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  <head>
    <title>049-02 Bedside abdominal reasoning, physiological consequences, and time-critical investigation</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Bedside abdominal reasoning and time-critical tests">
      <outline text="History as a physiological map">
        <outline text="Pain onset and movement trace inflammation spread"/>
        <outline text="Vomit content estimates level and duration"/>
        <outline text="Stool features separate bleeding, inflammation, malabsorption"/>
        <outline text="Urgency: perfusion, sepsis, peritonism, organ failure"/>
      </outline>
      <outline text="Pain mechanisms and history">
        <outline text="Visceral pain poorly localised">
          <outline text="Afferents converge across spinal segments"/>
          <outline text="Foregut epigastric, midgut periumbilical, hindgut lower"/>
        </outline>
        <outline text="Parietal peritoneum: sharp, local, worse on cough">
          <outline text="Central to focal migration reflects this shift"/>
          <outline text="Muted in older, immunosuppressed, pregnant patients"/>
        </outline>
        <outline text="Sudden maximal pain: perforation, occlusion, rupture"/>
        <outline text="Colic: contraction against resistance">
          <outline text="Biliary pain often steady after onset"/>
        </outline>
        <outline text="Pain out of proportion suggests mesenteric ischaemia">
          <outline text="Mucosa hypoxic before peritoneum inflamed"/>
        </outline>
        <outline text="Give analgesia promptly, examine repeatedly"/>
        <outline text="Record timing, radiation, pretest modifiers">
          <outline text="Improvement alone does not exclude danger"/>
        </outline>
      </outline>
      <outline text="Consequences of vomiting">
        <outline text="Gastric acid loss gives metabolic alkalosis">
          <outline text="Volume contraction drives sodium retention"/>
          <outline text="Distal potassium and hydrogen loss follows"/>
        </outline>
        <outline text="Low potassium impairs motility and conduction">
          <outline text="Worsens obstruction and vomiting"/>
        </outline>
        <outline text="Distal bowel loss of bicarbonate gives acidosis"/>
        <outline text="Replace chloride and potassium, not only water"/>
        <outline text="Stopped vomiting is not resolved obstruction"/>
      </outline>
      <outline text="Bleeding severity and resuscitation">
        <outline text="Colour does not indicate severity">
          <outline text="Coffee grounds can coexist with active bleeding"/>
          <outline text="Melaena may come from small bowel or right colon"/>
          <outline text="Brisk upper bleeding can give bright rectal blood"/>
        </outline>
        <outline text="First haemoglobin may be normal"/>
        <outline text="Perfusion signs and ongoing loss guide resuscitation"/>
        <outline text="Haemoglobin fall also reflects dilution"/>
        <outline text="Source, haemostasis, restarting antithrombotics separate"/>
      </outline>
      <outline text="Examination">
        <outline text="Starts before touch">
          <outline text="Motionless patient suggests peritoneal irritation"/>
          <outline text="Restlessness more typical of colic"/>
        </outline>
        <outline text="Resuscitate first if shock or altered consciousness"/>
        <outline text="Voluntary guarding eases, rigidity persists"/>
        <outline text="Rebound testing unnecessary and painful"/>
        <outline text="Pulsatile mass with shock: do not press"/>
        <outline text="Bowel sounds have low discriminatory accuracy">
          <outline text="Distension, obstipation, imaging more useful"/>
        </outline>
      </outline>
      <outline text="Laboratory tests and pregnancy">
        <outline text="Tests measure consequences and competing mechanisms"/>
        <outline text="Lipase supports pancreatitis only in a compatible syndrome"/>
        <outline text="Normal lactate possible in early ischaemia">
          <outline text="Biomarker never overrides high-risk anatomy"/>
        </outline>
        <outline text="Pregnancy testing whenever biologically possible">
          <outline text="Do not rely on relationship status alone"/>
          <outline text="Uterus displaces organs, signs differ"/>
          <outline text="Needed imaging not delayed by fear"/>
        </outline>
      </outline>
      <outline text="Imaging and endoscopy">
        <outline text="Imaging follows the question and stability"/>
        <outline text="Ultrasound fast but operator and gas dependent"/>
        <outline text="Computed tomography finds transition points"/>
        <outline text="Angiography urgent: portal phase misses vessels"/>
        <outline text="Uncontrolled bleeding may need theatre instead"/>
        <outline text="Endoscopy needs physiological preparation">
          <outline text="Bowel preparation worsens dehydration, electrolytes"/>
          <outline text="Full colonoscopy in severe colitis risks perforation"/>
          <outline text="Capsule may lodge, patency assessment reduces risk"/>
        </outline>
      </outline>
      <outline text="Obstruction and perforation">
        <outline text="Mechanical or functional, simple or strangulated"/>
        <outline text="Closed loop obstructed at two points">
          <outline text="Distension compromises venous then arterial flow"/>
        </outline>
        <outline text="Distension creates a self-worsening cycle">
          <outline text="Barrier fails, translocation, necrosis, perforation"/>
        </outline>
        <outline text="Colicky to constant pain demands reassessment"/>
        <outline text="Perforation releases gas and contents">
          <outline text="Free gas absent in contained or small leaks"/>
          <outline text="Question is controllable contamination and viability"/>
        </outline>
      </outline>
      <outline text="Mimics and serial reassessment">
        <outline text="Extra-abdominal causes: myocardial, pneumonia, ketoacidosis"/>
        <outline text="Fluid response does not prove the problem solved"/>
        <outline text="Compare the same sites with time and examiner"/>
        <outline text="A soft abdomen does not exclude ischaemia"/>
      </outline>
      <outline text="Safe discharge">
        <outline text="Needs more than pain improvement"/>
        <outline text="Explicit return triggers explained"/>
        <outline text="Owners assigned for pending results"/>
        <outline text="Teach-back of warning signs and plan"/>
        <outline text="Discharge transfers surveillance to the community"/>
      </outline>
    </outline>
  </body>
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