol abuse felt a sharp, girdle pain in the upper abdomen, which was accompanied by repeated vomiting without relief. The patient's condition is grave, skin is pale, covered with cold sweat, blood pressure 90/60 mmHg., Heart rate - 110 per minute. Distended abdomen, tenderness on palpation. Which figure is decisive for diagnosis in this case? A Neutrophil leukocytosis with a shift to the left. B. Increased blood glucose levels. C. Hyperamylasemia. D. Hyperasotemia. E. Increase in ALT, AST. 9. A 28-year-old patient has been hospitalized for the pain in the epigastric region. He has a 10-year history of duodenal ulcer (DU). Recently, the pain character has changed: it became permanent, persistent, irradiating to the back. There are general weakness, dizziness, fatigue. The patient has lost weight. Objectively: HR- 68/min, AP- 120/80 mm Hg. What is most likely cause of deterioration? A. Haemorrhage B. Penetration C. Perforation of duodenal wall D. Exacerbation of duodenal ulcer E. Stenosis development D:\home\e231282mla\Одеський національний медичний університет\Методичні матеріали - Documents\Методичні Сторінка: 4 з 10 матеріали\Міжнародний, English\Аудиторна СРС, eng\44-Acute abdominal pain.docx, версія: 70 від 31.03.2021 13:21:00 Дата друку: 31 березня 2021 р. Theme № 44. Management of patient with acute abdominal pain. Management of patient with gastrointestinal bleeding Кафедра внутрішньої медицини №4 ОНМедУ 10. Patient 44 years old, received treatment with nonsteroidal anti-inflammatory drugs for the reactive arthritis. Suddenly he felt sharp pain
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