A diagnostic approach

Cardiovascular

• myocardial infarction

• dissecting aneurysm aorta

• mesenteric artery occlusion Neoplasia

• large or small bowel obstruction A. Severe infections

A. • acute salpingitis

• peritonitis

• ascending cholangitis

• intra-abdominal abscess Ectopic pregnancy Small bowel obstruction Sigmoid volvulus Perforated ulcer

Q. Pitfalls (often missed)

Acute appendicitis Myofascial tear Pulmonary causes

• pulmonary embolism Faecal impaction (elderly)

A. Herpes zoster Rarities

• lead poisoning

• haemochromatosis

• sickle cell disease

• tabes dorsalis

Q. Seven masquerades checklist

Depression x

Diabetes x

Drugs x

A. Anaemia sickle cell

Thyroid disease —

Spinal dysfunction x

UTI x

Q. Is the patient trying to tell me something? A. May be very significant.

A. Consider Munchausen's syndrome, sexual dysfunction and abnormal stress.

Table 30.3 Chronic or recurrent abdominal pain (adult): diagnostic strategy model

Q. Probability diagnosis

Irritable bowel syndrome A. Mittelschmerz/dysmenorrhoea Peptic ulcer/gastritis

Q. Serious disorders not to be missed

Cardiovascular

• mesenteric artery ischaemia

• abdominal aortic aneurysm Neoplasia

• carcinoma bowel/stomach

• carcinoma pancreas

• ovarian tumours Severe infections

• recurrent PID

Q. Pitfalls (often missed)

Food allergies Lactase deficiency Constipation Chronic pancreatitis Crohn's disease Endometriosis Diverticulitis Rarities

• lead poisoning

• sickle cell disease

• Addison's disease

Q. Seven masquerades checklist

Depression x

Drugs x

Thyroid disease —

Spinal dysfunction x

UTI x

Q. Is the patient trying to tell me something?

A. A strong possibility: consider hypochondriasis, anxiety, sexual dysfunction.

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