EMQs in Clinical Medicine.pdf - Peshawar Medical College

166 The abdomen and surgery
ANSWERS
54 Abdominal pain
Answers: B K F E J
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A 45-year-old man with a history of gallstones presents in A&E with
severe epigastric pain radiating to the back and vomiting.
Severe epigastric pain radiating to the back is the classic description of
acute pancreatitis, and gallstones and alcohol are its two most common
causes. Serum amylase is usually significantly raised but this is not
specific because amylase can be raised with other conditions that
present with an acute abdomen, such as cholecystitis and perforated
viscus.
A 28-year-old man presents with sharp left loin and left upper
quadrant pain radiating to the groin. He is not jaundiced.
Renal colic is severe and often associated with nausea and vomiting. It is
very important to provide adequate analgesia and morphine may be
required.
A 44-year-old woman presents with continuous right upper quadrant
pain, vomiting and fever. Murphy’s sign is positive.
Murphy’s sign is an indicator of acute cholecystitis. The hand is placed
over the right upper quadrant and the patient is asked to breathe in. The
pain resulting from the inflamed gallbladder moving downwards and
striking the hand is severe and arrests the inspiratory effort.
A 26-year-old man with a previous history of abdominal surgery
presents with colicky central abdominal pain, rapidly followed by
production of copious bile-stained vomitus.
There is usually early onset of vomiting and late development of
distension in small bowel obstruction. An abdominal radiograph may
show distended loops proximal to the obstruction and lack of gas in the
large bowel. In large bowel obstruction vomiting only occurs later and
is faeculent (mixed with faeces).
A 50-year-old man presents with epigastric pain worse at night and
relieved by eating or drinking milk.
Classically the pain of duodenal ulceration is described as being relieved
by eating, whereas the pain of gastric ulceration is described as worsening
on eating. In practice it is difficult to identify the site of ulceration
based on such information.