A 72 year old man presents to the Emergency Department with left sided abdominal pain. The pain came on suddenly at night and is located around the left flank.

The pain is sharp and stabbing and moves into his left groin. He is sweaty and pale, and is unable to keep still on the trolley. He denies dysuria but has felt nauseous and has vomited once. He denies diarrhoea and opened his bowels earlier in the day. He denies ever having this type of pain before. He is normally otherwise fit and well.

  • PMHx: Nil of note

  • PSHx: Nil

  • DHx: Nil

  • NKDA

  • FHx: Mother died of MI aged 86, father died of lung cancer aged 79

  • SHx: Non-Smoker, occasional alcohol. Lives with wife, independent of ADLs.

On Examination

  • Temp 38.2, BP 116/78, HR 110, RR 20, SpO2 100% on air, Pain Score 10/10.

  • CVS: Nil Abnormality

  • Resp: Clear

  • Abdominal: Tender in the left renal angle and in the left groin. Nil guarding, nil peritonism and no rebound tenderness. No obvious abdominal distension. No organomegaly and normal bowel sounds heard.

  • Neuro: Grossly Normal

  • Urine dip: Blood +++

Questions

Answer one question before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. The first part of teaching will be spent discussing this case:

  1. Give 3 differential diagnoses for this man's abdominal pain and reasoning behind your choices.

  2. How would you initially assess this man and provide details of the steps you would take?

  3. What initial Emergency Department bedside investigation could you undertake to rule in or out your differentials?

  4. Given the most likely diagnosis, what is the gold standard investigation? What other investigations can you use to diagnose this condition?

  5. Given the most likely diagnosis, how could you risk stratify patients who are fit for discharge?

  6. What are the risk factors for forming this condition?

  7. What features would prompt you to admit the patient?

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