Appendicitis most likely diagnosis

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In appendicitis, the initial presenting symptom is generalized periumbilical abdominal pain, which localizes over a 24-hour time period to the right lower quadrant. The pain is initially mild, but increasing to become steady and more severe. It may be aggravated by movement or cough. The patient experiences anorexia, nausea, and possible vomiting. These symptoms are found in classic appendicitis, and Mariah is in the right age group to have the classic symptoms. This is the most likely diagnosis, and the most important one to rule out. The true test would be more time for observation, or even obtaining a surgical consultation, which could result in a trip to the operating room to confirm or refute the diagnosis.

Annals of Emergency Medicine. Volume 36 • Number 1 • July 2000. STATE OF THE ART: Acute appendicitis in children: Emergency department diagnosis and management.

Steven G. Rothrock MD and Joseph Pagane MD

Bates' Guide to Physical Examination and History Taking.

Chapter 9: The Abdomen, pp 350--351

Multiple Choice

1. The correct answer is (D) Mesenteric ischemia

Mesenteric ischemia is caused from thrombosis, emboli, or hypoperfusion. It often begins periumbilically, radiating diffusely. Severe pain, vomiting, and bloody diarrhea are common. In this patient it is not surprising, in light of known cardiac and peripheral vascular disease, that a large meal would have precipitated such a condition.

Acute pancreatitis is an incorrect choice. The pain from acute pancreatitis is generally in the epigastric or left upper quadrant, radiating into the back. Although there is vomiting associated with it, there is no diarrhea. On exam, the patient will be tender but will not generally have a rigid abdomen. Past medical history often reveals previous gallbladder problems and social history commonly reveals alcohol abuse. Acute cholecystitis is also incorrect. The pain associated with acute cholecystitis generally is in the epigastric or right upper quadrant, radiating into the right scapular region. There is often vomiting but no diarrhea associated with it. On exam, there will often be a positive Murphy's sign but no rigid abdomen. Likewise, acute appendicitis is incorrect. Although acute appendicitis begins with periumbilical pain, it localizes to the right lower quadrant.

On exam, there is often involuntary guarding and rebound with decreased bowel sounds. Although anorexia and vomiting are associated with it, diarrhea is not.

2. The correct answer is (B) Acute mechanical intestinal obstruction

Mechanical obstructions are often cause by tumors, surgical adhesions, and, in this case, hernia. Often straining will cause a weakened inguinal area to herniated, leading to an incarcerated hernia. Symptoms include bilious vomiting, which can become fecal in material, and the development of a rigid abdomen.

Acute appendicitis is incorrect. Although appendicitis often causes vomiting, the emesis is generally not fetid. There often is involuntary guarding and rebound, but the testicular exam is usually normal. Acute cholecystitis is also incorrect. The pain in acute cholecystitis is epigastric or in the right upper quadrant. Although bilious vomiting is common, fecal material in the emesis is not. Mesenteric ischemia is likewise incorrect. Ischemia is more common in the elderly with known peripheral vascular disease. Although there is vomiting involved, bloody diarrhea is also common. On exam, there is often involuntary guarding and rebound, but the testicular exam should be normal.

3. The correct answer is (B) Biliary colic

Biliary colic is caused by a sudden obstruction in the cystic duct or the common bile duct by a gallstone. A fatty meal can precipitate the attack. The pain is usually severe and steady and can radiate to the scapula. Nausea, vomiting, and restlessness are common. A positive Murphy's sign is often found.

Peptic ulcer disease is not the correct choice. Although the pain from peptic ulcer disease is epigastric in nature, it tends to hurt intermittently, and the pain varies from burning to gnawing to aching. Often food and antacids can bring temporary relief. Acute cholecystitis is also incorrect. Although acute cholecystitis is also due to inflammation of the gallbladder due to duct obstruction, its onset is usually gradual. Nausea and vomiting are common, but fever and signs of sepsis are often seen. Nor is acute pancreatitis correct. Acute pancreatitis also causes epigastric pain and radiates into the back, but it more often causes tenderness in the left upper quadrant. There is no positive Murphy's sign. There is often a history of long-standing gallbladder disease or recent alcohol ingestion.

4. The correct answer is (B) Esophageal cancer

Esophageal cancer often is slowly progressive but invariably leads to difficulty in swallowing liquids. Weight loss often develops as the disease progresses. Risk factors include tobacco and alcohol use.

Esophageal stricture is an incorrect response. Although it is also a slowly progressive disorder, difficulty drinking liquids is unassociated. Usually there is a long-standing history of gastroesophageal reflux leading to heartburn. Esophageal spasm is also incorrect. Like esophageal cancer, the dysphagias from esophageal spasms include problems with food and liquids. However, an important distinction is that the symptoms of esophageal spasms are intermittent, while those of cancer are progressive. Also the chest pain from esophageal spasm can be treated with medication or physical maneuvers (Valsalva). Scleroderma likewise is not the correct answer. The dysphagia from scleroderma progresses from solid food to liquid much like that associated with esophageal cancer. However, physical maneuvers such as straining against a closed glottis or the Valsalva maneuver is often successful in relieving symptoms. Scleroderma generally is accompanied by systemic manifestations such as thickened skin.

5. The correct answer is (D) Painful anal lesions

Any lesion around the anus, including hemorrhoids (common in pregnancy), or the repair of a perineal birth injury can cause pain severe enough that it can lead to constipation. In this case, the positive occult blood was from enlarged painful internal hemorrhoids.

Obstructing lesion is not a correct choice since all causes of obstructing lesions (such as diverticulitis, volvulus, intussusception, and hernias) cause abdominal pain. The constipation is from the narrowing or complete obstruction of the bowel. In this case, there was no abdominal pain or vomiting. Although irritable bowel syndrome is common in young women, it includes alternating constipation and diarrhea. In this case, the fact that there is no prior history of abdominal pain and alternating constipation and diarrhea makes this diagnosis less likely. Rectal cancer does cause occult and gross bleeding in the stool, but the symptoms of constipation usually progress slowly as the tumor enlarges. Also rectal cancer is more common in the elderly with a strong familial disposition.

6. The correct answer is (B) Inflammatory infections

Bloody diarrhea with a fever after foreign travel is often indicative of invasion of the intestinal mucosa by enteropathic bacteria. An in-depth travel history of different foods and liquids is often warranted.

Although often preceded by foreign travel, secretory infection causes watery diarrhea without blood because the infectious agents (viruses and bacterial toxins) do not invade the bowel wall, causing bleeding. These infections also do not tend to cause high fever. Vomiting is usually associated with the beginning of the illness. Irritable bowel syndrome should never have bloody diarrhea associated with fever. This syndrome is more likely found in young women with alternating symptoms of loose stools and constipation. Malabsorption syndromes are caused by the intestinal tract's inability to absorb nutrients due to an enzymatic deficiency. These stools tend to be bulky and greasy and often float in the toilet. The onset is very insidious, and systemic symptoms often include weight loss and fatigue, but not fever.

7. The correct answer is (A) Gastritis

Severe gastritis is often caused by alcohol ingestion. Bleeding from acute gastritis will be black when the transit time from the colon is slow. When the transit time increases, frank blood can be present. Bowel sounds are often increased, and the abdomen can be diffusely tender.

Inflammatory infectious diarrhea is incorrect. Although some types of infectious diarrhea cause blood to be present in the stool, it is very rarely black since the transit time from the colon is too short to cause melena. Fever and a history of foreign travel are also often found. Mallory-Weiss tear is incorrect. Although vomiting can cause bleeding, this patient has only vomited once. Usually a great deal of retching must be present to cause this significant of a bleed. Esophageal varices are often found in alcoholic patients, but only when they have a diagnosis of significant cirrhosis. This patient has no symptoms of cirrhosis by exam, despite his alcohol use. He has a normal size liver, no jaundice, no ascites, and no veins noted on the abdomen.

8. The correct answer is (B) Urge incontinence

Strong detrussor contractions of the bladder overcome normal urethral resistance, causing urge incontinence. In this patient's case, a condition called interstitial cystitis has caused a deconditioning of voiding reflexes. Frequency, urgency, and voiding small amounts of urine are also often associated with urge incontinence.

On the other hand, stress incontinence usually occurs when the intraabdominal pressure goes up during coughing, sneezing, or laughing. This is usually due to a weakness of the pelvic floor, with inadequate muscle support of the bladder. Vaginal deliveries and pelvic surgery are often associated with these symptoms. Usually female patients are postmenopausal when stress incontinence begins. Overflow incontinence is characterized by continuous dripping of urine. It is often caused by obstruction of the bladder outlet, such as occurs with benign prostatic hypertrophy in men or with a pelvic mass in either sex. In this case, the abdominal, pelvic, and rectal exams were all normal, making a tumor unlikely.

Chapter 10

Male Genitalia and Hernias Multiple Choice

1. The correct answer is (B) Hypospadius

Hypospadius is a congenital displacement of the urethral meatus to the inferior surface of the penis. A groove extends from the displaced urethral meatus to its normal location on the tip of the glans. There is no association between aging and displacement of the urethral meatus.

Strictures affect the internal lumen of the urethra, rather than the meatus; circumcision affects the prepuce and glans, not the meatus.

2. The correct answer is (C) An indirect inguinal hernia

An indirect hernia generally causes pain with straining and a soft swelling in the scrotum that enlarges with increased intraabdominal pressure. It originates above the inguinal ligament near the midpoint and touches the examining finger during examination. This is the most common type of hernia, found in all ages and both sexes.

An incisional hernia is found in the suture line of a surgical intervention. A femoral hernia is relatively rare and occurs more often in women. It is never found in the scrotum or pressing into the inguinal canal. It is often hard to differentiate from lymph nodes. A direct hernia is more common in men over 40 and rare in women. It originates above the inguinal ligament close to the pubic tubercle and rarely enters the scrotum. It bulges anteriorly and pushes the side of the finger forward during examination.

3. The correct answer is (C) A decrease in the size of the penis

In the older male, you may note thinner, more sporadic gray pubic hair and a decrease in the size of the penis. A change in color, size, and scrotal fluid are symptoms requiring further investigation and are not associated with aging.

4. The correct answer is (D) "If you notice any change from what you normally see or feel, call your health care provider."

A firm painless lump, a hard area, or an enlarged testicle is each an abnormal and unexpected finding, which should be assessed by a trained clinician. Time of week and time of day are not factors men should consider relating to self-testicular examination. Regular examination should be encouraged, and changes or abnormal findings need to be reported.

5. The correct answer is (C) Smegma may be present under the foreskin of an uncircumcised male

Some cheesy smegma may collect under the foreskin of an uncircumcised male. The glans looks smooth and without lesions. Pubic lice and nits settle in the base of the penis and excoriations or wrinkling may suggest activity. Hair distribution is variable.

6. The correct answer is (D) When palpating for a hernia on the right side, have the client shift his standing weight onto the left leg

Positioning to the left leg allows the examiner to follow the inguinal canal and document any hernia-related bulge.

Chapter 11 Female Genitalia

Multiple Choice

1. The correct answer is (C) Urethral meatus and vaginal orifice

The labial structures encircle a boat-shaped space called the vestibule. Within it are several openings. The urethral meatus appears as a small, raised structure between the clitoris and the vagina. Just posterior to the urethral meatus at the 5 and 7 o'clock positions are the tiny openings of the paraurethral (Skene's) glands. The vaginal orifice is posterior to the urethral meatus. On either side and posterior to the vaginal orifice are two vestibular (Bartholin's) glands, which secrete a clear lubricating mucus during intercourse. Their ducts are not visible but open in the groove between the labia minora and the hymen.

2. The correct answer is (B) Press the inferior margin of the introitus down to enlarge the vaginal opening, open, insert the speculum with the blades at an oblique downward angle, and apply gentle downward pressure

Hold the speculum in your right hand with the index and the middle fingers surrounding the blades and your thumb under the thumbscrew. This prevents the blades from opening painfully during insertion. With your left index and middle fingers, push the introitus down and open to relax the pubococcygeal muscle. Tilt the width of the blades at an oblique angle and insert the speculum past your left fingers, applying any pressure downward. This avoids pressure on the sensitive urethra above it. Ease insertion by asking the woman to bear down. This relaxes the perineal muscles and opens the introitus. As the blades pass your left fingers, withdraw the fingers. Now turn the width of the blades horizontally and continue to insert at a 45° angle downward toward the small of the woman's back. This matches the angle of the vagina vault.

3. The correct answer is (C) The cervix should move when palpated; an immobile cervix may indicate malignancy.

Characteristics of a normal cervix are: consistency is smooth and firm; contour is evenly rounded; and mobility is flexible. An abnormal cervix would be firm, fixed, possibly nodular, and painful when moved.

Chapter 12

The Pregnant Woman

Case Study: Irregular Menses

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