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Ataloss
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#1
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This used to be popular on another student site - see if it takes off on here.

The case is based on a recent patient - but with details changed to protect confidentiality.


A 22 year old male is referred to the surgical admissions unit with acute onset of left iliac fossa pain. He had felt generally unwell for 2 days with vague symptoms and then developed severe LIF pain. He complains of feeling nauseated and feverish. There has been no change in bowel habit and no urinary symptoms.

Examination of the abdomen found a soft abdomen with rebound and guarding in the LIF. No masses. No organomegaly. Bowel sounds normal.

Initial bloods showed a raised WCC of 17.3 and a CRP of 150. Otherwise bloods were unremarkable.

AXR was also unremarkable.

His ECG showed right axis deviation with extremely low voltage QRS complexes in V4-6.

This is a little bit contrived - but :-

1. What is the diagnosis of the abdominal pain?
2. What is the underlying diagnosis?
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Renal
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My guess is sinus invertus, the RAD is actually dextracardia.

The abso signs would lead to the differential diagnosis of appendicitis.
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Né Stig
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(Original post by Renal)
My guess is sinus invertus, the RAD is actually dextracardia.

The abso signs would lead to the differential diagnosis of appendicitis.
Woo! Go The Barts (or QM)
I don't even know if you're right. But it just looks impressive. :laugh:

Does it not scare you that you have to make the correct diagnosis everytime without fear of repercussions? A wrong one could mean life . . . . not something anyone wants on their conscience. But it kind of puts me off wanting to be a medical student unless you make an 'accident'.
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Ataloss
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(Original post by walshie)
Woo! Go The Barts (or QM)
I don't even know if you're right. But it just looks impressive. :laugh:

Does it not scare you that you have to make the correct diagnosis everytime without fear of repercussions? A wrong one could mean life . . . . not something anyone wants on their conscience. But it kind of puts me off wanting to be a medical student unless you make an 'accident'.
Doctors are humans so are always going to make mistakes. Often the initial diagnoses are wrong. The essential thing is to always keen an open mind and not start damaging treatments. Don't let it put you off doing medicine.

In this case, Renal has proven to be super-human with a correct diagnosis:-

Acute appendicitis in a patient with dextrocardia situs invertus.
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Renal
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w00t!



(Thank you google! )


Let me think of one, give me an hour or so to find a nice juicy one.
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iceman_jondoe
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o man i cant wait till i start med
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friendlyneutron
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I know, I can't wait till I'm able to do that! Well, in theory...
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Helenia
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But appendix is RIF pain, surely? At least, it was for me.

Or should I wait till I go to clinical school?
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Renal
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(Original post by Helenia)
But appendix is RIF pain, surely? At least, it was for me.
It was for you because your appendix was on your right, this chap's was on his left. In situs invertus the organs of the body are reversed but function normally; so the heart is on the right, liver on the left, stomach on the right and appendix on the left.
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Ataloss
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(Original post by Helenia)
But appendix is RIF pain, surely? At least, it was for me.

Or should I wait till I go to clinical school?
It is in 99.9% of people.

Those who have dextrocardia situs (not sinus :p: ) invertus have a reversal in position of some organs, such that the appendix lies in the LIF rather than the right as Renal has googled.

The ECG of dextrocardia typically shows right axis deviation with a low voltage QRS complex in V4-6 - because the heart is on the other side.

So if you ever have a patient with a classical history of appendicitis but in the LIF just have a quick listen to the heart sounds to make sure the heart is in the normal place.
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Renal
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(Shamelessly ripped from a PBL scenario)

A 5 year old boy was admitted to hospital. His mother had taken him to their general practitioner with a recent history of listlessness and excessive bruising.

On examination he was pale and had ecchymoses and petechial haemorrhages, particularly on his legs. He also had generalised lymphadenopathy and a palpable spleen on deep inspiration.

Blood test results were as follows:

Hb 6.0 g/dl (Normal 12.0 – 14.0)
MCV 86 fl (Normal 76 – 92)
WBC 100.0 x109/l (Normal 5.0 – 15.0)
PLT 10 x 109/l (Normal 150 – 400)

Leucocyte differential:
Neutrophils 1.0 x109/l (1%)
Lymphocytes 4.0 x 109/l (4%)
Blasts 95.0 x 109/l (95%)
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Renal
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(Original post by Ataloss)
Those who have dextrocardia situs (not sinus :p: ) invertus have a reversal in position of some organs, such that the appendix lies in the LIF rather than the right as Renal has googled.
I knew what it was! Just had bugger all idea what it was called. :p:
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Ataloss
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(Original post by Renal)
(Shamelessly ripped from a PBL scenario)

A 5 year old boy was admitted to hospital. His mother had taken him to their general practitioner with a recent history of listlessness and excessive bruising.

On examination he was pale and had ecchymoses and petechial haemorrhages, particularly on his legs. He also had generalised lymphadenopathy and a palpable spleen on deep inspiration.

Blood test results were as follows:

Hb 6.0 g/dl (Normal 12.0 – 14.0)
MCV 86 fl (Normal 76 – 92)
WBC 100.0 x109/l (Normal 5.0 – 15.0)
PLT 10 x 109/l (Normal 150 – 400)

Leucocyte differential:
Neutrophils 1.0 x109/l (1%)
Lymphocytes 4.0 x 109/l (4%)
Blasts 95.0 x 109/l (95%)

Please sir - I know what it is. :p:

I will play it cool whilst people have a think/google. :cool:
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Fenella
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Sounds like AML to me.
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Fluffy
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(Original post by Ataloss)
Doctors are humans so are always going to make mistakes. Often the initial diagnoses are wrong. The essential thing is to always keen an open mind and not start damaging treatments. Don't let it put you off doing medicine.

In this case, Renal has proven to be super-human with a correct diagnosis:-

Acute appendicitis in a patient with dextrocardia situs invertus.
Arse! I wish I posted now, but didn't want to look a ****** Then again, after a certain doc's (then a BL finalists) final OSCE, I have an obsession with being 'tricked' with a case of dextrocardia!
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Fluffy
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(Original post by Fluffy)
Arse! I wish I posted now, but didn't want to look a ****** Then again, after a certain doc's (then a BL finalists) final OSCE, I have an obsession with being 'tricked' with a case of dextrocardia!
I won't play Renals, as I have also done that for PBL
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lil groovy dude
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I cant wait till I can do this either!!!





































Just another 4 years & 5 months to go until I start med school!!! (Inshallah)

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Renal
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(Original post by lil_groovy_dude)
I cant wait till I can do this either!!!
There's no reason you can't do it now.

It looks complicated but it's not that difficult if you think laterally and use a good reference. You can read all sorts of textbooks online.




It is a PBL scenario for us, there's no reason you can't do the same.

Start by getting a definition for words and acronyms you don't know - plenty of online sources for this.
Then look at what's not right - Is the Heamoglobin high or low? Low
Then think about what that means - What does low Hb mean? Anaemia
Then think about what causes that - What are the types and causes of anaemia?
And so on.

You should be able to work through, let us know if you get stuck.
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j00ni
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#19
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As regards the OP's case, surely in situs inversus the AXR would be anything but unremarkable! - and would in fact give the diagnosis

/edit: as for the 2nd case, I think the medics should let the non medics have a stab at getting some differentials, and we help them along, so that they can have a go at some PBhell, see if they like it
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Renal
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(Original post by j00ni)
As regards the OP's case, surely in situs inversus the AXR would be anything but unremarkable! - and would in fact give the diagnosis
How many times have you held up a CXR and had it the wrong way round without checking the indicator?

But yer, good point!
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