Another case: Abdominal pain
 

Going to work this one a little differently than in the past threads. Instead of starting it off by giving you most of the (O) information up front, you are going to have to ask for the info from "either the patient" to fill in your (S) portion or by listing what you would do (exam) to get the results for your (O) information. After all, patients in the real world don't come up to you with all the necessary info to Dx their condition written on a napkin. You have to figure it out by history, thorough physical exam, and sometimes future labs/other advanced techniques.

Scenario:
You are performing an UW mission. You are the only medical expert available for at least 48 hours if not longer.
Your Team Sergeant comes to you three hours after breakfast (it was a MRE).

-S- 36 yr old, WM, CC: " recently very nauseous and have severe/sharp stomach pain all of the sudden" Pt reports no Hx of trauma in the past week.

-O- Vitals WNL,PERRLA



Anyone with a serious response is encouraged to post. Even WAG's can be a learning experience if a short explanation of why one thinks it was the answer is included for further discussion.

Let’s work this patient-
Questions to ask the patient? Any objective info that you want, just ask or list what/where/how you would do the exam to get the results and they will be given.

For starters

Is the pain localized to one area?
If not, can you pin point the pain?
Did he vomit or just feel nauceous?
Does he feel hot? Fever?
How soon after eating did the pain occur?
What did he eat?

He can not pinpoint the pain when you simply ask him. He described it as around his belly button and "maybe a little lower sometimes and on my side".

No vomiting... not yet anyway. He still feels bad.

He doesn't have a fever at this point.

He ate three hours ago... along with the rest of the team. Everyone ate the same exact things.


Any other questions you want to ask him when dealing with unknown abdominal pain? I am sure we would want to rule out "common" non-emergency type stuff.


Anything you want to do upon exam?

He can not pinpoint the pain when you simply ask him. He described it as around his belly button and "maybe a little lower sometimes and on my side".
Which side and does it stay localized?

He ate three hours ago... along with the rest of the team. Everyone ate the same exact things.
Yes, but what was it? The reason

Any other questions you want to ask him when dealing with unknown abdominal pain? I am sure we would want to rule out "common" non-emergency type stuff.
I'm trying to rule out gas, ulcers, maybe appendicites sp?)


Anything you want to do upon exam?

If I knew what I was doing I'd have the PT lay on his back and I'd press around to locate the pain as well as to check for swelling.

To rule out appendicites, I believe the correct procedure is a reflex-test where you press down on the area around the appendix and release. If the release hurts less than the pressure, he does not have appendicites.

Is that the right procedure?

Solid

you are trying to describe "rebound" pain....

and you can have an acute appendicitis without rebound because patients never read the text books.

doc t.

Any of the others on the Team showing S/S?
HX of heart disease?

What does his abdomen look like? Distended? Rigid?
Bowel sounds?
What do I feel on palpation?
Percussion? + Murphey's sign?
Rebound tenderness?
Guarding?
Stool - Color, ordor, consistanc? Frequency? LBM?

Is the pain getting worse or about the same? If its getting worse - quickly or gradually?

Pain intermittent or constant?

Does the pain radiate? Say to the back?

Pain better or worse lying down? Sitting up?

WBC Count?

still working on history....

has he been taking any meds...motrin for example?
you said the pain came on suddenly.... has the intensity changed or is it the same as when he first felt it?
which came first : pain or nausea?
similar episodes of pain in the past?

doc t.

LOL - Check 6 SACA! Me and Doc T are on you and your ass is out now!:munchin

I can confirm that first hand.

TS

Mac Burney..

Last Autumn, battle exercises. Third night, i began to have a very upset stomach, not your average stomach pains.

We had a night demo later in the evening and after that could not walk at normal pace to our camp area. Was evaced to our base hospital where i spent the night. The next day the attending doctor made a quick diagnosis, they did not have the proper equipment to monitor so they sent me straight to the main hospital in our area. Spent approx. 2 hours at the ward waiting, the chief surgeon did the basic reflex test and i was scheduled for surgery. It was a severe case of appendicites.

The day following the surgery i returned to unit on my request since i was able to walk, slow, but still able. We had our military oaths sworn on the day following my return so it was personally important to attend the ceremony.

??Charles McBurney

American surgeon, born February 17, 1845, Roxbury, Massachusetts; died November 7, 1913, Brookline, Massachusetts.

McBurney's point
A point midway between the umbilicus and the right anteriorsuperior iliac spine. A guide to the position of the appendix, determined by the pressure of one finger.

McBurney's sign
Maximum tenderness and rigidity over McBurney’s point. May be indicative of appendicitis

Yep, thanks for the correction.

A friend of mine who is studying Medicine told me that the rebound test was the first means of diagnosing appendicitis... Apparently, he was wrong (must tell him before he fails a test). Out of curiousity, what is the normal procedure for diagnosing appendicitis?

Thank you,

Solid

there is no first test.... I am not sure what Saca's diagnosis is yet so don't want to go into too many details.

in short, you obtain a history that should make you suspicious of an appendicitis and then look for localized right lower quadrant tenderness if its early...can be diffuse pain if its late. The one finger tenderness at mcburney's point is pretty consistent especially if its a male patient.....

so I would say the diagnosis is made on history and tenderness, not necessarily rebound.

doc t.

Thank you very much Doc. T.
Sorry for the hijack, Sacamuelas, back to your thread.

Solid

HOT DAMN!! that is a great start
 

Alright! this is exactly what I was hoping for when I started this thread. Everyone can now see how a clinician's thought process works. Thanks NDD, Doc T, and others. I will be printing this thread so that I can answer all the info for the questions and exam you have stated you would do.

Yes, Kyo, I figured out what you were wanting, but I couldn't tell if you wanted the info derived by questioning alone or in conjunction with an actual abdominal exam by you... Since you didn't tell me to do an exam on his abdomen, I didn't give you the benefit of the doubt. Now that you have clarified what you want/would do, your exam results info may just vary from what he "thought and told you" and therefore told you. haha)

Back in a few with info for your guys/ladies...

I know you didn't just call me a clinician?

How Many stars does that make by the name "JawBreaker" on that list of yours?:D

LOL... I am alright, my six is covered.. you guys took the path that I wanted you to follow in this thread. Are you sure you haven't walked into a SACA ambush? LOL


Quick note for Tuuka-

Doc T has of course covered most of this info. For you medics to be, here is a brief diagram that covers what Doc T said about Mcburney's sign... (see diagram at the end of this post)

In our case we are working:

palpation/percussion exam reveal the following:

• pt has moderate tenderness to direct palpation around umbilicus
• pt's abdomen is rigid in RLQ w/associated severe tenderness upon palpation of RLQ.
• "Mcburney's point", however, is not specifically more tender than any other are within the RLQ
• Quick note about potential palpation/percussion exam findings:
  ------Rovsing sign (ie, RLQ pain with palpation of the LLQ), obturator sign (ie, RLQ pain with internal rotation of the flexed right hip), and psoas sign (ie, RLQ pain with hyperextension of the right hip) are present in a minority of patients with "our TS's condition".
  ***None of these findings were observed when we examined our patient.
  
• guarding present upon exam
• no rebound tenderness noted upon exam

Other items/info requested:

• Patients pain seems to increase when standing/walking
• pt was taking IBU 800, TID prn for sprained ankle beginning two days prior.
• stools regular and WNL per patient's recollection. Last known bowel movement 24 hours ago.
• Pain getting worse compared to when first noticed
• no radiating of pain described by patient, however, as it has worsened , he states it could hurt in his back as it hurts all over and is giving him worse nausea.
• Pain is worsened by walking/standing verses supine
• WBC?? You don't have access to this info in the jungle NDD., however, your jedi powers indicate that the count is elevated though. (ONLY NDD can use this info... none of you would have this ability except him) LOL
• Pt reports similar pain in the past, not as severe, and resolved in its own after an hour or so.
• Pt states his nausea came before pain, and that his appetite has been minimal for the last 48 hours for unknown reason.

Alright.. I think that covers all the wanted exam techniques and questions to ask the patient. Now that you have this info... Any more questions? Do you have a guess as to Diagnosis? What have you now ruled out ( which is just as important since you must do this before you can make a legit Dx)?

18Ds have the capabilities of doing WBCs in UW environments. or did in my day.

In that case.. WBC(/mm3) count 15,000.:cool:

Is he experiencing any heartburn?

a few more questions...

is he a heavy drinker ( i know...its all relative)
do jedi powers extend to other labs?
or xray vision?

doc t.

LOL.... no more jedi powers

-He is not a "heavy" drinker.
-Only NDD has jedi powers... labs are not available ( even IF you could perform the test NDD. LOL)
-standard KUB x-rays show the following only 10% of the time(according to what little I know from research). I shouldn't post this but what the hell... most will not know what it shows anyway, and even you may not be able to tell due to the poor resolution of the copy.

Back later tonight after my crawfish boil/party....

Doc T.. Pm incoming late tonight or tomorrow morning about this thread. I want to discuss certain things about this one. Make sure I have given enough info without making it to difficult in your opinion. :D

Until then, I'm looking forward to hearing WAG's and why. Some have already ruled out some possibles with their professional questions.

again, hint..hint... I don't post thread topics that are extremely rare events unlikely to be seen by the future/current SF docs. This is something that I now KNOW has happened and will possibly be faced by you in your career. Almost like I am psychic or something... LOL

Is this the appendix? (red circle). If it is I don't think it looks right. But then, what do I know?

Is he passing a more gas than normal? Does it smell worse than normal?

This sucks not nowing enough to ask the right questions.

well, now I know the diagnosis based on the Xray... and an appendix in and of itself will not show up on a plain xray.


will wait and see what others think.


doc t.

I don't know what this is called, but it seems to fit the symptoms- a twisted/knotted intestine?

Solid

All the symptoms seem to fit appenecitis. Add in Doc T's comment and I'll say Appendecitis

KYO is correct
 

Well, due to my intense hangover/long recovery time from Saturday night(crawfish/beer/boat drinks/bourbon)... it appears this thread almost died on the vine before being picked when it was ripe. Sorry All...


No PM will be needed Ma’am, as it appears that the Dx was determined with the given info. I am sure NDD(the clinician-haha) had made the Dx as well, based on his line of questioning and given info in return. Doc T made it on the questions and confirmed with the radiograph.

Doc T- Ma'am, will you benefit us with your knowledge of what you see and why it only shows up specific to appendicitis and not just in a normal radiograph of the area? I ask for the 18D's that may have access to films and need to recognize this when/if it presents with these symptoms.

Note: the reason I did not include this radiograph in the original info is because from my understanding (limited, I admit) this visualization of an appendicolith in a patient with symptoms consistent with appendicitis is highly suggestive of appendicitis, but this occurs in fewer than 10% of cases. The consensus in the literature is that plain radiography is insensitive, nonspecific, and not cost-effective. As an 18D, you are much more likely to have to Dx this problem without an Xray facility available, but even with this radiograph you won't be able to rule out appendicitis even if it is not visible to you on the film. So, to me, it is MORE important to refresh on the diagnosis without having an obvious glaring sign like the x-ray presented to you up front.

To get the most potential learning from this thread...
From what little I know, it appears that this would have been a much more difficult diagnosis on a female patient than that of my Team Sergeant example. Anyone know why?

What other items were on everyone's differential Dx of these symptoms?
I will start off by noting that NDD was aware of and ruled out constipation early on in the thread. Through good history taking questions on bowel movements/frequency,etc a very common cause of some of the initial symptoms was ruled out. I doubt anyone would want to call for an emergency evac only to find out the Dx was constipation and you had not asked the obvious questions of the patient before making coms to command.

After we run through how we ruled out other potential causes ( to the best of our ability out in the field with limited technology), then we can go over what we would do. After all, remember that the scenario is that we don’t have access to evac for at least 48hrs.

(if you guys want to cut to the end... just give a shout and we can go directly to Tx- just trying to cover all the possible useful info):cool:

Alright.. I let the thread die, so I will try and revive it with my internet ACLS.

Another observation I made from y’alls questioning.

Why was it important for Doc T to ask about nausea/vomiting and when it occurred when compared to pain?

Because when vomiting occurs due to appendicitis, it nearly always follows the onset of pain. Vomiting that precedes pain is more suggestive of intestinal obstruction, and therefore your diagnosis of appendicitis should be reconsidered and scrutinized.
-just another point that could be lost if we don't go over exactly how GOOD you guy's history taking questions were.

Anyone else want to report why they were asking a certain question? Or what certain info I reported back ruled out or made likely when it was given? :munchin

Or hell, if this is to boring for you "cutters", what would you do now that you have diagnosed it as appendicits?

AKA Volvulus.

I'm not good with KUB although I thought I detected gas in the transverse colon.

What I want to know is if it is hot appy (or meckel diverticulum) what could be done about it? If transport out is not available for 48H then the probablity of burst appendix with subsequent peritonitis is imminent. That is life threatening and means time in the hospital, possibly with an open incision for tx.

If it is volvulus or other type of obstruction is it possible to decompress it in the field with tubes?

ccrn

Edit for spelling
**edited FORMAT only...see note in your next post ccrn, thanks

Threads got a pulse again!!! will continue rescue breathing...
 

I will leave that to Doc T for definitive answer. I do not want to mislead you, but to me gas on the radiograph would not be an uncommon finding and therefore would not help me diagnose this particular set of symptoms.


It could be life threatening if it ruptures, but again that must be tempered with the current situation that the SF medic in this thread is dealt. It is an unfortunate circumstance he finds himself in to be sure....BUT

I have read reports that describe the success of IV antibiotics in treating acute appendicitis in patients without access to surgical intervention (eg, submariners, individuals on ships at sea). In one prospective study of 20 patients with ultrasound-proven appendicitis, 95% had resolution of symptoms with antibiotics alone, but 37% of these patients experienced recurrent appendicitis within 14 months.
***This may be useful when appendectomy is not accessible or when it is temporarily a high-risk procedure.


I defer to Doc T, Eagle, NDD, or others to answer this one.:munchin

Re: Threads got a pulse again!!! will continue rescue breathing...
 

I had considered this and wondered if even loading with a PO antibiotic prophylacticly wouldnt be prudent if nothing else was available. Do 18D's carry these types of meds?

ccrn

Re: Re: Threads got a pulse again!!! will continue rescue breathing...
 

Recommended Non-surgical Tx:

• Establish IV access and administer aggressive crystalloid therapy to patients with clinical signs of dehydration or septicemia.
  
• Do not give anything by mouth to patients with suspected appendicitis.
  
• Administer IV antibiotics to those with signs of septicemia and those who are to proceed to laparotomy.
  
• Administration of analgesics to patients with acute undifferentiated abdominal pain has historically been discouraged and criticized because of concerns that they would render the physical examination less reliable. At least 8 randomized controlled studies now report that administering opioid analgesic medications to adult and pediatric patients with acute undifferentiated abdominal pain is safe; no study has found that analgesics adversely effect the accuracy of the physical examination.

Again the above is an opinion from well researched literature. Doc T should be along to confirm and/or give her professional opinion based on experience.

x

Thank you Doctor Doom. That was an excellent post. You filled in some of my interpretations with facts and experience. Thanks for spending the time to post all that except that "bamboo tube into the sigmoid colon part! :eek:"... I bet that gave NDD bad flashbacks of his last over 40 exam in the jungles of Colombia. LOL