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1

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

2

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

3

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

4

presentation of bowel perforation

severe sudden abs pain + pyrexia + vomiting + peritonitis +- bowel sounds

5

Investigations of bowel perforation

CXR: gas under diaphragm
ABG: acidotic
BLD: ↑WCC, ↓Hb, ↑Amylase, ↑lactate
urgent CT when stable

6

Mgmt bowel perforation

Oxygen, IV fluids, analgesia (morphine + cyclizine), cross match, IV Abx (co-amoxclav + metronidazole (cover anaerobes), NGT, surgery

7

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

8

Presentation of bowel obstruction

Colicky abdo pain - tender
distended bowel
tinkling bowe
constipation
N&V (bilious or faecal)

9

Inv of bowel obstruction

AXR →
• Dilated bowel loops (look at thickness of bowel, position and presence of valvulae commiventes or haustra)
• Bloods
• Contrast enema

10

Mgmt of bowel obstruction

DRIP AND SUCK
→ NGT, IV fluids & NBM
• Avoid pro kinetic drugs
• Surgery

11

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

12

Acute appendicitis diagnosis

clinical
urine: ↑nitrates, ↑WCC
USS - 90% sensitive

13

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

14

3 main causes of acute pancreatitis

gall stones, ethanol, trauma (GET)

15

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

16

Invs of pancreatitis

↑ Amylase > 600 +- lipase
Bloods: ↑WCC/CRP, ↑glucose, ↓Ca, ↓Hb (if bleed)
AXR: retroperitoneal fluid + no psoas shadow (sentinel loop sign)

17

What scoring system is used to predict mortality from acute pancreatitis. What is a severe score

Modified Glasgow Score (> 3)

18

Mgmt pancreatitis

IV fluids, Oxygen, Analgesia
Catherter
NBM + NGT

HDU/ICU?
Gallstone - ERCP

19

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

20

INV + Mgmt

Bloods: ↑WCC/CRP + deranged LFT
USS

Mgmt
NBM
Analgesia
Abx: Co-amoxiclav
Urgent cholecystectomy

21

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

22

Ascending cholangitis

Charcot's triad
• Constant RUQ pain
• Fever
• Jaundice of skin + sclera

↑ inflammatory markers

→ risk of septic shock (hypotension + confusion

23

Investigations + Mgmt

Blood: WCC/CRP, bilirubin, LFT
Imaging
ERCP

Abx
Remove block: ERCP or shockwave lithotripsy or widened with stent or cholecystetectomy

24

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)

25

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)

26

Investigations of peptic ulcer disease

• Upper GI endoscopy + biopsy
• H pylori test (Breath test, serology)

27

Mgmt

PPI
Triple therapy if H Pylori - Amoxicillin + Clarithromycin + Lansoprazole

Fluid rhesus if bleed
Check NSAIDs

28

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?

29

Invs/Mgmt

Bloods (G+S) /AXR/Colonscopy

NBM + Analgesia + Abx

30

CF of renal colic

Sudden onset severe colicky loin pain, radiate to the groin, enlarged palpable kidney, tender
• N&V
• Sweaty & restless
• Retention Sx

31

Invs

Urine: ↑blood, ↑nitrates
Bloods: ↑creatinine, urea, K ↑Na
KUB XR: 60% show
Contrast CTKUB: 90%

32

Mgmt of kidney stones

Analgesia (Diclofenac, opioids)
Tamsulosin (a-blocker)
Antiemetic
Shock wave lithotripsy
Nephrostomy?

33

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

34

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

35

Mgmt

ABCDE if haemorrhage
• Methotexate (single dose then redo HCG at 7 days
• Salpingostomy

Rupture → syncope + shoulder tip pain

36

PID

Pelvic pain (constant or intermittent), deep dyspareunia, vaginal discharge + dysuria, irregular periods

37

Inv

G+C tests (endocervical = Vulvocaginal for NAAT + culture
• Bloods ↑ WCC
• USS if risk of ovarian access

38

Mgmt

Abx
• Ceftriaxone IM + doxycycline + metronidazole

39

Miscarriage

< 24 weeks, see antenatal notes

• Pelvic pain
• Uterine contractions
• Bleeding
• Offensive discharge if septic

40

Inv + Mgmt

• bHCG (<66% in 48hrs)
• USS exclude ectopic + IU

Admission: ABCDE
Analgesia + Antiemtic
• IM oxytocin
• Anti-D

41

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

42

Inv + Mgmt

Pregnancy Test
FBC
Urinalysis: urinary signs
USS
CA125

43

Mgmt

Analgesia (most cyst resolve spontaneously)
Lapro-cystectomy if > 5cm
Urgent Laparoscopy if ovarian torsion, rupture or bleed

44

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"

45

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

46

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)

47

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

48

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

49

Acute lower back pain differential

- AAA
- Mechanical pain
- nerve root pain
- spinal pathology (caudal equina)
- spinal cord compression

50

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

51

Perineal injury causes

foot drop (loss of muscles in anterior comparement)
loss of sensation over dorsum of foot
↓ proprioception of ankle joint

52

Name acute problems with urinary symptoms

Renal colic
Testicular torsion
UTI
AKI
Urinary retention

53

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

54

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

55

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)

56

AKI general symptoms

• N, V, anorexia
• Dehydration, fatigue, ↓LOC, ↓UO

57

Nephrotic casuses + symptoms

Cause in adult: Glomerulonephritis
Child: Minmal change disease

• Periorbital swelling
• Ascites
• Oliguria + frothy urine
• Abdo pain

58

HUS symptoms

• Haemoltyic anemia, thrombocytopenia, ARF
If D+ve → bloody diarrhoea

59

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

60

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

61

Describe urinary retention

More common in males,
Male: Hx BPH/cancer/urethral stricture
Female: retroverted uterus, atrophic urethritis, MS, pregnancy

62

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

63

Mgmt of urianry retention

• Urgent decompression
→ Urethral catheter

• Post-bladder drainage
• Monitor U+Es, fluids, UO
• refer urology
• Urgent MRI
• Trial without catheter