DIP Episode 629 - The Clutch Right Lower Quadrant Podcast

All right, welcome. My name is divine. This is episode 629 of the Divine Intervention Podcasts. And into this podcast we're going to be addressing right lower quadrant pain. In fact, I'm going to call this the clutch right lower quadrant podcast for the USML exams. This should be a pretty helpful podcast and I think it's really going to help you with your with your exams. All right, so I think the very first thing I just want to say is this. If a female, so very first thing. If a female presents with sodium onset, uh, abdominal pain of any sort, especially if it's in the right lower quadrant. And they ask you for your next best step on your exams. Please make sure you're checking if she's pregnant or not, right? That's like the right first thing to do. Get a urine pregnancy test. Something you can do very quickly, right? Just to make sure I'm not missing like some pregnancy or a topic or something like that. All right. So now let's go to number two. So what if they give you a question about a patient and they tell you that this patient, you know, over the last like 12 hours has been having progressively worse than abdominal pain. You know, started around the umbilikus, you know what I'm getting to hear. I study around the umbilikus, right? And then it's, uh, you know, it's now becoming more and more pronounced towards the right lower quadrant, right? So obviously this is going to be up in the slightest, right?

And the thing is the USML is these days as, you know, I was telling people in my classes that are running now. The USML is these days. One thing they love to do is they don't like to ask you direct questions anymore. They like to ask you derivatives. They like to ask you surrogates, right? So the thing is they actually give you a question that you clearly know is appendicitis. And then you're like, okay, they ask you like what's the pathophysiology, right? Remember, there are many things that can cause appendicitis, right? It can be from a fickle th that is occluding the appendix, the lumen of the appendix. So bacterial infection kind of sets up shop. You get a lot of inflammation, right? You get a lot of inflammation and you're getting trouble. And remember that when the appendix is inflamed, right? It's going to irritate the pridele peritoneum, you know, Neumachbernis point. And then you're going to get in trouble. You're going to get in trouble, right? Again, the pain usually is going to start off periombilical, right? And then it's going to migrate to the right lower quadrant, right? Again, that irritation that causes the pain is from irritation of the pridele peritoneum, right? The inflamed appendix irritates the pridele peritoneum, right? Again, that's very important to know for you exams. Maybe like, why does divine keep emphasizing pridele peritoneum is super high or to know that for you exams, right?

So they're going to be vomiting, they're going to be nauseous, they're going to have fever, right? Again, they're going to be rolling in pain, they're going to be rolling in pain, okay? So again, key things to know. And you know, sometimes on the exams, they test some of these physical exam findings that appendicitis, you know, like they can have tenderness at like Bernice point, right? That's like two thirds of the distance between the omblicus and the anterior superior iliacas spine, right? And then they can also have a rossin sign where you pop in the left lower quadrant, right? And then they have right lower quadrant pain, you, or you at least exacerbate the right lower quadrant thing, right? They can have so a sign where you pretty much extend the hip, right? And their right lower quadrant really hurts. Or they can have obturator sign where you internally rotate the hip and they have right lower quadrant pain. When you see all these things, you want to think about appendicitis, right? And the thing is appendicitis, typically on the US Emily exams, if they're asking you for a diagnostic test, just ask yourself, what kind of patient population am I dealing with? Right? So if you're dealing with an adult, then you want to get a CT scan, to a CT of the abdomen and pelvis, right? But if you're dealing with a child or a person that is pregnant, on your exams, I will encourage you to consider going with an ultrasound, right?

I'll encourage you to consider going with an ultrasound. I will absolutely consider, encourage you to consider going with an ultrasound, okay? And typically this is going to be managed surgically in the US. Again, remember you're taking the United States medical licentory exam, not some other countries medical licentory exam, right? So you're going to ultimately consult surgery, right? You're going to have surgery, you're going to usually do it laparoscopic, you know, you can do laparoscopic surgery, you can do laparoscopic, either one is perfectly fine, right? Now, the thing is one thing that our friends at the MBM is love to do occasionally is that you'll see a person that has a pain decided, right? So they're having like really bad abdominal pain and all those things. And then you notice that there is this profound worsening, you're like, gee, what happened here? Like the person goes from the heart pain and then it now start having sodding acute onset, very severe pain, right? And then they tell you that the patient cannot tolerate an abdominal exam because whenever you're popping the abdomen, the person has like very significant pain. When you see something like that, I would really hope you're thinking about like a preparation of the appendix. The person has literally perforated the appendix. So now they have signs of peritonitis, right? In fact, if you do a chest radiography in that person, you may actually see free air under the diifer, right?

And another thing that they also test with appendicitis, friends at the MBM is love to test, is they can give you a question about a person, you know, that, you know, has appendicitis, right? And you know, you've treated them, but they seem to have like this persistent fever. The fever doesn't seem to be going away, right? And they tell you that, you know, on parpatient, you can pop it like a regular quadrant mass, right? And the fever just doesn't seem to be going away. Whenever you see something like that, you absolutely positively need to think about an abscess, right? Those people have developed an appendicitis, abscess. They've developed an appendicitis, right? And again, remember, when you have a GI tract infection, you're always going to give antibiotics, at least on the exams for the most part. And that regimen is usually going to be safe traction plus metronidazole, right? One, PC-lingent, a miceymplosa metronidazole, right? So that's something you want to keep at the back of your mind for your exams, right? Now, what if they give you a question about a patient and they tell you that this patient, you know, has a vitamin, you know, this person, they give you some labs, you notice that they have a macrosidic anemia. And then you're told that this person has a long history of like just, you know, very serious, right lower portion of abdominal pain, right? And the person has like chronic diarrhea and is like a young-gish person.

When you see something like this, I hope you're saying, oh, divine, this person sounds like they have Crohn's disease, right? Remember Crohn's disease is about the shorter. It's a kind of inflammatory bowel disease, but it pretty much always affects the terminal ilium, right? The most commonly affected region in the GI tract in a person with Crohn's disease is the terminal ilium, is the terminal ilium. So keep that at the back of your mind for your exams, right? So that's why they may have a lower quadrant thing. And why does that person have macrosidic anemia? Well, the person has macrosidic anemia because of a B12 deficiency, because remember vitamin B12 is reabsorbed in the terminal ilium. So if you see a person that has Crohn's disease and they have macrosidic anemia or a person that has Crohn's disease and they show you hyper segmented neutrophils on a blood smear, I want you to absolutely positively think about that person having a B12 deficiency, because again vitamin B12 is reabsorbed in the terminal ilium. All right, and then I also want to say something, right? So typically appendicitis on your exams, you know, first, second pathology we talked about, appendicitis is typically going to be diagnosed in a younger person, right? Much, much, much younger individual. If on your exams, you see appendicitis in a person that is like over age 50, right?

After they recover from the bowel of appendicitis, you take out the appendix, they can ask you what's going to be your next best step in management. Those people are going to need colonoscopy about six weeks after the episode, or about six weeks after the episode. That's kind of a pretty high-yield concept to know for your exams, but basically whenever people have GI tract inflammation, right? Especially people over age 50. Typically, you know, about six weeks after the acute episode comes to an end, you're going to go ahead and do a colonoscopy in those people, right? So that applies to like appendicitis in person over 50, that particular lightest in a person over 50, just something want to kind of lock down your brain for your exams, right? And then what if they give you a question about a woman that is like 30 years old, you know, and she has a, you know, she has us multiple sex partners, and she inconsistently uses condoms, right? And then you're told that all that her last month's period was eight weeks ago, right? And she has like vaginal bleeding, right? And you know, she just has like unilateral pelvic pain or unilateral regular or quadrant pain, right? Whenever you see something like this, I want you to think of an endopic pregnancy, right? I want you to think of an endopic pregnancy. Again, the first thing you want to do for those people, right? If they're hemodynamically unstable, go ahead and give them fluids, right?

So they may give you an answer that says to give fluids like normal saline or they may give you an answer that says to do a urine pregnancy test, right? If the person is hemodynamically unstable, you need to settle that hemodynamic instability first, right? So that person should get fluids first, right? But if the person is completely stable, go ahead and do a urine pregnancy test, okay? Confirm the pregnancy by doing a urine pregnancy test. And then after that, if the urine pregnancy test is positive, then your next step is going to be to do a transvaginal ultrasound, to do a transvaginal ultrasound, right? And one thing I want to say here is that sometimes when people have a topic pregnancies, believe it or not, they can actually have referred pain to the shoulder, right? They can have referred pain to the shoulder through the diaphragm, right? So remember, it's not only splinic or hepatic pathologies that can cause referred pain to the shoulder, right? Believe it or not, on the USMLE exams, a topic pregnancy sometimes they can actually bring in shoulder pain as part of the, as part of the what's going on, right? Because remember, people can have these are tubal pregnancies. When you have a tubal pregnancy, you can have a free pain from the, from the diaphragm, right? And again, very important, very important, you're going to notice that the beta-hesiogen you exams is going to be over 2000, right?

Because remember, that's the beta-hesiogen level that we need for us to say that, oh, person is pregnant or, you know, for us to see a gestational sac, right? For us to see a gestational sac, right? So that's very important to know for you exams, right? So the beta-hesiogen has to be over 2000, right? For you to see a gestational sac, right? If he's on the 2000, you may not see a gestational sac yet on an ultrasound, right? Yet on an ultrasound, right? So that's very important to keep in mind, right? And again, how do you manage a topic pregnancy? Well, if the person is very unstable, right? The person is very unstable, right? Or the ectopic pregnancy has ruptured, the person absolutely positively is going to need surgery, right? To be honest with you, pretty much every time a person has an ectopic pregnancy, the person is going to need surgery on your exams. You know, there's all this stuff about methotrexids that many resources like to harp about, but I can tell you that our friends at the USML Es, they are not very big on people using methotrexid for ectopic pregnancies. You know, and there's all this criteria you've got in me to know, like the beta-hesiogen has to be over 5000, right? And they must be new evidence of phenocoreal activity, right? And the patient has to be reliable, right? The patient has to keep coming back, coming back, coming back for reliable follow-up. You've got to fill the beta-hesiogen way down to zero, right?

So the thing is that's just not that's not very ideal, right? So, typically on the USMLE exams, you're just going to go ahead and do surgery, okay? Laptoproscopic surgery, all-aparotomy, that's perfectly fine, right? And remember, the most common location of an ectopic pregnancy is in the phallopian tubes, right? It's going to be in the phallopian tubes, right? So again, the person has a positive urine pregnancy test and they have vaginal bleeding, and if recently meets the period, that's pretty easy. That's ectopic pregnancy, right? That's ectopic pregnancy, right? That's ectopic pregnancy. All right. Now, what if they give you a question about a patient and they tell you that, you know, this is like a 32-year-old female, right? And they tell you that, you know, she was working out, right? And then she presents with very sudden severe retaroculture and pain, right? Very severe sudden retaroculture and pain, but have vitals are fine, right? You know, she's more humorous than with your unstable. And then they ask you for your next best step again, what are you supposed to do on your exams? Get a urine pregnancy test, right? Get a urine pregnancy test, right? But then they'll tell you that the urine pregnancy test is negative. And then they ask you what's going to be your next best step, or your next best step is going to be to do a transvaginal ultrasound. Typically, you're going to do this with Doppler, right? So what am I getting at here?

What I'm getting at here is ovarian torsion, right? Ovarian torsion, ovarian torsion, right? Again, ovarian torsion can present to you exams as right lower quotient pain, right? It's going to present as right lower quotient pain, especially you notice that it's going to be pretty lateral, right? It's going to be like side right lower quotient pain, side right lower quotient pain in a female, right? So typically, you're going to see this moment that was doing something that was doing something pretty strainer, right? And then she has that sodium onset, you know, severe unilateral, you know, pelvic right lower quotient pain, right? And she'll be nauseous, she'll be vomiting, right? And the thing is sometimes if the NBM is going to throw you a bone, they will tell you that, oh, the person, you know, like a previous well-woman exam or whatever, they had some kind of ovarian cyst, right? Like a benign ovarian cyst, right? Because remember, whenever something makes the ovary bulky, then the ovary can start twisting around its mesenteri. And when the ovary twists around its mesenteri, you're going to have impaired blood flow to the ovaries, right? That can cause infarction of the ovaries, right? That can cause that torture, right? So this is actually a surgical emergency, right? So again, how you're going to diagnose this? You're going to do a transvaginal ultrasound with Doppler. That's going to be the first thing you're going to do, right?

That's going to be the first thing you're going to do, right? Okay, that's going to be the first thing you're going to do. And then after that, that person is going to go for surgery, right? And usually this surgery is going to be laparoscopic, right? You're going to go ahead and detours that ovary. And if there is a cyst, you're going to go ahead and do a cystectomy. You're going to go ahead and remove that cyst during that procedure as well, right? And then what if you see a lady, you know, that is sexually active multiple partners, uses condoms in consistently, right? And then depressing, you're told that this person has been having like this purulent vaginal discharge, right? And this person has like very significant retinal or quadrant pain, right? When you see something like that, I want you to think about pelvic inflammatory disease, right? Perfect inflammatory disease. Again, it's going to be in a person that's sexually active, right? They can have like a retinal or quadrant pain, they can have pelvic pain, right? Lower abdominal pain, right? And they'll tell you that they have cervical motion tenderness. Again, I can almost promise you, our friends at the NBM Es, they're not going to say cervical motion tenderness. That's insane, right? What they're going to do is they're going to tell you that the person has severe, severe, severe, severe, severe, intolerable pain when you do a pelvic exam. When you see something like that, that's a person that has PID, right?

PID is pelvic inflammatory disease, right? It's pelvic inflammatory disease, right? Pervic inflammatory disease, right? And remember, this is a polymicrobial infection. This is a polymicrobial infection, right? It's a polymicrobial infection, right? So you need to give something that gives you both aerobic and anaerobic coverage, right? So, claim that my scene is going to be part of the treatment regimen for a person that has pelvic inflammatory disease, right? And the thing is, if they give you a question about a person that has PID, right? And the person, despite treatment, the person continues to have persistent fevers, right? And the person has persistent retinal or quadrant pain, right? One thing you want to think about is a tubal ovarian abscess, right? A tubal ovarian abscess, a tubal ovarian abscess, right? So the person has an abscess that we involve the tubes, so the fallopian tubes or the ovaries, right? Or the ovaries. And the thing is, this tubal ovarian abscess, it can actually rupture, right? And if it ruptures, the person is in big, big, big trouble, right? The person is in big, big, big trouble, right? In fact, when the person has a tubal ovarian abscess, one classic trick question you will ask on your exams is to provide the incision and drainage as one of the treatment strategies. I will not do that on the exams, right? A tubal ovarian abscess is managed with antibiotics on the USMEL exams, right? It's money with antibiotics on the USMEL exams, right?

So again, pretty, pretty high yield to know that for your exams. Again, pelvic inflammatory disease, most times you don't have to do any kind of diagnostic testing, right? It's a pretty clinical diagnosis, right? Has a pretty consistent presentation, right? Has a pretty consistent presentation. Again, don't get me wrong. There's some rare circumstances where you drain, where you do an incision and drainage for tubal ovarian abscess, yes. But again, that's typically what you're going to do on the USMEL exams, right? And then what if they give you a question about a patient, right? And they tell you that this patient, you know, was recently started, you know, was presented to the hospital, you know, with a lot of edema, right? Cracles in the lungs, right? And the person has a history of his chemicardomyopathy. And then the person was placed on therapy, you know, for, you know, for systemic edema. And then the person now presents with like very significant record, right? And you know, like very severe record, right? And then you're giving your analysis findings and you notice that you have like 30 to 40 rib lot cells per high power filled, right? When you see something like that, I would really, really hope you're thinking about a person having a kidney stone, right? The person that has a kidney stone, right? So remember, a kidney stone is going to present a sodium onset, severe, you know, you know, lateral flank pain, right?

Redidding towards the groin, redidding towards the testicle, right? Again, many times they're going to be nauseous, they're going to be vomiting, right? And what caused it in this person? Well, this person came in with a CFF exacerbation and the person was given a lube diuretic. Well, the thing is, if you take a lube diuretic, a lupes loose calcium, right? Because you don't more calcium in your urine, right? So they can make you have more calcium in your urine, they can make you hypercalcyuric, right? And that hypercalcyuria can precipitate stone formation, right? Can precipitate stone formation, right? So again, you do your analysis, you're going to see blood, right? You're going to see blood, right? And the thing is, remember, whenever you suspect a kidney stone, typically you're going to diagnose it with a non-contrast abdominal CT, non-contrast abdominal CT. I'm going to say that again, non-contrast abdominal CT, right? You don't want to give contrast because that contrast is going to obfuscate the stone and you're not able to see the stone and that's not going to be very, not going to be very, very awesome, right? Again, though, if you're worried about a kidney stone moment that is pregnant, I'll encourage you to go with an ultrasound. I will do that as an ultrasound instead of a CT scan, okay? Instead of a CT CT scan, right? Instead of a CT scan. And again, stones, the management depends on the size.

You know, sometimes if you use anywhere from like six to 10 millimeters, you can give like alpha one blockers, right? But one cornerstone of management, right? Because again, I know many resources like to go all up to the about the size of the stone. The classic thing I have friends at the MBMS once you're used to hydrate those people with fluids, hydrate, hydrate, hydrate, hydrate, then with fluids, so the stone can pass, right? So the stone can pass, right? But if the stone is really big, you know, typically like more than 10 millimeters or they're about, then in that case, you can consider something like shockwave lethal tripsy, like shockwave lethal tripsy, right? Like shockwave lethal tripsy, okay? So something you want to keep at the back of your mind for, for your exams, right? And again, I remember I talked about Crohn's disease earlier about how he can cause like B12 deficiency and stuff. Remember Crohn's, right? Don't forget like your classic boss words for Crohn's, right? You're going to see a person that has chronic diarrhea, right? And again, usually it's going to be non-bloody. That's kind of different from all three different varieties, right? They tend to have chronic bloody diarrhea, right? And again, remember when people have Crohn's disease, right? If you do a biopsy of the intestine, you're going to see a transmural lesions, you're going to see these skip lesions, right? So it doesn't continuously affect the GI tract, right?

You're going to see these skip lesions, some normal mucus and some abnormal mucus, right? And remember that Crohn's disease is one of those things that loves to form fistulas, right? So like you can have like a, like a, like a colovesicle fistula, for example, where they can have like fecaluria, right? Or they can have like gas bubbles in their, in their urine, right? That tells you that, ooh, they formed some kind of fistula from the colon to the, to the bladder, right? So just going to keep those things in mind, right? But between all three of the colitis and Crohn's disease, Crohn's is the one that loves to do fistulas and loves to do strictures, right? That loves to do strictures, right? And one thing I'm just going to say on the exams is that sometimes instead of putting the word Crohn's disease as the answer, they will just put elitis as the answer elitis, ILEITIS, right? Because Crohn's disease literally is an inflammatory bowel disease, right? So they will literally have inflammation of the terminal helium, right? Again, remember I said that the terminal helium is the most commonly involved region in a person that has Crohn's Crohn's disease, right? So again, keep that at the back of your mind for your exams, right? And then what if they give you a question about like a five-year-old boy and you're told that, you know, for the last, you know, three months, he kind of complains of this intermittent retro-acquodian pain, right?

Intermittent retro-acquodian pain and they tell you that sometimes that they actually do a hemocort test of his stool, right? You know, they do a hemocort test of his stool and you find a microscopic red blood cells. Whenever you see something like this, I would really hope you're, and it's going to be in a boy on your exams, right? I'd really hope you're thinking about mechals that are particular, right? Mechals, mechals, mechals, that are particular, right? Remember, this is actually a true diverticular, right? It's a true diverticular, right? You pretty much did not obliterate the Vidal Induct. Sometimes on the exams they call that the unfollow mechalum is enteric doctrine. You did not obliterate those things, right? You did not obliterate those things and then you're literally getting trouble, right? And most times this kid, sometimes they can have like, you know, GI bleeding, right? And many times it's going to be painless, but sometimes they can actually have, you know, like just right lower-acquodian pain, but it's going to be more of kind of a chronic course, right? I mean, I wonder like divine, like what's the thing that's causing this pain, right? What's the thing that's causing this bleeding? Well, remember that this thing can contain a topic gastric mechalsat, right? And what does gastric mechalsat contain? Gastric mechalsat contains parietal cells. Parietal cells are going to make acid, right?

And if they make acid, that can be nude, that can leech away your GI mechalsat, that can cause bleeding, right? It can cause bleeding, okay? So sometimes this can present with regular racquanjuan pain on the USMLE exams, right? And how you're going to diagnose this? Remember, you're going to diagnose this with a mechal scan, right? Sometimes on the exams they're going to call it the technician 99 M per-technitate scan, right? Technician 99 M per-technic-teet scan. Why do you use this scan? Well, this scan is pretty good for picking up the ectopic gastric mechalsat. And then don't forget that you may actually find pancreatic mechalsat. You may actually find pancreatic mechalsat in a person that has a mechalsat, a diverticula brain, a person that has mechalsat diverticula, right? And then, what if they give you a question about a person, you know, that is older, right? A person that is older, right? And you're told that this person for the last few weeks, you know, they've had like changes in the in the consistency of their stool, right? And then you notice that these people, they have like quite significant record-regrochroned pain, right? They have like quite significant, you know, record-regrochroned pain, right? They're having like signs and symptoms of like bowel obstruction, maybe vomiting and all these things, again, in an older person, right? So again, let me, let me, okay, let me, let me, let me backtrack a little bit, right? So you see an old person, old person, right?

And as we have in these weird abdominal complaints for a few weeks, although sometimes, instead of having complaints for a few weeks, these symptoms may actually be very acute, acute, acute, right? They can have like acute abdominal pain, the abdomen can be distended, right? They'll have like, they may present almost like a small, like a bowel obstruction in a sense, right? So they may have nausea, they may have a lot of vomiting, right? And then they tell you that you do a CT scan of the abdomen, right? And or you do like an abdominal radiograph, and you see what looks like a coffee bean sign in the right-row quadrant, right? Or sometimes, you may even see that you see a bird-beak sign in the right-row quadrant, right? When you see something like this, I want you to think of a sickle-volvulus, okay? I want you to think of a sickle-volvulus. I want you to think of what a sickle-volvulus. Remember, the sickum is the earliest part of the colon pretty much, right? And it's in the right-lower quadrant, so it can present with right-lower quadrant pain, right? It's pretty much a bowel obstruction in the right-lower quadrant at the level of the sickum, right? And again, it's going to present with a coffee bean sign. But again, the USML is, they know that everybody that has the job description medical student has memorized coffee bean sign. So sometimes these days on the exams, they'll use the term bird-beak sign, right?

So if you see the bird-beak sign in the right-lower quadrant in an older person, you absolutely positively want to think about a sickle-volvulus. Okay? Remember, bird-beak sign in the esophagus is what? It's going to be what? It's going to be what? It's going to be what? Bird-beak sign in the esophagus is going to be a calisia. All right. Now, what if they give you a question about a patient that has, you know, very high fever, the person's absolutely neutral field count is like 100, right? And this person, you're told that is a person that is being treated with chemotherapy for some kind of hematologic malignancy. And the person has like very severe sodium-inocytic-red-lower quadrant pain. Whenever you see something like this, I want you to think of something called typhlides. Typhlides. Typhlides. Typhlides. Think of typhlides. Think of typhlides. Right? This person basically has neutropenic enterocolitis or necrotizing enterocolitis. Right? This is something that happens in people that have a fever on neutropenia. Right? So if you see a fever on neutropenia, a retrochlorion pain, think of something called typhlides. Think of necrotizing enterocolitis. Sometimes they call it neutropenic enterocolitis. Right? And the thing is, this is inflammation of the sickle. The sickle is commonly what is involved in these people. Right? And this thing can cause necrosse of the bowel. It can cause perforation of the bowel. Right?

So these people are going to get tons and tons and tons of antibiotics. You need to give them like super broad spectrum antibiotics. Typically, you're going to give them antisodomonal antibiotics if not they can die. Right? And if they develop a complication like they develop like necrosse of the bowel or they develop rupture of the bowel or they develop perforation of the bowel, that person needs to go for exploratory, laparotomy, exploratory, laparotomy. Right? And then remember, some other minor pathologies as I begin to wrap up this podcast that can cause rectal reoccurrence pain. Remember, if a person has a heast stroke like a hernia, right? That typically is reducible, reducible, reducible, and then it becomes irreducible. Right? And then they start having significant rectal reoccurrence pain. Right? So they tell you that they have like this growing bulge, they have like very severe pain, and they just have like bowel obstruction symptoms. Right? You know, they're vomiting. You know, they don't plat, they don't pass fladers. They're not passing a bowel movement. Think of an incase-rated or strangle-edate hernia. Right? Think of an incase-rated or a strangle-edate hernia. Right? Remember, an incase-rated hernia is a hernia that is not reducible. A strangle-edate hernia is a hernia that, hey, you study having a skew of the bowel, right? Because it's possible the bowel that basically hernia into whatever region that you have the hernia with. Right?

So keep that at the back of your mind. And the thing is, when a person has a strangle-edate hernia, it's the worst, right? That person needs exploratory laparotomy or the person at least needs laparoscopic surgery. So pick an answer that says laparoscopic surgery or exploratory laparotomy. Right? And then don't forget, right? You see a young child, right? A young child, young male, typically having like very significant retro-acquodian pain, right? You can say that, you know, he's through the inside of the child's thighs and the scrotum does not elevate, right? And they have a high-right-in test, he's going to be testicular torsion, right? Remember, testicular torsion is going to present with severe study nonsense. Sometimes on the exams, they can present it as retro-acquodian pain. But typically he's going to be scrotal pain. He's going to be scrotal-scroto pain, okay? Scroto-scroto pain, right? So just be careful. Just be careful, right? This can be testicular torsion and this child needs surgery ASCP, right? Because again, within about four, six hours, the presence of test disease is going to die and that's not going to be awesome, right? And then if you notice a woman like in the middle of her cycles, right? In the middle of her cycles, she has like this retro-acquodian pain, right? Typically around like 14 days, you know, before her next period, if you see this, think of something called middle shmerts, right? Middle shmerts, M-I-W-T-E-L-S-C-H-M-E-R-Z, right?

It's just pain of ovulation. Basically, as the egg is popping out, it kind of hurts, right? It kind of hurts, right? So can I keep that at the back of your mind for your exams, right? So I think I'm going to go ahead and stop here. Again, if you love the way I teach, you're absolutely going to love my classes, right? So I have, you know, coming up in the month of February, I have a 25 hour step one class, and then I have, and that's first step one of our people taking step two step through poor, you know, poor basic science foundations, and step two step three, by the way, I'll be coming more basic science focus, right? So many people that take step two step three are actually benefit from taking the 25 hour step one class, right? And then I have a test-taking strategy class, that's first step one to step three. I have a biostatistics class, first step one to step three, I have a social sciences, ethics, quality improvement, and hospital medicine class, also first step one to step three. And then I have a first step two and step three specifically. I have a last minute review that's three hours long, a 20 hour class, right? And then in June, the first week, so June, I have a 50 hour step two step three class, right? So if you're interested in any of these classes, just shoot me an email through the website and give you some more information.

And then the other thing I want to say is I'd also do offer one or one tutoring for the USMEL exams, and also help with ERAS applications, mock interviews, personal statements, rec letters, and things of that nature, right? And these podcasts are on Apple Google and Spotify, so please check out those media, as I make a new podcast, it updates on those things, right? And also check out the other website I have, divineinterventionlifelessons.com, divineinterventionlifelessons.com, many of you know I'm a a a a a a a a a a a a a a a a week, I post like one or two podcasts where from a biblical perspective, address a life lesson. There's actually an Apple podcast associated with that called the divine intervention life lessons podcast. So thank you for joining me today. Again, I hope you find this podcast to be helpful and to really help you categorize and put a lot of high old things together. So I will see you God willing episode 630. Have a wonderful day. God bless you and bye for now. Thank you.

Obtain a urine pregnancy test, regardless of stability or other findings.

Tenderness at McBurney's point, Rovsing's sign (LLQ tenderness exacerbating RLQ pain), Psoas/Obturator signs.

Free air under the diaphragm (suggesting peritonitis).

Terminal ileum involvement, skip lesions, transmural inflammation, and propensity to form fistulas/strictures.

Stabilize hemodynamic instability (e.g., administer IV fluids).

Transvaginal ultrasound with Doppler flow study.

Broad-spectrum regimen providing both aerobic and anaerobic coverage (e.g., Ceftriaxone + Metronidazole).

The terminal ileum.

Macrocytic anemia and hypersegmented neutrophils.

Beta-hCG must be over 2000 mIU/mL to visualize a gestational sac.

Hypercalciuria (increased calcium excretion in urine).

CT scan of the abdomen and pelvis.

Antibiotics (avoid recommending Incision and Drainage).

Growing bulge, severe pain, and signs of bowel obstruction (vomiting, inability to pass flatus).

The terminal ileum.

Macrocytic anemia and hypersegmented neutrophils.

Beta-hCG must be over 2000 mIU/mL to visualize a gestational sac.

Hypercalciuria (increased calcium excretion in urine).

CT scan of the abdomen and pelvis.

Antibiotics (avoid recommending Incision and Drainage).

Growing bulge, severe pain, and signs of bowel obstruction (vomiting, inability to pass flatus).