Ms. F, 48 years old, has been admitted to the hospital with severe abdominal pain. Earlier that day she had generalized abdominal pain, followed by a severe pain in the lower right quadrant of her abdomen, accompanied by nausea and vomiting. That evening she was feeling slightly improved and the pain seemed to subside somewhat. Later that night, severe, steady abdominal pain developed, with vomiting. A friend took her to the hospital, where examination demonstrated lower right quadrant tenderness and mild abdominal rigidity. Fever and leukocytosis indicated infection. A diagnosis of acute appendicitis, with possible perforation, was indicated, with immediate surgery.
Discussion Questions
- Why is the sequence of pain (location and type of pain) significant in the diagnosis of acute appendicitis? Describe the rational for each type of pain. Does this sequence confirm the diagnosis?
- Using the pathophysiology, describe the reason for:
- the pain subsiding and then recurring.
- leukocytosis and fever.
- abdominal rigidity.
Ms. T, age 28 years, has noticed urgency, frequency, and dysuria recently, as well as an unusual odor to the urine. Urinalysis indicated a heavy concentration of Escherichia coli in the urine, some pus, and WBCs. Ms. T was prescribed antibiotics, which she took for the first few days. This seemed to give her relief, but she then stopped taking the medication. Within a few days, the symptoms returned, but she decided to “just live with it.”
Discussion Questions
- Explain why women are predisposed to cystitis.
- What preventive measures are important in reducing recurrence?
- Discuss other signs and symptoms that may indicate cystitis.
- What potential problems may she experience if she does not adhere to the treatment prescribed?
Expert Solution Preview
Introduction:
These discussion questions address two different medical cases. The first case is about a patient with acute appendicitis, and the second case is about a patient with cystitis. These questions are designed to test the medical students’ knowledge and understanding of the pathophysiology of these conditions, as well as the clinical presentation, diagnosis, and management.
1. The sequence of pain in acute appendicitis is significant because it helps to localize the site of the inflammation. The initial pain is usually generalized, followed by pain in the lower right quadrant of the abdomen, which is known as McBurney’s point. This pain is caused by inflammation of the appendix, which irritates the adjacent peritoneum, causing pain that is usually dull and aching in nature. As the inflammation progresses, the pain becomes more severe and localized. The severe, steady abdominal pain that develops later is due to the possible perforation of the appendix, which can lead to peritonitis. The sequence of pain, along with other clinical signs, such as tenderness and fever, confirms the diagnosis of acute appendicitis.
2. a) The pain subsiding and then recurring in cystitis is due to the bacterial infection being temporarily suppressed by the antibiotics. However, when the patient stops taking the medication, the infection re-establishes itself, leading to the recurrence of the symptoms.
b) Leukocytosis and fever in cystitis is due to the body’s immune response to the bacterial infection. The immune system releases white blood cells to fight the infection, which leads to an increase in leukocytes. Fever is also a response to the infection, as the body raises its core temperature to create a hostile environment for the bacteria.
c) Abdominal rigidity in acute appendicitis is due to the involuntary muscle guarding that occurs as a result of the inflammation. The rigidity is a protective mechanism to prevent further irritation of the peritoneum.
3. Women are predisposed to cystitis because of their shorter urethra, which makes it easier for bacteria to enter the bladder. Sexual activity, pregnancy, and use of certain contraceptive methods can also increase the risk of developing cystitis in women.
4. Preventive measures that are important in reducing the recurrence of cystitis include regular voiding, wiping from front to back, urinating after sexual intercourse, staying hydrated, and avoiding irritating substances such as bubble baths and certain feminine hygiene products.
5. Other signs and symptoms that may indicate cystitis include urinary urgency, pain or discomfort during urination, lower abdominal pain, and cloudy or foul-smelling urine.
6. If the patient does not adhere to the prescribed treatment for cystitis, the infection can spread to the kidneys, leading to a more severe condition known as pyelonephritis. Pyelonephritis can cause complications such as kidney damage, sepsis, and even death if left untreated. Therefore, it is essential for the patient to take the full course of antibiotics as prescribed by the healthcare provider.
