Clinical skills/ reasoning Flashcards
What are the causes of right iliac fossa pain?
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
What are the causes of left iliac fossa pain?
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
What are some of the common differential diagnoses for abdominal pain?
- appendicitis
- pancreatitis
- biliary colic
- diverticular disease
- peptic ulcer
- renal colic
How would a stone in the ureter present as?
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
How does peptic ulcer present?
Severe epigastric pain.
How could you differentiate (by history) between a gastric ulcer and duodenal ulcer?
Gastric ulcer=pain DURING meals
Duodenal ulcer=pain BETWEEN meals (hunger pain) and at night
- what can relieve the pain of peptic ulcer
2. what can worsen the pain of peptic ulcer
- drinking milk
2. eating spicy food
What are the other features of peptic ulcer?
Nausea Vomiting Heartburn Bleeding from a possible perforation Epigastric tenderness
How does appendicitis usually present?
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
What are the symptoms of pancreatitis?
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
What is grey Turner’s sign?
Swollen, tender abdomen with bruising in flanks
What is Cullen’s Sign?
Superficial oedema and bruising in subcutaneous fatty tissue around the umbilicus
What are the symptoms of biliary colic?
Right upper quadrant pain radiating to back (worse at night)
Nausea after eating
Pain is classically colicky
Jaundice
What can indicate biliary tract infection?
Local peritonism
Fever
Vomiting
What are the symptoms of diverticular disease?
Abdominal pain Bloating Cramps Tenderness around left side of lower abdomen Fever Nausea Vomiting Constipation
What is Murphy’s sign?
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
What is the difference between vomiting and regurgitation?
Regurgitation=return of undigested food back up oesophagus without force
Vomiting=ejection of contents of stomach and upper intestine, more active process than regurgitation
What are the extra-intestinal manifestations of Crohn’s?
Ocular manifestations Arthropathy Arthritis Thromboembolic event Osteopenia/osteoporosis Skin manifestations
What is dark urine and pale stools suggestive of?
Post hepatic jaundice/obstruction
What hand signs do you check for in abdominal examination?
Clubbing Leukonychia Koilonychia Palmar erythema Duputyrens contracture
What can clubbing be a sign of?
Liver cirrhosis
IBD
Coeliac disease
What can leukonychia be a sign of?
Cirrhosis
Hypoalbuminaemia
What can koilonychia be a sign of?
Iron deficiency anaemia
What can palmar erythema be a sign of?
Chronic liver disease
What can duputyrens contracture be a sign of?
Liver cirrhosis
What are the causes of abdominal distension?
9Fs Fat Faeces Fluid Flatus Fetus Full-sized tumours Full bladder Fibroids False pregnancy
What are the potential causes of right iliac fossa mass?
Appendix mass or abscess Colon cancer Crohn’s disease Transplanted kidney Tuberculosis mass
How can you differentiate between the left kidney and an enlarged spleen?
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
What are the common presenting symptoms of Crohn’s disease?
Chronic diarrhoea
Weight loss
Right lower quadrant pain (mimicking acute appendicitis)
How is a diagnosis of Crohn’s disease confirmed?
Colonoscopy with ileoscopy and tissue biopsy
What are the key diagnostic features of Crohn’s Disease?
Presence of risk factors
Abdominal pain
Prolonged diarrhoea (non bloody or bloody intermittent)
Perianal lesions
What are the key diagnostic factors in irritable bowel syndrome?
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
What does the presence of blue vessels visible on colonoscopy suggest?
Haemorrhoids
During colonoscopy how can you tell you are seeing the small bowel?
Presence of villi
