Study notes - Examples

Bullet point a list of important questions necessary to achieve a diagnosis

• Abrupt, rapid or gradual?
• Colicky or Constant?
• Well localised or poorly localised?
• Worse with movement?
• Fever? Bilious vomiting? Haematemesis? PV/penile discharge? Dyspareunia? Menstruation? PR blood? Dysuria or haematuria? Jaundice?
• Previous abdominal operations?
• Pregnant?

• Abrupt onset
• Worse with movement. Disturbs sleep. Severe, unrelenting.
• Bilious vomiting
• Low BP
• Metabolic acidosis
• Fever / Chills / Night sweats
• Elderly and paediatric patients, spinal patients, patients on steroids.

• Cholecystitis –Usually due to gallstones. Other gallstone conditions = biliary colic, jaundice, ascending cholangitis, pancreatitis, rarely gallstone ileus
• Appendiciitis – Often difficult to diagnose in early stages or retrocaecal/pelvic appendix. Point tenderness, fever, anorexia are highly suspicious. Vague presentations require careful observation.
• Pyelonephritis – Must rule out complications such as renal calculi with obstruction. Antibiotic course longer than pure cystitis.

• ‘Peritonism’ – combination of cough, percussion and rebound tenderness with involuntary guarding. Often associated with pain on slight movement.

• ‘Charcot’s triad’ – combination of fever, RUQ pain and jaundice. Signifies ascending cholangitis.

DISEASE – AN EXAMPLE

• Central crushing chest pain radiant to arm/shoulder with nausea and sweating
• ST elevation on ECG
• Troponin rise between 4-24 hours later

• Atypical symptoms – vague chest/arm symptoms, variable radiation
• Initial ECG often normal
• Ruling out MI before 24 hr troponin available

• Aspirin
• GTN S/L
• Heparin bolus + infusion
• Urgent cardiac admission with monitoring
• Serial cardiac enzymes and ECG
• Angioplasty (if STEMI or unstable)
• Consider thrombolysis (if STEMI and no access to cath lab)