1. Case Presentation Acute Diarrhoea

2. Mr AB 24 yo man lives interstate Presents with 3 days diarrhoea and 4 days abdominal pain and feeling generally unwell. 12-15 episodes of diarrhoea a day –normal colour –not watery but loose ++ –no blood or mucous Generalised non-specific crampy abdo pain, right worse than left, radiating to right back. –worst pain ever experienced like ‘stomach in a vice’ No vomiting, no fevers/sweats/rigors. Loss of appetite.

3. Past Medical History Gastroenteritis one year ago – 24 hr bug Gastritis – 18yo – took Somac for a while Medications No medications or allergies Family History Socially Parents and sister (25) well No infectious contacts, Just quit smoking 3 pk/wk, w/e ETOH binges Ate a ‘dodgy’ chicken schnitzel on Friday at shopping centre

4. Examination HR 100, BP 100/70, T 36 4, RR18, Sats 100%RA Looks unwell but not distressed or haemodyn. compromised. Soft abdo Right sided and bilateral IF tenderness No renal angle tenderness Mild RIF rebound No organomegaly BS increased

5. Examination II Stong Pulses, Dual Heart Sounds, no murmurs Chest Clear MMM, normal turgor, warm to touch, appears well perfused, thirsty FWT – NAD BSL – 4.6mmol

6. FBE

7. Other Bloods

8. Abdo XR

9. Questions Any other questions or examination points? DDx? Plan?

10. Progress Analgesia –Pain well treated though not completely relived by Panadol and Buscopan IV Fluids –HR 75, BP 120/80, T 37 3 Admit Surg – Single Room –Observe ?appendicitis DDx gastroenteritis Faecal Spec for MCS collected in ED –Loose brown sample, occasional WCC, RBC+ Overall feeling much better on PM WR.

11. 21/7/2006 – AM WR Little change: –few bouts of diarrhoea overnight –crampy abdo pain persists on right side though not guarding as was yesterday –still no temperature above 37 3 –feels hungry Dilemma: –definitive diagnosis of appendicitis can really only be made on laparoscopy –What to do now?

12. Repeat Bloods

14. CT Abdo/Pelvis

62. CT Report Severe right sided colitis extending from caecum to hepatic flexure. No terminal ileitis. No skip lesions. Suggest biopsy!!!! AXR Report No soft tissue definition. Some ‘loss of definition’ within the right sacroiliac joint. ? inflammatory arthropathy.

63. Further History Frequently gets sore knees and shoulders from time to time. –blames it on football Back pain occasionally –when standing for long periods –doesn’t know if always worse on right No chronic diarrhoea. No history of red eye, skin complaints, non- axial joint pain, redness or stiffness, no mouth ulcers, no other extra-intestinal manifestations of IBD.

64. Progress Diarrhoea and pain settled and patient tolerating FWD at day two admission. Back pain occasional and mild. Gastro Med Review: –no active treatment required at this stage if symptoms improving –requires gastro and rheum f/u –otherwise can go home –will need colonoscopy in 4-6 weeks GP in Newcastle was contacted. D/C three days after admission.