Revision Flashcards
Name causes of acute abdominal pain. (Note there are 16 of them!!)
AAA Perforation Bowel obstruction Acute appendicitis Acute pancreatitis Acute cholecystitis Cholangitis Biliary Colic Obstructive jaundice Peptic ulcer disease Diverticulitis Renal colic Ectopic pregnancy PID Miscarriage Ovarian cyst
AAA presentation & management
- Abdo pain radiating to back, iliac fossa or groin
- expansile mass
- Rupture → grey turners/cullens from bleeding + acutely unwell (↓GCS, ↓BP, syncope)
Mgmt →
• Watch & wait if < 5.5cm
• Prophylactic surgery if >5.5cm
• Emergency surgery if rupture
Causes of perforated bowel?
From previous GI condition: Diverticulitis Ulcerative colitis Crohn’s disease Toxic megacolon Strangulated hernia, which can result in poor blood flow to the intestines Peptic ulcer disease Forceful vomiting Bowel Ischaemia
Trauma (knife wound, severe blow, swallowing sharp object)
Appendicitis
presentation of bowel perforation
severe sudden abs pain + pyrexia + vomiting + peritonitis +- bowel sounds
Investigations of bowel perforation
CXR: gas under diaphragm
ABG: acidotic
BLD: ↑WCC, ↓Hb, ↑Amylase, ↑lactate
urgent CT when stable
Mgmt bowel perforation
Oxygen, IV fluids, analgesia (morphine + cyclizine), cross match, IV Abx (co-amoxclav + metronidazole (cover anaerobes), NGT, surgery
Bowel obstruction causes
Obstruction:
- adhesions secondary to intra-abdominal surgery
- tumour
- Crohn’s disease causing strictures
- hernia
→ tingling bowel sounds
Post-op paralytic ileus:
- ↑surgical time, electrolytes imbalance (especially hyperkalaemia), hypothyroid, opiates,
→ no or sluggish bowel sounds
Presentation of bowel obstruction
Colicky abdo pain - tender distended bowel tinkling bowe constipation N&V (bilious or faecal)
Inv of bowel obstruction
AXR →
• Dilated bowel loops (look at thickness of bowel, position and presence of valvulae commiventes or haustra)
• Bloods
• Contrast enema
Mgmt of bowel obstruction
DRIP AND SUCK
→ NGT, IV fluids & NBM
• Avoid pro kinetic drugs
• Surgery
Acute appendicitis CF
normally 10-20 years
• Central, colicky abdo pain → worse on movement, voluntary guarding
• N&V&D
• Mild fever + fatigue
Late →
• McBurney’s RIF pain → involuntary guarding, rigid abdomen
• Rovsings sign
• Swinging pyrexia
Acute appendicitis diagnosis
clinical
urine: ↑nitrates, ↑WCC
USS - 90% sensitive
Mgmt of acute appendicitis
NBM, IV fluids, analgesia
IV Abx: co-amoxiclav + metrondiazole
appendicectomy which can be performed via either an open or laparoscopic approach. Laparoscopic appendicectomy is now the treatment of choice
3 main causes of acute pancreatitis
gall stones, ethanol, trauma (GET)
CF of a. pancreatitis
Constant epigastric pain
- radiates to the back
- worse with alcohol
- relieved by sitting forward
- tenderness
- abdonminal rigidity
- Grey turners + Cullens sign
- anorexia + vomiting (shock)
- ↓ bowel sounds
- NB: gallstone can give RUQ pain + shoulder tip pain
Invs of pancreatitis
↑ Amylase > 600 +- lipase
Bloods: ↑WCC/CRP, ↑glucose, ↓Ca, ↓Hb (if bleed)
AXR: retroperitoneal fluid + no psoas shadow (sentinel loop sign)
What scoring system is used to predict mortality from acute pancreatitis. What is a severe score
Modified Glasgow Score (> 3)
Mgmt pancreatitis
IV fluids, Oxygen, Analgesia
Catherter
NBM + NGT
HDU/ICU?
Gallstone - ERCP
Acute cholecystitis cause & CF
BG inflamed due to stone impaction at neck
• Constant colicky pain (biliary colic), radiates to R shoulder • Worse on eating fatty foods • RUQ tender • Murphy sign (RUQ pain on palpation) • N,V,D + bloating • NOT peritonitic \+- obstructive jaundice
INV + Mgmt
Bloods: ↑WCC/CRP + deranged LFT
USS
Mgmt NBM Analgesia Abx: Co-amoxiclav Urgent cholecystectomy
Acute (ascending cholangitis) cause
choledocholithasis causes biliary stasis in common bile duct leading to ascending bacterial infection from the bowel.
5 F’s: Fair, Fat, Forty, fertile, Female
Ascending cholangitis
Charcot’s triad
• Constant RUQ pain
• Fever
• Jaundice of skin + sclera
↑ inflammatory markers
→ risk of septic shock (hypotension + confusion
Investigations + Mgmt
Blood: WCC/CRP, bilirubin, LFT
Imaging
ERCP
Abx
Remove block: ERCP or shockwave lithotripsy or widened with stent or cholecystetectomy
Biliary colic
GB stones obstruct cystic duct
Causes RUQ pain, intermittent radiates to R. shoulder
→ worse in morning or after food
If obstructive → Dark urine + steatorrhoea (pale stones)
Peptic ulcer disease CF
Dyspepsia (heartburn)
Epigastric pain relieved by eating or drinking milk
NB gastric worse on eating.
Bleed→ haematemesis, SOB, drowsy, confused, fatigue
Consider gastric cancer (wt loss, swallowing difficulty)
Investigations of peptic ulcer disease
- Upper GI endoscopy + biopsy
* H pylori test (Breath test, serology)
Mgmt
PPI
Triple therapy if H Pylori - Amoxicillin + Clarithromycin + Lansoprazole
Fluid rhesus if bleed
Check NSAIDs
Diverticulitis description + CF
Outpouching of gut mucosa common in descending + sigmoid becomes inflammed
Acutely symptomatic, L/R LQ pain, can be intermittent or constant
→ relieved by opening bowels
Maybe a palpable mass + bloating, ↓BS, possible chance in bowel habit
→ PR bleeding?
- bleeding can be sudden and painless, pass clots
→ Fever + Tachycardia
→ Anorexia N + V
→ Shock?
Invs/Mgmt
Bloods (G+S) /AXR/Colonscopy
NBM + Analgesia + Abx
CF of renal colic
Sudden onset severe colicky loin pain, radiate to the groin, enlarged palpable kidney, tender
• N&V
• Sweaty & restless
• Retention Sx
Invs
Urine: ↑blood, ↑nitrates
Bloods: ↑creatinine, urea, K ↑Na
KUB XR: 60% show
Contrast CTKUB: 90%
Mgmt of kidney stones
Analgesia (Diclofenac, opioids) Tamsulosin (a-blocker) Antiemetic Shock wave lithotripsy Nephrostomy?
Ectopic pregnancy CF
Lower abdo or pelvic pain Vague → colicky → constant Adenexal mass Cervical os small uterus normal size cerival excitation Vaginal bleeding Hx ammonrhoea 6-8 weeks N&V → dizzy + syncope
Inv Ectopic
Pregnancy test: +ve → USS b-HCG: > 1000IU/ml: or rises >66% in 48 hours: IUP decline or slow rising = ectopic or MisC TV-USS → ectopic or MisC
Mgmt
ABCDE if haemorrhage
• Methotexate (single dose then redo HCG at 7 days
• Salpingostomy
Rupture → syncope + shoulder tip pain
PID
Pelvic pain (constant or intermittent), deep dyspareunia, vaginal discharge + dysuria, irregular periods
Inv
G+C tests (endocervical = Vulvocaginal for NAAT + culture
• Bloods ↑ WCC
• USS if risk of ovarian access
Mgmt
Abx
• Ceftriaxone IM + doxycycline + metronidazole
Miscarriage
< 24 weeks, see antenatal notes
- Pelvic pain
- Uterine contractions
- Bleeding
- Offensive discharge if septic
Inv + Mgmt
- bHCG (<66% in 48hrs)
- USS exclude ectopic + IU
Admission: ABCDE
Analgesia + Antiemtic
• IM oxytocin
• Anti-D
Ovarian cyst
- What sort
- CF
Low abdo pain or pelvic pain
- Dull ache
- Radiates to the back
- Dyspareunia
- Bleeding if rupture
- Abdo mass - tender + peritonism if rupture
Inv + Mgmt
Pregnancy Test FBC Urinalysis: urinary signs USS CA125
Mgmt
Analgesia (most cyst resolve spontaneously)
Lapro-cystectomy if > 5cm
Urgent Laparoscopy if ovarian torsion, rupture or bleed
What is more common anterior or posterior dislocation of the shoulder? How to tell the difference on X-RAY
Anterior is more common.
Anterior → anterograde-inferior displacement
posterior → abnormal symmetry of shoulder - “light bulb sing”
The different between Colle’s fracture & Smith’s fracture
Colles: more common, fall on outstretched hand, fracture bone breaks dorsally whilst radius moves ventrally
Smith’s: fall on flexed wrist, fracture moves ventrally and radius moves dorsally
→ check for pulses
Describe the difference between intracapsular, extra capsular trochanteric and extra-capusular subtrachanteric hip fractures
Intracapsular → involves femoral neck - risk of avascular necrosis
• Hip appears externally rotated & shortened
Ex trochanteric → between two trochanters
Ex subtrochanteric → < 5cm of the lesser trochanter (proximal femoral shaft)
Shoulder examination
- Check pain
- Inspection - 3 angles
- Temperature
- Assess for tenderness of joint at scapula
- active movement: ab/ad + flex/ex + internal rotation/external
- passive movement
- rotator cuff →
• initiate abduction (supra)
• Painful arc
• external rotation (infra+teres minor) - assess patient from behind pushing wall → winged scapula
- watch patient reach behind back
Finish:
• Assess joint above & below (c-spine, elbow)
• neurovascular status of upper limb
• Appropriate imaging
Hip examination
pain assess gait trendelenburg inspection + temperature assess patient supine measure leg length 1) asis-medial 2) xiphisternum to medial malleolus both sides palpate - greater trochanter, a.s.i.s, hip joint active movement (hand under back) - flexion passive - flexion - internal + external rotation - abduction/adduction Prone →
- hip extension
- thomas test
finish:
- joint above & below - spine & knee examination
- neurovascular examination of lower limbs
- imaging if indicated
Acute lower back pain differential
- AAA
- Mechanical pain
- nerve root pain
- spinal pathology (caudal equina)
- spinal cord compression
Investigate acute lower back pain
- Hx
- PNS examination: tone, power, sensation, reflexes + special
- Rectal examination - anal tone, assess blood
- Palpate spine for tenderness
- Asses gait
- Abdo exam (AAA)
→
Urgent MRI - cauda equina or MSSC
Urgent USS - AAA
Perineal injury causes
foot drop (loss of muscles in anterior comparement) loss of sensation over dorsum of foot ↓ proprioception of ankle joint
Name acute problems with urinary symptoms
Renal colic Testicular torsion UTI AKI Urinary retention
How would testicular torsion present?
Usually male around 12 years
Sudden, acute pain, tender testicle which is swollen & red, N&V
→ Torted hydatid - gradual onset pain, with blue dot sign, hard mass above
Inv & mgmt of testicular torsion
Testicular & abdominal examination
- feel both testies
- Transilluminate the testies (hydrocele)
Doppler USS → examin blood flow
Compare both sides
Mgmt →
Emergency surgery within 6-12 hrs
- Untwist and fix both testicles
AKI Diagnosis
> 26 umol rise in creatinine over 48 hours
50% rise in serum creatinine over 7 days
Urine output <0.5/ml/kg/hr for > 6hours (adult) 8 hours (child)
25% fall in eGFR over 7d (child)
AKI general symptoms
- N, V, anorexia
* Dehydration, fatigue, ↓LOC, ↓UO
Nephrotic casuses + symptoms
Cause in adult: Glomerulonephritis
Child: Minmal change disease
- Periorbital swelling
- Ascites
- Oliguria + frothy urine
- Abdo pain
HUS symptoms
• Haemoltyic anemia, thrombocytopenia, ARF
If D+ve → bloody diarrhoea
Inv of AKI
- Assess fluid status
- Abdo exam (blot kidney + renal bruits
- Urine dip + MSU + plasma osmolarity
- Bloods: FBC, U+E, Creatinine, LFT, plasma osmolarity, clotting
- ECG: Tall tented T wave: hyperkalaemia
- Look at albuminuria
Mgmt AKI
ABCDE + treat cause
- Catheter for UO
- Regular creatinine monitor
- Fluids
- Hyperkalaemia → 10ml 10% calcium glucaonate (0.5ml/kg child), 10 units of act rapid insulin in 50ml 50% dextrose, 5mg salbutamol over 15 mins
- metabolic acidosis → bicarbonate 8.3% 50-100mls over 30 mins
- Pulmonary oedema → furosemide + o2
- Sepsis: BUFALO
- HTN: Nitrate or diuretics
- Review medications: remove neprotoxins, NSAIDS, gentamicin, ACEi
Describe urinary retention
More common in males,
Male: Hx BPH/cancer/urethral stricture
Female: retroverted uterus, atrophic urethritis, MS, pregnancy
CF urinary retention
Distended bladder + inability to urinate
→ oliguria → delirium
Abdo exam → suprapubic pain/discomfort → distended bladder → dull percussion over bladder → if prolapsed disc or cord compression → check LL power, reflexes, perianal sensation
Mgmt of urianry retention
• Urgent decompression
→ Urethral catheter
- Post-bladder drainage
- Monitor U+Es, fluids, UO
- refer urology
- Urgent MRI
- Trial without catheter
