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Yr 3 Oxford Clinical Cases > Right Iliac Fossa Pain > Flashcards

Right Iliac Fossa Pain Flashcards

1
Q

List the differential diagnosis for RIF pain.

A
  • Appendicitis
  • Gastroenteritis
  • Ureteric colic
  • Inguinal hernia (especially if strangulated)
  • Mesenteric adenitis
  • Acute pancreatitis
  • Testicular torsion
  • Meckel’s diverticulitis
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2
Q

State two causes of RIF pain that are more common in children.

A

Intussusception

Mesenteric adenitis

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3
Q

What causes of RIF pain are more common in the elderly?

A

Caecal pathology (e.g. tumours, volvulus, diverticuli) AAA

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4
Q

List some gynaecological causes of RIF and LIF pain.

A
  • Ectopic pregnancy
  • Pelvic inflammatory disease
  • Mittelschmerz
  • Torsion/rupture/haemorrhage of an ovarian cyst or tumour
  • Salpingitis
  • Threatened abortion
  • Fibroid degeneration
  • Uterine dehiscence
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5
Q

What is pelvic inflammatory disease?

A

Acute or chronic infection of the ovaries, fallopian tubes and uterus, usually resulting from an infection ascending from the vagina

Chlamydia trachomatis and Neisseria gonorrhoeae are causative agents

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6
Q

What is Mittelschmerz?

A

Mid-cycle RIF/LIF pain caused by rupture of the ovarian follicle

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7
Q

List some causes of RIF/LIF pain that are exclusive to males.

A
  • Testicular torsion
  • Haemorrhage into a testicular tumour
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8
Q

Before laying a hand on the patient, it is important to ascertain how much pain they are already in. State two ways in which you can assess how much pain they are in without touching them.

A
  • Ask them to cough
  • Ask them to suck their tummy in as far as possible and then puff it out again (Ask them to look at their toes when lying down)
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9
Q

List some features of examination that would suggest that the patient is acutely unwell.

A
  • Tachypnoea
  • Tachycardia
  • Fever
  • Hypotension
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10
Q

Why is it important to take note of any surgical scars the patient may have on their abdomen?

A

Previous surgery increases the risk of post-surgical adhesion

Adhesions can lead to bowel obstruction

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11
Q

Why is it important to check for cervical lymphadenopathy in a patient with RIF pain?

A
  • Mesenteric adenitis is often preceded by an upper respiratory tract viral infection
  • This viral infection can cause cervical lymphadenopathy NOTE: mesenteric adenitis is very difficult to distinguish clinically from appendicitis
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12
Q

What can cause absent bowel sounds?

A

Occurs if there is a functional bowel obstruction (e.g. paralytic ileus)

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13
Q

What can cause tinkling bowel sounds?

A

Small bowel obstruction

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14
Q

Why is it important to check for hernias in a patient with RIF pain?

A

Hernias can become strangulated and cause small bowel obstruction

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15
Q

What useful clues may be gained from performing a DRE?

A
  • Constipation
  • Masses
  • Blood (suggests inflammatory bowel disease, Meckel’s diverticulum bleed or caecal diverticular bleed)
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16
Q

Why is it particularly important to examine the external genitalia of men with RIF/LIF pain?

A

Testicular torsion and strangulated inguinal hernias can cause referred RIF/LIF pain

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17
Q

Where is pain caused by testicular torsion, epididymitis and orchitis referred?

A

It is referred to the abdomen via T10 innervation

18
Q

What is Prehn’s sign?

A

Elevation of the testes relieves pain in epididymitis but does NOT relieve pain in testicular torsion

19
Q

Describe how the cremasteric reflex is used to narrow the differential in a male patient with RIF/LIF pain.

A

The absence of the cremasteric is NOT diagnostic of testicular torsion

However, the presence of a cremasteric reflex strongly suggests that testicular torsion is not the cause of the pain

20
Q

What is the time limit within which surgery should be performed in a patient with testicular torsion?

A

6 hours

21
Q

What form of imaging is sometimes used to aid diagnosis of testicular torsion?

A

Doppler ultrasound

22
Q

List some blood tests that may be performed in a patient with RIF/LIF pain.

A
  • FBC
  • CRP
  • VBG
  • Serum amylase
  • U&Es
  • Blood glucose
  • Liver enzymes
23
Q

Why is a VBG important in patients with RIF pain?

A

High lactate and metabolic acidosis may indicate that there is ischaemia or severe sepsis

24
Q

Why is blood glucose important to check in a patient with RIF pain?

A

DKA can present with acute abdomen

25
Q

Why is it important to do urinalysis on someone presenting with RIF pain?

A
  • Haematuria – could result from infection, renal/ureteric colic and inflamed pelvic or retrocaecal appendix
  • Glycosuria and ketonuria – indicates DKA
  • Positive leucocyte esterase and nitrites – indicates UTI
  • Proteinuria – can result from UTI or appendiceal irritation of the bladder
26
Q

List some forms of imaging that may be used in a patient with RIF pain.

A
  • Ultrasound – allows visualization of appendicitis and it is good for detecting free fluid
  • Erect CXR – check for perforated viscus Abdominal
  • CT
  • ECG – useful if patient is tachycardic
  • Abdominal X-ray
27
Q

List some indications for performing an abdominal X-ray.

A
  • Foreign body
  • Toxic megacolon
  • Bowel obstruction
28
Q

Describe the typical presentation of mesenteric adenitis.

A

Usually occurs in children < 15 years

Typically follows an upper respiratory tract viral infection

Cervical lymphadenopathy often present

Clinically difficult to distinguish from appendicitis

29
Q

What is Meckel’s diverticulum?

A

It is a remnant of the omphalomesenteric duct that is found in the ileum. This congenital abnormality could become inflamed and mimic appendicitis. It may also contain embryonic remnants of stomach mucosa, which can form a peptic ulcer that could bleed.

30
Q

Describe a presentation of acute-onset Crohn’s disease that causes RIF pain.

A

Inflammation of the terminal ileum can cause RIF pain This symptom is often accompanied by a history of diarrhoea and weight loss

31
Q

RIF pain can also be caused by gastroenteritis. What other symptoms would help identify gastroenteritis as the cause of the RIF pain?

A
  • Vomiting
  • Diarrhoea
  • Symptoms seen in close contacts
32
Q

Describe the typical presentation of renal/ureteric colic.

A
  • Waxing and waning loin to groin pain
  • Often described as being ‘worse than child birth’
  • Urinalysis often shows microscopic haematuria
33
Q

Describe the pattern of pain caused by appendicitis.

A

Initially, the patient will experience low-grade central abdominal pain

This pain will gradually migrate to the RIF over 12-24 hours It will become more intense

34
Q

What other clinical feature is strongly associated with appendicitis?

A

Anorexia – most patients with appendicitis lose their appetite

35
Q

List some other signs of appendicitis.

A
  • Rovsing’s Sign – palpation of the LIF causes more pain in the RIF than the LIF
  • McBurney’ point tenderness – percussion tenderness at McBurney’s point (1/3 of the way between the right ASIS and the umbilicus)
  • Psoas Sign – extension of the hip causes pain (suggests that the appendix is retrocaecal)
  • Cope’s Sign – flexion and internal rotation of the hip causes pain (suggests that the appendix is close to the obturator internus)
36
Q

Describe the management of appendicitis.

A
  • IV fluids
  • Analgesia
  • Appendicectomy preparation
37
Q

Describe the pre-operative preparation for appendicectomy.

A
  • NBM for food and non-clear fluids for 6 hours pre-op
  • NBM for clear fluids for 2 hours pre-op
  • Peri-operative broad-spectrum antibiotics
  • DVT prophylaxis
38
Q

List the criteria for SIRS.

A
  • Heart Rate > 90 bpm
  • Temperature < 36 or > 38
  • Breathing Rate > 20 or PaCO2 < 32 mm Hg
  • WCC < 4000/mm3 or > 12,000/mm3
39
Q

What is sepsis?

A

SIRS with a confirmed or presumed infectious process

40
Q

State the Sepsis Six.

A
  • High flow oxygen
  • Blood cultures
  • Broad-spectrum antibiotics
  • IV fluid challenge
  • Measure serum lactate and haemoglobin
  • Measure hourly urine output
41
Q

What is an appendix mass?

A

This is a complication of acute appendicitis

It is formed when the greater omentum, caecum and/or adherent loops of small bowel wrap themselves around an inflamed/perforated appendix forming a localised mass

Yr 3 Oxford Clinical Cases (28 decks)

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