Clinical skills/ reasoning

Question 1

What are the causes of right iliac fossa pain?

Answer 1

APPENDICITIS

• Appendicitis/abscess
• Period Pain/pelvic inflammatory disease
• Pancreatitis
• Ectopic pregnancy
• Neoplasia
• Diverticulitis
• Intussusception
• Crohn’s disease/cyst
• Inflammatory Bowel Disease
• Testicular torsion
• Irritable Bowel syndrome
• Stones/salpingitis

Question 2

What are the causes of left iliac fossa pain?

Answer 2

SUPERCLOTS

• Sigmoid diverticulitis
• Ureteric colic
• Pelvic inflammatory disease/period pain
• Ectopic pregnancy/endometriosis
• Rectus sheath haematoma
• Colorectal carcinoma
• Left lower lobe pneumonia
• Ovarian Cyst
• Testicular torsion
• Salpingitis/stones

Question 3

What are some of the common differential diagnoses for abdominal pain?

Answer 3

• appendicitis
• pancreatitis
• biliary colic
• diverticular disease
• peptic ulcer
• renal colic

Question 4

How would a stone in the ureter present as?

Answer 4

Severe pain in the loin that radiates to the groin

Begins with sudden onset dull, colicky ache, blood in urine and nausea and vomiting following periods of dehydration

Question 5

How does peptic ulcer present?

Answer 5

Severe epigastric pain.

Question 6

How could you differentiate (by history) between a gastric ulcer and duodenal ulcer?

Answer 6

Gastric ulcer=pain DURING meals

Duodenal ulcer=pain BETWEEN meals (hunger pain) and at night

Question 7

1. what can relieve the pain of peptic ulcer

2. what can worsen the pain of peptic ulcer

Answer 7

1. drinking milk

2. eating spicy food

Question 8

What are the other features of peptic ulcer?

Answer 8

Nausea
Vomiting
Heartburn
Bleeding from a possible perforation
Epigastric tenderness

Question 9

How does appendicitis usually present?

Answer 9

Diffuse central abdominal pain, shifting to right iliac fossa when peritonism develops
Pain worsened by movement, touch and coughing
Hot, feverish and nauseous
Often constipated
Reduced appetite

Question 10

What are the symptoms of pancreatitis?

Answer 10

Gradual or sudden onset severe epigastric pain that radiates to the back or chest
Pain may be constant for hours or worse by drinking alcohol or eating
Relief by bending forward or curling up
Fever/jaundice/rapid pulse/nausea and vomiting
Grey turner sign

Question 11

What is grey Turner’s sign?

Answer 11

Swollen, tender abdomen with bruising in flanks

Question 12

What is Cullen’s Sign?

Answer 12

Superficial oedema and bruising in subcutaneous fatty tissue around the umbilicus

Question 13

What are the symptoms of biliary colic?

Answer 13

Right upper quadrant pain radiating to back (worse at night)
Nausea after eating
Pain is classically colicky
Jaundice

Question 14

What can indicate biliary tract infection?

Answer 14

Local peritonism
Fever
Vomiting

Question 15

What are the symptoms of diverticular disease?

Answer 15

Abdominal pain 
Bloating
Cramps
Tenderness around left side of lower abdomen
Fever
Nausea
Vomiting
Constipation

Question 16

What is Murphy’s sign?

Answer 16

Patient breathes out and you place a hand below the costal margin on right side (near gallbladder)
Positive sign is when patient stops inhaling due to pain when pressure is placed on gallbladder
Acute cholecystitis

Question 17

What is the difference between vomiting and regurgitation?

Answer 17

Regurgitation=return of undigested food back up oesophagus without force

Vomiting=ejection of contents of stomach and upper intestine, more active process than regurgitation

Question 18

What are the extra-intestinal manifestations of Crohn’s?

Answer 18

Ocular manifestations 
Arthropathy 
Arthritis 
Thromboembolic event
Osteopenia/osteoporosis 
Skin manifestations

Question 19

What is dark urine and pale stools suggestive of?

Answer 19

Post hepatic jaundice/obstruction

Question 20

What hand signs do you check for in abdominal examination?

Answer 20

Clubbing
Leukonychia 
Koilonychia 
Palmar erythema 
Duputyrens contracture

Question 21

What can clubbing be a sign of?

Answer 21

Liver cirrhosis
IBD
Coeliac disease

Question 22

What can leukonychia be a sign of?

Answer 22

Cirrhosis

Hypoalbuminaemia

Question 23

What can koilonychia be a sign of?

Answer 23

Iron deficiency anaemia

Question 24

What can palmar erythema be a sign of?

Answer 24

Chronic liver disease

Question 25

What can duputyrens contracture be a sign of?

Answer 25

Liver cirrhosis

Question 26

What are the causes of abdominal distension?

Answer 26

9Fs
Fat
Faeces
Fluid
Flatus
Fetus
Full-sized tumours
Full bladder
Fibroids
False pregnancy

Question 27

What are the potential causes of right iliac fossa mass?

Answer 27

Appendix mass or abscess
Colon cancer
Crohn’s disease
Transplanted kidney 
Tuberculosis mass

Question 28

How can you differentiate between the left kidney and an enlarged spleen?

Answer 28

Left kidney= smooth shape, moves late in inspiration, resonant, possible to get above the kidney, directed downwards

Splenomegaly= notched edge, moves early in inspiration, dull, cannot get above spleen (ribs on top), enlarges towards RIF

Question 29

What are the common presenting symptoms of Crohn’s disease?

Answer 29

Chronic diarrhoea
Weight loss
Right lower quadrant pain (mimicking acute appendicitis)

Question 30

How is a diagnosis of Crohn’s disease confirmed?

Answer 30

Colonoscopy with ileoscopy and tissue biopsy

Question 31

What are the key diagnostic features of Crohn’s Disease?

Answer 31

Presence of risk factors
Abdominal pain
Prolonged diarrhoea (non bloody or bloody intermittent)
Perianal lesions

Question 32

What are the key diagnostic factors in irritable bowel syndrome?

Answer 32

Presence of risk factors
Abdominal discomfort-general cramping in lower abdomen
Alteration of bowel habits associated with pain
Abdominal bloating or distension
Normal on examination

Question 33

What does the presence of blue vessels visible on colonoscopy suggest?

Answer 33

Haemorrhoids

Question 34

During colonoscopy how can you tell you are seeing the small bowel?

Answer 34

Presence of villi