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This chapter discusses the epidemiology of pain in children. It summarizes key data in the field, focusing on three of the most common childhood pains: low back pain, abdominal pain, and headache. It also considers potentially modifiable risk factors.

Note that certain diagnoses are going to be more likely in different patient groups. Children and elderly people are more likely to have a longer differential as symptoms are often less pronounced and non-specific. Intussusception is almost exclusively seen in children, and the vast majority of cases of mesenteric adenitis are also seen in children. By contrast, caecal pathology (tumours, volvulus, or a solitary mesenteric diverticulum) is usually associated with advancing age. An abdominal aortic aneurysm would be extraordinarily rare in a young adult but should be considered in anyone >50 years of age. You must of course consider gynaecological pathology, such as ectopic pregnancy, pelvic inflammatory disease/ salpingitis, torsion/haemorrhage/rupture of an ovarian tumour or cyst, mittelschmerz (mid-cycle pain corresponding to a ruptured ovarian follicle), threatened abortion, fibroid degeneration, or uterine dehiscence. In any woman of reproductive age you must perform a pregnancy test—this is not only to exclude particular diagnoses such as ectopic pregnancy, but is also essential to help weigh up the risk of radiation to the fetus against the diagnostic usefulness of the test. It is very useful to have an idea of the degree of abdominal tenderness before you even lay a hand on the patient. Remember that you will win no prizes (either in exams or with patients themselves) if you actually cause a patient pain. So, start by asking the patient to suck their tummy in as far as possible and then puff it out again (this is particularly useful in children). A patient with board-like abdominal rigidity secondary to generalized peritonism will only make very minor movements. Now ask the patient to cough: patients with inflammation of the parietal peritoneum will be reluctant to cough deeply and may well place their hands over the area of tenderness. Whether you palpate the abdomen in quadrants or nine zones, be sure to start in the opposite area to that which the patient states is most painful. Start by palpating gently and keep looking at the patient’s face for a reaction. Patients are likely to demonstrate guarding (involuntary muscular rigidity in tender areas of the abdomen).

We have arranged the differential diagnosis in order of likelihood in a man of this age with more likely diagnoses in larger font and less likely diagnoses in smaller font in Figure 12.1. Pathologies that should be excluded at the earliest possible opportunity are shown in bold. Bear in mind that this differential diagnosis refers to epigastric pain as a presentation of ‘acute abdomen’ and thus differs markedly from epigastric pain presenting as outpatient dyspepsia. Note that although we have adopted a standard approach of history, examination, and investigations over the course of the following pages, you should use clinical judgement to deviate from this path if one of the ‘must exclude’ diagnoses is suspected, or if there is a need for urgent resuscitation. For example, if a 69-year-old male diabetic patient with known unstable angina presents with exercise-induced epigastric pain, you would be wise to perform an electrocardiogram (ECG) and obtain baseline observations at the earliest opportunity. Various characteristics of the pain will help to narrow our differential diagnosis of epigastric pain: Site: • Pain that has spread from the epigastrium to involve the rest of the abdomen may suggest peritonitis from a perforated GI tract (e.g. perforated gastric ulcer, which causes epigastric pain because the stomach is embryologically a foregut structure). • Pain that has spread from the epigastrium to involve the chest may be cardiac. • Biliary disease, although anatomically located in the right upper quadrant, may present with purely epigastric symptoms. Onset: • Pain that is of very sudden onset suggests perforation of a viscus (e.g. a perforated duodenal ulcer or Boerhaave’s perforation) or myocardial infarction. • Pain from acute pancreatitis and biliary colic develops maximal intensity over 10–20 minutes. • Inflammatory processes such as acute cholecystitis or pneumonia typically take hours to reach their peak. Character: • ‘Crushing’ or ‘tightness’ qualities are typical of cardiac pathology. • Sharp, ‘burning’ pain is typical of peptic ulcers, gastritis, and duodenitis. • Deep, ‘boring’ pain is typical of pancreatitis. Radiation: • Back pain is classically associated with pancreatitis, leaking abdominal aortic aneurysms, and sometimes seen with peptic ulcers.

Virtually every person will experience abdominal pain at some point. Although symptoms of pain are often vague and entwined with emotional overtones, careful assessment, combined with knowledge of the relationship of embryology and pain characteristics, will be most helpful to the clinician in diagnosing and using optimal mechanism-based treatment. Some pains are localized, and others ‘referred’; some pains are acute and potentially lethal, while others are chronic and ‘miserable’. ‘Total pain’ components such as worry, anger or depression always accompany and may exacerbate the severity of actual physical pain etiology. This chapter focuses particularly on the understanding the complexities and assessment of pain to enhance clinical acumen, leading to best practice management.

Basic sciences: Applied anatomy

Which among the following statements regarding the functions of the extraocular muscles is incorrect?

The inferior oblique muscle abducts the eye and moves it upwards

The superior rectus muscle abducts the eyes and moves it laterally

The...

Basic sciences: Applied anatomy

Which of the following arteries does not arise from the axillary artery?

Superior thoracic artery

Lateral thoracic (pectoral) artery

Thoraco-acromial artery

Costo-cervical trunk

Subscapular artery

This chapter covers core curriculum topics relating to small intestinal disorders and malabsorption. This includes a discussion of key gut hormones involved in digestion and absorptive processes including with relevance for obesity. Questions on gastrointestinal neurotransmitters and transporters provide education in gut physiology. The protean presentations of several micronutrient deficiencies seen in clinical practice are discussed. Focus is given to the diagnosis, initial management and follow up of patients with coeliac disease and villous atrophy including later-onset complications such as enteropathy-associated T cell lymphoma. Also covered is the investigation of small intestinal motility disorders and the manifestations and management of functional abdominal conditions such as irritable bowel syndrome. Disorders of bile acid recirculation, microbial dysregulation including through acute infections, and key medications causing presentations with diarrhoea are incorporated in this chapter. Additional curriculum material regarding small intestinal disorders will also be covered in the mock examination chapter.

During normal voiding the bladder empties completely. The inability to do so is referred to as urinary retention. In acute urinary retention there is an inability to pass any, or at most only small volumes of, urine. This is associated with severe lower abdominal pain and represents one of the most common reasons for emergency urological hospital admission. In chronic urinary retention, the ability to void is usually still present but a significant volume remains in the bladder at the end of micturition. The symptom of overflow incontinence may be associated, and generally there are pre-existing lower urinary tract symptoms (LUTS). Bladder decompression and prevention of upper tract deterioration are amongst the initial goals in the approach to this problem. Surgery remains the most effective means of relieving obstruction and preventing further episodes of retention in those fit for it.

Basic sciences: Applied anatomy

Which of the following structures is unlikely to be damaged during a carotid endarterectomy procedure?

Hypoglossal nerve

Buccal branch of the facial nerve

External laryngeal nerve

Ansa cervicalis

Pharyngeal branch of the vagus nerve

Sjögren’s disease may involve the entire gastrointestinal tract, liver, and pancreas. Sjögren’s patients commonly experience gastroesophageal reflux, difficulty swallowing (dysphagia), issues with gastric emptying, and abdominal pain and bloating. The symptoms may vary from mild to severe. Abnormality in esophageal function and motility is detected in up to 35% of patients with Sjögren’s. Celiac disease occurs in up to 12% of Sjögren’s patients, irritable bowel syndrome (IBS) in 39%, and indigestion (dyspepsia in 65%). Proper evaluation, diagnosis, and treatment will prevent possible complications and will significantly improve the patient’s quality of life. With certain complications, lifestyle choices can help to manage and improve the symptoms.

In both polyuria and high urinary frequency the patient will be passing urine more often than before. But in polyuria, patients will pass abnormally large volumes of clear urine each time. In urinary frequency, the volume voided each time will be normal or reduced. The only way of knowing objectively whether this is the case is by collecting a 24-hour urine sample (>3 L = polyuria). As this is usually impractical outside of hospital, one must rely on the patient’s recall, with the caveat that many patients find it difficult to estimate urine output. In the history, then, ask them whether they feel they are passing a larger volume every time they go to the toilet. Remember that it is important to be as sure as you can that you are dealing with polyuria and not urinary frequency or nocturia, as the differential diagnoses are quite distinct. Chronic renal failure and hypercalcaemia (e.g. due to bone metastases) cause polyuria by inducing nephrogenic diabetes insipidus. Similarly, steroids and Cushing’s syndrome can cause polyuria by causing diabetes mellitus. • Temporal pattern of urine output (number of times in the day and at night), especially nocturia. At night, the kidneys concentrate urine in order to retain fluid (as intake is zero), removing the need to urinate during sleep. Thus nocturia (in the absence of other causes of nocturia, e.g. benign prostatic hyperplasia (BPH)) is often one of the earliest signs of a loss of concentrating ability. This symptom makes primary polydipsia less likely. • Fatigue, weight loss, recurrent infections. All can be features of diabetes mellitus. • Lower urinary tract symptoms (LUTS), e.g. frequency, urgency, hesitancy, terminal dribbling, incomplete voiding. These symptoms indicate pathology in the bladder or the outflow tract, e.g. prostatism in men, detrusor instability and prolapse in women. Not strictly speaking polyuria. • Pain, frequency, change in urine colour and smell. These are all symptoms suggestive of a urinary tract infection (UTI), which would cause increased frequency but not polyuria. • Past medical history. Look for any history of renal problems or conditions that may precipitate chronic renal failure (e.g. vasculitides, hypertension, chronic urinary retention).

abstract

This task assesses the following clinical skills: Patient safety Communication with colleagues Applied clinical knowledge In Box 4.1 are the findings of an audit on Service provision of Termination of Pregnancy. Your task is to: • Go through the findings in the first six minutes • In the next six minutes you will be asked to critically appraise the methodology and results of the audit You have 12 minutes for this task. Use the 2 minute initial reading time to start going through the article findings. Instructions for Assessor The candidate has six minutes to prepare for this station. Please do not interrupt them in this time. Ask them to critically appraise the audit. If you need to prompt, adjust the marks accordingly. You may need to prompt them to comment on why the audit was done, the appropriateness and limitations of the methodology, findings, and the implications for change in practice. Patient safety • Are any of the practices harmful/ affecting adversely the patient’s safety? Has this been recognized and changes made before the completion of audit? • Is patient service user included in the audit? (Type a quote from the document or the summary of an interesting point. You can position the text box anywhere in the document.) • Is it a patient survey questionnaire? • Is the confidentiality maintained Communication with colleague • Explains why a particular topic was chosen • Explains which national/ local standards are chosen • Explains if data is collected appropriately • Explains where the results were discussed • Explains if any robust plans for re- audit are in place • Explains if re- audit results are presented in this presentation Applied clinical knowledge • Understands what a clinical audit is and the cycle. • Understands what an audit is not about • Understands the difference between audit and research • Selecting a topic—service evaluation • Standards of best practice (audit criteria).