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