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Scenario 3, Red Flags: Sudden onset severe pain Rebound Tenderness …
Scenario 3
Focused Examination:
Vitals:
Assess for fever, tachycardia, Hypotension, Shock, Dehydration and Pain Score.
Abdominal Examination:
Look for distention, scards, abnormal pigmentation, rigidity, bowel sounds, tenderness, guarding, rebound tenderness and palpable masses, fluid and fecal loading. Perform a Rovsing's sign, Psoas sign and Obturator sign
Pelvic Examination:
Rule out PID or Testicular Torsion
Rectal Examination:
Assess for rectal tenderness or masses (if indicated).
History
Pain Characteristics
:
Onset: Gradual or Rapid
Progressive or Regressive
Spasmodic, Dull or Colicky
Site and Severity: Right lower abdominal pain indicates possible Appendicitis.
Pain Duration
: 8 hrs of symptom suggests an acute infection.
Radiation pattern.
Associated Symptoms
: Fever and vomiting indicate systemic involvement. potentially indicating an infectious process.
Exacerbating and Relieving Factors.
Past Medical and Surgical History
Diagnosis
Probable:
Appendicitis
Differentials:
Gastroenteritis
: similar presentation but usually less localized pain.
Mesenteric Adenitis:
Mimics appendicitis but typically presents with a history of preceeding upper respiratory infection.
Cholecystitis:
Right upper quadrant pain, but can refer to the right lower quadrant.
Renal Colic:
Can present with acute flank pain radiating to groin, nausea and vomiting.
Ectopic Pregnancy:
Important to consider in females of reproductive age.
Management Strategies:
Appendicitis:
Immediate Action:
I/V access, NPO, fluids, analgesia (avoid opiods initially), antibiotics (Ceftriaxone and Metronidazole).
Surgical Consultation
: Urgent Appendectomy is usually indicated.
Monitoring:
Serial abdominal examinations, monitoring for signs of perforation.
Gastroenteritis:
Fluid Replacement:
ORS or IV fluids if severe dehydration.
Symptomatic Relief
: Antiemetics for vomiting, antidiarrheals cautiously.
Dietary Modifications
: Gradual reintroduction of clear liquids then a bland diet as tolerated.
Red Flags:
Sudden onset severe pain
Rebound Tenderness
Rigidity of Abdomen
Presence of blood in vomit or stool
Previous history of similar episodes
Pain exacerbated with movement: Peritonitis.
Recent Abdominal Trauma or Surgery.
Irreducible Inguinal Hernia.
These management strategies should be implemented promptly based on clinical suspicion and further investigations.
Always consider patient specific factors and adjust management accordingly.
References:
1.Medscape
https://emedicine.medscape.com
› General Surgery
https://bestpractice.bmj.com/topics/en-gb/503
Contributors:
Dr. Saara Muddasir Khan
Dr. Ben Lipesa Ondere
Algorithm made by Dr. Maheen Batool