Combined Differential Diagnosis Student...
Transcript of Combined Differential Diagnosis Student...
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Differentials
Eyes
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Red Flags
• Sudden, marked eye pain • Visible flashes followed by partial,
peripheral vision loss • Developing tunnel vision or a central blind
spot
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Eye Pain
• What conditions would present with eye pain as a symptom?
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Conjunctivitis (Pink Eye)
• Typical biographical profile or onset, circumstances and course- following contact in daycare, schools & institutions; with seborrhea and rosacea
• Symptom characteristics- red, burning, itching eye(s) • Aggravating and alleviating activities- bright lights
(photophobia) • Physical findings- typical conjunctival injection, slight
pain, purulent discharge and the lids may stick together during sleep; pupils and visual acuity are normal
• Diagnostic studies- usually unnecessary
• Unilateral or bilateral onset?
• Conjunctivitis is the most common ocular condition seen by primary care physicians
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Allergic Conjunctivitis
• Similar features: • Painful, red eyes with unaffected acuity
and pupils • Distinguishing features: • Persistent or seasonal episodes; other
associated allergic complaints or known hay fever, allergic rhinitis and asthma
• Itching: key feature, unusual to have allergic conjunctivitis without it
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Corneal Abrasion • Similar features: • Painful, red eye(s) • Distinguishing features: • The patient reports an eye injury, marked pain,
photophobia and perilimbal injection or a circumcorneal flush in one eye; decreased visual acuity is dependent on the extent of damage
• Risk factors: occupation, contact lenses, dusty environments, dry eye condition, lack of eye protection
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Acute Iritis/Anterior uveitis
• Similar features: • Painful, red eye(s) • Distinguishing features: • The patient reports marked pain,
photophobia in one eye; perilimbal injection and pupillary responses are sluggish in that eye; it may be secondary to eye trauma
• Seen in: physical trauma, inflammatory and connective tissue diseases, infections
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Acute Glaucoma • Similar features: • Painful, red eye(s) • Distinguishing features: • patient reports marked pain, photophobia,
dimmed vision and halos around lights; perilimbal injection, dilated pupil, sluggish pupillary responses, increase eyeball tension and disc cupping in one eye
• POAG vs. NAG: (primary open angle vs narrow angle) – Clogged drain vs. obstruction by the iris – (P)OAG most common – Increased IOP
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Loss of Peripheral Vision
• What conditions would present with loss of peripheral vision as a symptom?
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Chronic Glaucoma • Typical biographical profile- adults > 40 y/o • Onset, circumstances and course- insidious
tunnel vision over the course of many years • Symptom characteristics- slowly progressing
tunnel vision in both eyes • Aggravating and alleviating activities-
Physical findings- obvious tunnel vision checking peripheral field of vision; enlarged physiologic cup
• Diagnostic studies- tomometry and perimetry
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Retinitis Pigmentosa
• Similar features: • insidious tunnel vision over the course of many
years • Distinguishing features: • May occur at a younger age than chronic
glaucoma; retinopathy differs
• Abnormalities of the rods and cones (dystrophy) • Black bone-spicule pigmentation is
pathognomonic
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Differentiate Optic Nerve Tract Lesions
• Similar features: • Peripheral vision loss • Distinguishing features: • Quadrant or hemisphere visual loss • Causes?
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Differentiate Retinal Detachment
• Similar features: • Peripheral vision loss • Distinguishing features: • Secondary to trauma or existing
retinopathy; flashes of light or multiple new floater may precede progressive quadrant visual loss
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Loss of Central Vision
• What conditions would present with loss of central vision as a symptom?
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Central Cataract
• Typical biographical profile- adults > 40 y/o • Onset, circumstances and course- insidious
over the course of many years • Symptom characteristics- slowly progressing
central vision loss in one or in both eyes • Aggravating and alleviating activities- none • Physical findings- central shadow in the red
reflex • Diagnostic studies- ophthalmology consult • Risks: aging and eye surgeries and injuries
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Differentiate Corneal Scar
• Similar features: • central vision loss • Distinguishing features: • History of corneal injury
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Differentiate Macular Degeneration
• Similar features: • slowly progressing central vision loss in one or in
both eyes • Distinguishing features: • Altered color and configuration of the macula/
fovea
• Dry and wet forms: presence of exudate or not • Drusen bodies—are these indicative of only
macular degeneration?
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What’s the name of this exam?
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Differentials
Ears
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Red Flags
• Sudden or rapidly progressive hearing loss • Vertigo • Unilateral or pulsatile tinnitus • Bleeding due to foreign object or pressure
change injury
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Presentation Earache
• What conditions have earache as a symptom?
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Otitis Externa • Typical biographical profile- people with
seborrhea or eczema of the ear or who irritate the canal excessively cleaning or swimming
• Onset, circumstances and course- • Symptom intensity, quality, location &
distribution- earache • Associated symptoms- • Aggravating and alleviating activities- • Physical findings- red, swollen canal with canal
debris or discharge; hearing likely normal • Diagnostic studies- usually not necessary
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Differentiate Auditory Tube Blockage
• Similar features: • Earache • Distinguishing features: • Secondary to an upper respiratory infection,
swollen adenoids or barotraumas; landmarks are prominent due to drum retraction; no signs of inflammation
• PROBABLY THE MOST COMMON EARACHE CAUSE YOU’LL SEE
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Differentiate Suppurative Otitis Media
• Similar features: • Earache • Distinguishing features: • Secondary to an auditory tube blockage;
fever, diminished hearing, red and bulging tympanum with possible purulent discharge, most often in pre-schoolers; Weber lateralizes to and Rinne´ is negative on the affected side
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Presentation Diminished or Absent Hearing
• What conditions have hearing loss as a symptom? – Remind me to tell you a funny story about
Silly Putty
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Excessive Wax
• Typical biographical profile- Anyone possible, but more common in adult males
• Onset, circumstances and course- insidious or Q-tip use
• Symptom intensity, quality, location and distribution- hearing loss
• Physical findings- dark wax occluding the canal; Weber lateralizes to and Rinne´ is negative on the affected side
• Diagnostic studies- usually not necessary
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Differentiate Serous or Mucoid Otitis Media (OME)
• Similar features: • Hearing loss • Distinguishing features: • Secondary to auditory tube blockage;
normal, yellow or dark tympanic membrane with possible air bubbles or fluid line; Weber lateralizes to and Rinne´ is negative on the affected side; no signs of inflammation; can persist for extended periods
• Risk factors: URI
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Differentiate Suppurative Otitis Media (Perforation)
• Similar features: • Hearing loss • Distinguishing features: • Secondary to auditory tube blockage;
fever, diminished hearing red and bulging eardrum with possible purulent discharge most often in pre-schoolers; Weber lateralizes to and Rinne´ is negative on the affected side
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NEVER put liquid through a perforated TM
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Differentiate Otosclerosis (sclerosis and fixation of the ossicles) • Similar features: • Hearing loss • Distinguishing features: • Familial trait; no abnormalities of the canal
or eardrum; Weber lateralizes to and Rinne´ is negative on the affected side
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Meniere Disease
• Similar features: • Hearing loss • Distinguishing features: • Familial trait; classic triad of hearing loss,
vertigo, and tinnitus; no abnormalities of the canal or eardrum; Weber lateralizes to the unaffected side; Rinne´ is negative on the affected side—what happens to AC:BC?
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Differentiate Noise Induced Hearing loss
• Similar features: • Hearing loss • Distinguishing features: • Reported history of recreational or
occupational noise exposure; no canal or middle ear signs; Rinne´ AC>BC but less than 2:1 ratio; high frequencies 3000 to 6000 Hz are the first lost
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Differentiate Presbycusis (age related)
• Similar features: • Hearing loss • Distinguishing features: • Older patient who complains that others
are mumbling or that he/she can’t understand what’s being said when background noise is present; Rinne´ AC>BC but less than 2:1 ratio; low frequency sounds & whispers are first lost
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Differential Diagnosis
Chest
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Red Flag Lung Symptoms
• Unprovoked, sudden onset of dyspnea, and/or chest pain
• Persistent or escalating dyspnea or coughing provoked or aggravated by mild exertion
• Yellow, green, rusty, pink frothy or blood streaked sputum
• Any unexplained weight loss
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Red Flag Lung Signs
• Diminished or absent breath sounds • Displaced bronchial breath sounds (heard
in vesicular locations) • Dull, hyperresonant or tympanic
percussive notes over the lung fields
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Presentation
• What respiratory conditions could present with acute fever, dyspnea, and/or cough?
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Acute Bronchitis • Typical Patient Profile –preschoolers mostly, but
anyone • Onset, circumstances and course- often
secondary to an URI • Symptom intensity, quality, distribution and
duration– fever, dyspnea and cough often secondary to a cold gradually wane within 7-14 days
• Aggravating and Alleviating activities – exertion • Physical exam findings – possible coarse crackles
and no other chest findings • Diagnostic Studies– clinical findings; rarely x-ray
• “Chest cold” and exertional dyspnea
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Differentiate Whooping Cough
• Similar features • Persistent, childhood cough, fever and
malaise • Distinguishing features • After a week or two the cough turns into
severe coughing attacks (up to 15 in a row) that end with a high-pitched “whoop” during the next inspiration (stridor)
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Differentiate Measles
• Similar features • Childhood cough, cold, and conjunctivitis • Distinguishing features • Koplik’s spots appear 1-2 days before the minute
maculo-papules, which rapidly coalesce – Koplik’s spots: bluish-white spot surrounded by red
• Rubeola: “hard measles” or “red measles” • Rubella: “German measles” or “three day measles”
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“Grains of salt on a wet
background”
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Differentiate Viral Pneumonia
• Similar features • Most likely an adult with malaise, dyspnea cough • Distinguishing features • Fever persists beyond the expected 4-5 days;
possible crackles and wheezes, CBC may help - clinical differentiation from acute bronchitis may be impossible
• Causes: influenza, RSV, herpes and varicella, adenovirus
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Differentiate Bronchopneumonia • Similar features • Fever, dyspnea and cough; possible crackles
and wheezes • Distinguishing features • Persistent scattered crackles, wheezes and
malaise; labs (sputum sample) and x-ray
• AKA: Lobular pneumonia • Strep., staph., H. influenza, coliform, fungi • Secondary pneumonia: end of life or with other
illnesses (cancer, renal failure)
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Differentiate Lobar Pneumonia • Similar features • Fever, dyspnea, and cough; possible crackles
and wheezes prior to consolidation • Distinguishing features • Higher fever, tachypnea, severe lethargy; rusty
sputum, bronchial breath and spoken sounds transmitted better through the consolidation; increased fremitus and dull percussive note over that area; labs and x-ray
• Named for its lung distribution, not pathogen • Strep., pseudomonas, Klebsiella • Usually affects younger patients
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Differentiate Influenza
• Similar features • Fever, dyspnea, and cough; possible
crackles and wheezes • Distinguishing features • Sudden onset, persistent higher fever,
cough induced throat and/or chest pain; contact cases; positive serologic tests- clinical differentiation from acute bronchitis may be impossible
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Presentation
• What respiratory conditions would present with chronic or recurrent dyspnea and cough?
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Chronic Bronchitis • Typical Patient Profile – 50 y/o adult exposed to
cigarette smoke or pollution • Onset, circumstances and course- Repeated attacks
of a productive cough over several years • Symptom intensity, quality, distribution and
duration– chronic productive cough and exertional dyspnea
• Aggravating and Alleviating activities – Exertion • Physical exam findings – scattered crackles and
eventual wheezes • Diagnostic Studies– clinical findings, labs, x-ray and
spirometry
• “Dirty Chest” on x-ray
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Differentiate Emphysema • Similar features • Chronic productive cough and exertional
dyspnea in an adult over 50 • Distinguishing features • May be impossible to clinically differentiate early
stages, since it results in hyperinflated alveoli due to the bronchial fibrosis of chronic bronchitis; eventually general hyperresonant percussion and diminished fremitus occur; auscultation may reveal breath and spoken sounds with superimposed expiratory wheezes
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Differentiate Secondary Tuberculosis
• Similar features • Fever, dyspnea, and cough; possible wheezes • Distinguishing features • Persistent cough (blood stained), dyspnea and
lethargy; history of contacts or prior TB diagnosis; labs and x-ray
• S.N.: primary TB is usually asymptomatic • If lung is fibrotic -bronchial breath and spoken
sounds are transmitted better through the consolidation, increased fremitus and dull percussive note over those areas may be heard
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Differentiate Bronchiectasis
• Similar features • Chronic productive cough and exertional
dyspnea in an adult over 50 (often secondary to the previous conditions)
• Distinguishing features • Bronchoscopy • S.N.: 50% of cases secondary to cystic
fibrosis
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Differentiate Bronchogenic Neoplasm
• Similar features • Chronic cough and dyspnea in an adult,
smoker over 50 • Distinguishing features • Difficult to differentiate from smoker’s
cough and other pneumonic conditions; x-ray, bronchoscopy and sputum cytology
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Differentiate Left-Sided Congestive Heart Failure
• Similar features • Chronic cough and dyspnea in an adult,
smoker over 50 • Distinguishing features • History of heart disease, high cholesterol
and/or BP, fine basilar crackles, orthopnea, added heart beats and/or sounds
• S.N.: Cor Pulmonale signs and symptoms may also be present with chronic lung disease
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Differentiate Asthma
• Similar features • Dyspnea, cough, and chest tightness;
scattered wheezes and crackles • Distinguishing features • Allergy or exercise induced episodes of
obstructive dyspnea usually beginning in early childhood
• Chest x-rays: Normal
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Presentation
• What respiratory conditions would present with some degree of chest pain?
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Pleuritis (pleurisy)
• Typical Patient Profile – adults often with no history of lung problems
• Symptom intensity, quality, distribution and duration– sudden pleuritic pain
• Onset, circumstances and course- may be viral or follow serious lung pathology (mesothelioma)
• Aggravating and Alleviating activities – coughing, deep breathing or movement
• Physical exam findings – possible friction rub • Diagnostic Studies– clinical findings and x-ray
(lack of x-ray findings) • Cause: usually viral, could be TB, cancer, SLE, RA
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Differentiate Spontaneous Pneumothorax
• Similar features • Sudden, severe, continuous chest pain • Distinguishing features • Dyspnea parallels lung compression; fremitus,
breath and spoken sounds are diminished or absent; tympanic percussive note; x-rays confirm dx
• Who? Anyone, but taller and thinner body
habitus is more common
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Differentiate Pulmonary Embolus
• Similar features • Sudden, severe, continuous chest pain; possible
shock • Distinguishing features • History of phlebitis, prolonged sitting or bed rest;
dyspnea marked, cyanosis; local crackles and wheezes aggravated by respiration or cough; hospital investigation
• Risk Factors: clotting disorders, immobilization, long bone fractures, atherosclerosis
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Cardiac Red Flag Symptoms
• Sudden onset of unprovoked or exertional chest, arm, neck or jaw pain
• Persistent or escalating dyspnea and/or cough
• Heart palpitations • Bilateral foot/leg edema • Cyanosis
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Cardiac Red Flag Signs
• Rapid, slow and/or irregular heart beat or pulse
• Diminished or absent pulse or heard bruit • Added heart beats and/or sounds • Sudden increase or drop in blood pressure
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Presentation
• What cardiovascular conditions would present with some degree of chest pain?
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Myocardial Infarct • Typical biographical profile- middle aged or older,
overweight, heavy smoker, diabetic, high BP, high LDLs, claudication; personal or family history of atherosclerosis, angina or infarct
• Onset, circumstances and course- may be unprovoked
• Symptom location, quality and distribution- severe, continuous, substernal pain or tightness radiating to the arms, neck or jaws
• Associated symptoms- dyspnea; pale, perspiring and apprehensive
• Aggravating and alleviating activities- exertion; unrelieved by rest
• Physical findings- shallow, rapid or irregular pulse; drop in BP
• Diagnostic studies- EKG confirms
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Differentiate Angina Pectoris
• Similar features • Exertion induced chest, arm or neck pain • Distinguishing features • Rest relieves the recurring episodes of
discomfort
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Differentiate Pericarditis
• Similar features • Chest pain • Distinguishing features • “Sticking” in nature- worse with deep
breaths, coughing or twisting; friction rub consistent with the heart beat; hospital investigation
• Sounds very much like???
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Differentiate Dissecting Aneurysm
• Similar features • Sudden, severe, continuous chest pain
that may radiate to the arms or jaw • Distinguishing features • Impossible to differentiate clinically;
immediate hospital investigation
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Presentation
• What gastrointestinal conditions would present with some degree of chest pain?
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Differentiate GERD
• Similar features • Postprandial, persistent, burning chest
pain • Distinguishing features • Recurrent, position related (lying) rather
than exertional episodes; antacids relieve; eventually associated dysphagia (food sticking sensation); difficult clinical DD
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Differentiate Chronic Cholecystitis Episode
• Similar features • Low substernal chest pain • Distinguishing features • Episodic pain follows fatty meals and may
radiate to the right scapula; positive Murphy’s sign; imaging confirms if stones are present (cholelithiasis/choledocolithiasis/cholangitis)
• Do all gallstones show up on plain film? • US, CT, HIDA scan, ERCP
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Differentiate Peptic Ulcer
• Similar features • Low substernal chest pain which may
radiate through to the back • Distinguishing features • Food and antacids relieve the pains
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Differential Diagnosis
Abdomen
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Gastrointestinal Red Flag Symptoms
• 1. Unexpected weight loss or rapid weight gain and pitting edema
• 2. Bloody or coffee ground vomit • 3. Black or gray-colored stools; mucous,
pus or blood in the stools • 4. Pencil thin, ribbon-like stools or
persistent constipation or diarrhea • 5. Jaundice
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GI Red Flag • 6. An acute "surgical" abdomen – A patient
who reports a history of sudden, severe, persistent, escalating or writhing abdominal pain has a presentation that often indicates the need for hospital investigation and emergency surgical intervention. The source of the pain is often due to inflammation, perforation, obstruction, infarction or rupture of intra-abdominal organs. Examples are acute cholecystitis, appendicitis, perforated peptic ulcer, strangulated hernia, superior mesenteric artery thrombosis, and splenic rupture.
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Gastrointestinal Red Flag Signs
• Unexplained abdominal distention or masses
• Visible peristalsis or pulsatile masses • Absent or hyperperistaltic sounds • Organomegaly and/or chronic fatigue
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Presentation
• What common abdominal conditions would present with abdominal pain, vomiting and diarrhea?
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Abdominal Pain, Vomiting and Diarrhea
Acute Gastroenteritis (Stomach Flu) • Typical Patient Profile –no specific profile • Initial onset, circumstances and course – recently; may have
been exposed to others with the diagnosis • Symptom intensity, quality, location and distribution– mild, ache
located around the umbilicus that worsens with peristalsis • Associated symptoms – nausea, vomiting and diarrhea • Aggravating and alleviating activities – worse eating and better
not eating • Physical exam findings – clicks and gurgles in the high normal
range • Diagnostic Studies– usually unnecessary; diagnosis via clinical
finding • Causes: 50-70% noroviruses; rotovirus (mc in kids); adenovirus,
parvovirus; E. coli, salmonella, shigella, campylobacter, parasites • You are contagious for at least 3 days (and up to two weeks) after
symptoms
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Differentiate Food Poisoning
• Similar features: • diarrhea, vomiting and abdominal pain • Distinguishing features: • differentiation is difficult clinically; others
who ate the same food also have the symptoms; stool culture may identify a pathogen
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Differentiate Morning Sickness
• Similar features: • diarrhea, vomiting and abdominal pain • Distinguishing features: • Difficult differentiation; known pregnancy
or positive pregnancy test
• Other DDX? Peptic ulcers • Is it really MORNING sickness?
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Differentiate Hepatitis
• Similar features: • Bout of abdominal pain and vomiting • Distinguishing features: • Recurring bouts following a history of
possible oral-fecal or co-mingled blood transmission; urine is dark and stools are grey; AST, ALT and alkaline phosphatase levels may indicate liver damage
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5 types of hepatitis • Hepatitis A (HAV): contaminated food or water, oral-fecal
contact; hepatomegaly acutely, but usually full recovery • Hepatitis B (HBV): bodily fluid contacts (STD, needles,
bites, sharing personal items, passed from mother to newborn); SERIOUS illness, chronic hepatomegaly; is a risk factor for cancer (MOST COMMON in US)
• Hepatitis C (HCV): same transmission as HBV; similar illness presentation, possible infection, leading to scarring and cirrhosis
• Hepatitis D (HDV): opportunistic infection if you already have HBV; same transmission
• Hepatitis E (HEV): uncommon in the US; contaminated water, oral-fecal contact; usually full recovery
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Differentiate Irritable Bowel Syndrome
• Similar features: • Bouts of abdominal pain and diarrhea • Distinguishing features: • Recurrent bouts of diarrhea and
constipation (altered bowel habits); usually young to middle age; may have a history of low fiber diet and overuse of laxatives (self-treatment, not thought to be causative)
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Differentiate Crohn’s Disease
• Similar features: • Bouts of abdominal pain and diarrhea • Distinguishing features: • Young adults; recurring bouts indicates the
need for a CBC, upper GI study and/or colonoscopy
• Features: skip lesions, cobblestoning, affects any portion, but MC in ileum
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Differentiate Ulcerative Colitis • Similar features: • Recurrent bouts of diarrhea • Distinguishing features: • Young adults; recurring bouts of minimal
abdominal pain with mucous, pus or blood streaked diarrhea, which indicates the need for colonoscopy
• Features: granulation, loss of haustra, usually in the large bowel, so diarrhea
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Differentiate Clostridium Difficile Colitis
• Similar features: • Recurrent bouts of diarrhea • Distinguishing features: • History of recent antibiotic therapy
– Older, health care setting, underlying illness • Need to do a toxin assay to detect the
toxin the bacterium produces in a stool specimen
• Profuse, watery, foul-smelling diarrhea
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Differentiate Cholera
• Similar features: • Recurrent bouts of diarrhea • Distinguishing features: • Exposure to poor sanitation and water
purification; need a stool culture or cholera dipstick to differentiate; can be fatal within 24 hrs. if there is profuse diarrhea
• “Boil it, cook it, peel it, or forget it.”
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Differentiate Colon Cancer
• Similar features: • Possible abdominal pain and diarrhea • Distinguishing features: • Persistent, escalating, colicky abdominal
pain; mucous or blood in stools; 50+ males; palpable mass sometimes; need colonoscopy to differentiate
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Presentation
• What common abdominal conditions would present with upper abdominal pain (heartburn)?
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GASTROESOPHOGEAL REFLUX DISEASE (GERD)
• Hiatal hernias may be a factor contributing to the incompetent
esophageal sphincter • Typical Patient Profile – adult, male or female • Initial onset, circumstances and course – slow intermittent
progression over a few years period • Symptom intensity, quality, distribution and duration– recurrent,
frequent, substernal “heartburn” about an hour after eating • Associated symptoms – Lump in the throat sensation has
developed when swallowing. • Aggravating and Alleviating activities –worse lying down
especially at night; antacids help • Physical findings – no significant finding • Diagnostic Studies– imaging may reveal a hiatal hernia;
endoscopic exam • Anyone not responding to antacids needs to be evaluated for
esophageal or stomach cancer, which have similar signs and symptoms
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Differentiate Chronic Cholecystitis
• Similar features: • Recurrent indigestion and flatulence for a few
hours after eating • Distinguishing features: • Female, forty, fat and flatulent whose symptoms
are related to fatty foods and not relieved with antacids; positive Murphy’s sign and possible jaundice; a bile duct stone may cause an acute episode (“Surgical Abdomen”)
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Differentiate Duodenal Ulcer
• Similar features: • Burning, gnawing abdominal pain • Distinguishing features: • An adult with epigastric pain 2-3 hours
after eating, especially alcohol, spicy or fatty foods; barium radiographs and endoscopy differentiate
• A perforated ulcer would present as a “surgical abdomen”
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Differentiate (acute) Pancreatitis • Similar features: • A bout of upper abdominal pain • Distinguishing features: • Sudden, severe onset of symptoms lasting hours
– days with associated fever, and vomiting; alcohol and eating worsen it; fetal position may help; labs help differentiate
• Late stage pancreatic cancer can present with similar signs and symptoms
• Causes: gallstones, biliary diseases, alcohol use, viruses (mumps, coxsackie)
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Differentiate Gastric Cancer
• Similar features: • A bout of upper abdominal (indigestion)
pain • Distinguishing features: • Associated vomiting and unexpected
weight loss; symptoms are unresponsive to ulcer or reflux treatments; endoscopy differentiates
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Presentation
• What common abdominal conditions would present with lower abdominal pain?
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DIVERTICULITIS
• Typical biographical profile- male or female over 40 • Onset, circumstances and course- last about 1-3 days • Symptom intensity, quality location, and distribution-
recurring episodes of sudden, severe LLQ pain • Associated symptoms- diarrhea and rectal bleeding • Aggravating and alleviating activities- settles rapidly
with bed rest • Physical findings- LLQ tenderness and guarding • Diagnostic studies- contrast studies
• Polyps are extensions INTO the bowel; diverticulitis lesions are extensions OUTSIDE the bowel
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Differentiate Appendicitis
• Similar features: • Lower abdominal pain • Distinguishing features: • Sudden, severe or escalating LRQ pain
(“Surg. Abd.”) that migrated from umbilicus to McBurney’s point; positive Markle (heel jar), Rovsing, Blumberg, psoas, and obturator signs; labs help differentiate
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Differentiate Intestinal Obstructions
• Similar features: • Some lower abdominal pain • Distinguishing features: • Adults (50+) with sudden, severe or
escalating waves of abdominal pain (“Surg. Abd.”), distention, visible peristalsis and frequent high-pitched peristaltic sounds
• Special studies may be needed
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Differentiate Indirect Inguinal Hernia (Most common)
• Similar features: • Lower Abdominal pain • Distinguishing features: • Male with pain and/or inguinal mass that
are worse when coughing sneezing or straining; digital and/or Zieman’s exams are positive
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A: epigastric B: incisional C: umbilical D: direct E: indirect F: femoral
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Differentiate Femoral hernia
• Similar features: • Lower abdominal pain • Distinguishing features: • Female with pain and/or femoral triangle
mass that are worse when coughing sneezing or straining; digital and/or Zieman’s exams are positive
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Differentiate Direct Inguinal Hernia
• Similar features: • Lower abdominal pain • Distinguishing features: • Male with vague pain and/or mass medial
to the inguinal canal that are worse when coughing sneezing or straining; digital and/or Zieman’s exams are positive
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The End!