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Acute appendicitis
Published in Alexander Trevatt, Richard Boulton, Daren Francis, Nishanthan Mahesan, Take Charge! General Surgery and Urology, 2020
As part of a full examination, focus on: Is the patient showing signs of sepsis?Is there localised right lower quadrant pain or generalised peritonitis?Can you palpate a right lower quadrant mass? This may indicate an appendix mass or abscess.In the elderly: Is the patient confused/delirious?In children: Are they quiet and withdrawn or interacting and playing? Are the parents concerned?Always examine the testicles in boys as testicular pain can refer to the abdomen.The presence of percussion tenderness, rebound tenderness or guarding in the right lower quadrant has high diagnostic value.Rovsing's sign may be present: Pain in the right iliac fossa (RIF) when deep pressure is applied in the left iliac fossa.McBurney's sign may be present: This is tenderness at McBurney's point (one-third of the distance from the anterior superior iliac spine to the umbilicus, on the right side of the abdomen). It corresponds to the location of the base of the appendix. This sign is positive if the patient is most tender at this point.Psoas sign: Increased pain during passive extension of the right hip.Obturator sign: Pain felt on passive internal rotation of a flexed hip.
Emergency Surgery
Published in Tjun Tang, Elizabeth O'Riordan, Stewart Walsh, Cracking the Intercollegiate General Surgery FRCS Viva, 2020
Alastair Brookes, Yiu-Che Chan, Rebecca Fish, Fung Joon Foo, Aisling Hogan, Thomas Konig, Aoife Lowery, Chelliah R Selvasekar, Choon Sheong Seow, Vishal G Shelat, Paul Sutton, Colin Walsh, John Wang, Ting Hway Wong
A 23-year-old girl presents at 10 p.m. with a 2-day history of right iliac fossa pain, nausea and a low-grade pyrexia. How will you assess her?Take a history − GI/GU symptoms, last menstrual period, previous ovarian pathology, pregnancy.Examine her − RIF tenderness and peritonism.The classical signs of appendicitis on examination are: Rovsing's sign − right lower quadrant pain with palpation of the left lower quadrant (suggests peritoneal irritation in the RLQ precipitated by palpation at a remote location).Obturator sign − RLQ pain with internal and external rotation of the flexed right hip (suggests that the inflamed appendix is located deep in the right hemipelvis).Psoas sign − RLQ pain with extension of the right hip (suggests that an inflamed appendix is located along the course of the right psoas muscle).Appendicitis is primarily a clinical diagnosis, but I would take bloods (raised WCC and CRP), do a pregnancy test and dip the urine to exclude a urinary tract infection. The Alvarado scoring system is quoted in the literature as a diagnostic aid although its utility has been debated. Recent data indicate it may be restricted to young females.If the patient is not septic and the diagnosis is in question, I would keep her on free fluids and observe her overnight.If she is not septic and I am certain about the diagnosis, I would start her on broad-spectrum antibiotics and list her for theatre the next morning.If she is septic or peritonitic, I would start her on broad-spectrum antibiotics and book her for theatre that evening.
Abdominal pain – a common presentation with unusual diagnosis: a case report
Published in Journal of Community Hospital Internal Medicine Perspectives, 2020
Yeshaswini. P.S. Reddy, Sriviji Senthil Kumaran, Varun Vanka, Asra Rab, Viren Patel
During this hospitalisation, she remained hemodynamically stable but endorsed significant distress due to the abdominal pain. Severe tenderness in the right lower quadrant to mild palpation with guarding, positive McBurney’s point tenderness, and positive rovsing’s sign were observed; psoas sign and obturator sign however were negative. Mildly decreased bowel sounds and absence of organomegaly were noted. Given the presentation, our differential diagnosis included acute appendicitis, acute ovarian torsion, Mckel’s diverticulum, acute ileitis, PID, ovarian cyst, renal calculus, endometritis, ectopic pregnancy, or tubo-ovarian abscess.