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This is a quiz to explore pediatric acute right right iliac fossa pain differentials.

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Right iliac fossa pain

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Question 1

Stem 1 of 5

A 14 year old visibly distressed female attends A&E with a history of vomiting and diarrhoea. She complains of constant sharp 9/10 abdominal pain for the past 10 hours and has a temperature of 37.7 degrees.  When asked where the pain is, she points to right iliac fossa.

On examination there is rebound tenderness in the right iliac fossa. What is this examination finding called?
A
Rovsing's sign
B
Aaron's sign
C
Blumberg sign
D
McBurney's sign
E
Psoas sign
Question 1 Explanation: 
All of these signs are indicative of an appendicitis. Rovsing's sign: Palpation of left iliac fossa causes right iliac fossa pain Aaron's sign: Referred pain to the epigastrium upon continuous pressure placed on right iliac fossa Blumberg sign: Pain upon removal of pressure in the right iliac fossa McBurney's sign: Deep tenderness at McBurney's point (Right iliac fossa, one-third of the distance from the anterior superior iliac spine to the umbilicus) Psoas sign: Pain on right hip flexion or extension
Question 2

Stem 2 of 5

You believe the patient is suffering from an appendicitis. When taking a history from the patient where else may she have experienced pain?  
A
Left iliac fossa
B
Left shoulder
C
Right hip pain
D
Umbilical region
E
Lumbar region
Question 2 Explanation: 
In a typical presentation of appendicitis the pain starts peri-umbilically and then migrates to the right iliac fossa. This represents the inflammation stretching the visceral wall transforming into localised parietal peritoneal inflammation. In younger children this inflammation irritates the psoas muscle making walking very painful. Those who have a long appendix that is situated posterior to the caecum may conversely have lumbar back pain. If the appendix has ruptured gas and/or blood enters the abdominal cavity leading to irritation of the diaphragm. The diaphragm is innervated by the phrenic nerve C3-5 which can cause referred shoulder tip pain.
Question 3

Stem 3 of 5

After you complete your examination, what is the first investigation?  
A
Abdominal ultrasound
B
Urine pregnancy test
C
Blood cultures
D
Full blood count
E
Abdominal CT
Question 3 Explanation: 
It is most likely that a female of the age presenting with acute right iliac fossa pain and vomiting is suffering from an appendicitis. Although all the above will be needed to diagnose an appendicitis, it is very important to rule out an ectopic pregnancy in any females of child baring ages as this could be life threatening.
Question 4

Stem 4 of 5

What is the management of an appendicitis?
A
Antibiotics
B
Paracetamol
C
Fluids
D
Ileostomy
E
Appendectomy
Question 4 Explanation: 
Immediate surgical management is required to remove the inflamed appendix prior to its rupture. Most appendectomies occur within 24 hours of pain onset and are done by a laparoscopic approach.
Question 5

Stem 5 of 5

The consultant decides to to manage the patient with an open surgical management. What surgical incision would you expect to find post-operatively?
A
Gridiron
B
Rutherford-Morrison
C
Kocker
D
Lanz
E
Battle
Question 5 Explanation: 
Both Lanz and Gridiron give access to the appendix. However many surgeons prefer to use the Lanz incision as it follows Langer’s lines and therefore leads to better healing and reduced scarring
Question 6

Stem 1 of 5

A 14 year old visibly distressed female presents to A&E. She complains of constant sharp 9/10 abdominal pain for the past 10 hours and has a temperature of 39 degrees.  When asked where the pain is she states that her entire abdomen is tender. On examination she has enlarged cervical lymphadenopathy.
 
  Given the likely diagnosis, what is most likely cause of the cervical lymphadenopathy?
A
Glandular fever
B
Systemic lupus erythematosus
C
Diphtheria
D
Lymphoma
E
Upper respiratory tract infection
Question 6 Explanation: 
Although presenting similar to the appendicitis patient, the higher temperature, diffuse tenderness and cervical lymphadenopathy all point to a diagnosis of mesenteric adenitis. This usually occurs after a recent upper respiratory tract infection. Consequently it is important to ask about a recent cough or soar throat.
Question 7

Stem 2 of 5

What investigations are important for this patient?
A
Full blood count
B
CRP
C
Blood cultures
D
Abdominal ultrasound
E
Abdominal Xray
Question 7 Explanation: 
FBC and CRP is recommended in all patients to assess severity of infection or inflammation and are helpful to monitor the disease process.
Question 8
What is the treatment for this patient?
A
IV fluids
B
Paracetamol
C
None
D
Ciprofloxacin
E
Surgery
Question 8 Explanation: 
Typically the pain goes away within a few days after the lymph tissue inflammation subsides. Therefore no treatment is usually required other than pain relief and encouraging water consumption.
Question 9
At what age is it unlikely that this presentation is mesenteric adenitis?
A
Older than 25 years
B
Older than 16 years
C
Older than 40 years
D
Older than 5 years
E
Older than 65 years
Question 9 Explanation: 
Mesenteric adenitis is distinctly uncommon in those older than 20 years.
Question 10
At what age is it abdominal pain more likely to be an appendicitis rather than mesenteric adenitis?
A
older than 25 years
B
older than 16 years
C
older than 40 years
D
older than 5 years
E
older than 65 years
Question 10 Explanation: 
Mesenteric adenitis is more likely to present in the first decade of like while appendicitis most commonly presents within the second decade.
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