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Appendicitis

History

Vague nonspecific abdominal cramping and nausea (Nonspecific Phase) gradually progresses to localized pain (Localized Phase). The pain most commonly localizes in the RIGHT LOWER QUADRANT near McBurney’s Point.

Exam

• Focal tenderness in the right lower quadrant
• McBurney’s Point: 1/3 the distance traveled from anterior superior iliac spine (ASIS) to the navel.
• Psoas Sign: Pain with hyperextension of the right hip (while patient is laying on left side)
• Obturator Sign: Pain when flexing right hip to 90 degrees and rotating
• Rovsing Sign: Pain felt in the right lower quadrant when pushing on the left lower quadrant

Testing

Fact 1: The urinalysis can be abnormal in appendicitis

Fact 2: The white blood cell count can be normal in appendicitis

As far as imaging when appendicitis is suspected…

• Most people get a CT scan
• Most pregnant women get MRI
• Most pediatric patients get an ultrasound

Treatment

• Analgesia (example- 4mg IV morphine)
• Antiemetics (example- 4mg IV ondansetron… aka Zofran)
• Antibiotics (example- 4.5mg IV piperacillin/tazobactam.. aka Zosyn aka “pip-tazo”)

Diverticulitis

History

Similar to appendicitis. Vague nonspecific cramping and nausea gradually progressing to localized pain. This pain most commonly is located in the LEFT LOWER QUADRANT. Stool related complaints such as constipation and bleeding also common

Exam

Tenderness in the left lower quadrant

Testing

Easy… Get a CT scan

Treatment

If the patient has severe symptoms, big risk factors such as immunosuppression, or complications of diverticulitis (abscess, perforations, etc). Treat the same as appendicitis… Admit, antibiotics, surgery consult

If the patient has mild symptoms, they commonly are sent home on oral antibiotics and close follow up.

Additional Reading

• American college of radiology imaging options for appendicitis (ACR)
• American college of radiology imaging options for diverticulitis (ACR)

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EM Clerkship’s 10 Step Patient Presentation

1. Demographics (Age, Gender, Pertinent Medical/Surgical History, Chief Complaint)
2. At Least 4 Descriptors (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors)
3. Red Flags/Pertinent Positives and Negatives
4. Vital Signs
5. Focused Physical Exam of the Complaint
6. Suspected Diagnosis
7. Can’t Miss Diagnosis
8. Testing Plan
9. Treatment Plan
10. (If Asked) Anticipated Disposition

Vital Signs

“Vitals in triage showed a MILD TACHYCARDIA which she still does have in room. AFEBRILE here. Otherwise stable”

Address the vital signs

It is important you mention any abnormal vital signs from triage and that you rechecked them on your examination. You do not need to repeat normal vitals and it is usually acceptable to say something like “vital signs otherwise within normal limits”

PEARL: Frequently, triage OVERESTIMATES the patient’s heart rate and UNDERESTIMATES the respiratory rate. You get serious bonus points if you recheck vitals yourself and find a true discrepancy.

Focused Physical Exam of the Chief Complaint

“Abdominal exam shows nonspecific tenderness throughout, no focal guarding or rigidity. No masses. No CVA tenderness”

A Focused Exam

A common error by medical students is that they present a brief generalized exam of each body system rather than a detailed examination of the body system most pertinent to the case.

For example, a great medical student will perform the following…

• If the patient complains of back pain: palpate the spine, perform reflexes, ambulate the patient, do a straight leg raise.
• If the patient complains of headache: test cranial nerves, visual fields, finger to nose, gait stability, motor, sensation, speech
• If the patient complains of chest pain: auscultate the heart, examine the legs for DVT, look for JVD, obtain pulses in all 4 extremities.

Suspected Diagnosis

“I don’t have any particular diagnosis that I think is most likely yet”

Identify your most suspected diagnosis (or lack thereof)

Can’t Miss Diagnoses

“We do need to rule out the life threats of ECTOPIC PREGNANCY, DKA, and APPENDICITIS“

List several pertinent life threats

List 2-3 life threats you specifically considered and which seem MOST pertinent to the patient’s specific complaint and examination. If your attending requests more, then give more as needed.

Testing Plan

“For my testing plan I would like to get a PREGNANCY TEST, ELECTROLYTES, CBC, LIPASE, LIVER FUNCTION, and a CT SCAN WITH CONTRAST “

A TESTING PLAN

Common tests for abdominal pain potentially include (but are not required)…

• CBC
• Electrolytes (CHEM, BMP)
• Liver Function Tests
• Lipase
• Urinalysis
• Urine Pregnancy Tests
• Troponin
• EKG
• CT scan with (or without) contrast
• Ultrasound (especially common with right upper quadrant pain, pelvic pain, and with pediatrics)

Treatment Plan

“For my treatment plan I would like to get her 4mg Zofran, 4mg of morphine along with some FLUIDS“

a Treatment Plan

***A COMMON MISTAKE BY MEDICAL STUDENTS IS THAT THEY GIVE A GREAT TESTING PLAN BUT FORGET TO GIVE A BASIC TREATMENT PLAN

With abdominal pain, memorize a few basic antiemetics, pain medications, and types of fluids (with doses) so that you can give a treatment plan during your shift.

(If Asked) Anticipated Disposition

“I think that if everything returns normal she should be safe for OUTPATIENT followup WITHIN THE NEXT 24 HOURS as long as she is looking OK”

ANTICIPATED DISPOSITION STATEMENT

If a patient’s tests come back normal and the patient feels better with treatment they will usually go home with close follow up (sometimes as soon as 12 hours if the physician is truly concerned, in the ED if necessary)

Additional Reading

• Basic Analgesics and Their Doses (EM Clerkship)
• Cope’s Early Diagnosis of the Acute Abdomen (Amazon)

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EM Clerkship’s 10 Step Patient Presentation

1. Demographics (Age, Gender, Pertinent Medical/Surgical History, Chief Complaint)
2. At Least 4 Descriptors (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors)
3. Red Flags/Pertinent Positives and Negatives
4. Vital Signs
5. Focused Physical Exam of the Complaint
6. Suspected Diagnosis
7. Can’t Miss Diagnosis
8. Testing Plan
9. Treatment Plan
10. (If Asked) Anticipated Disposition

Demographics (Age, Gender, Pertinent Medical/Surgical History, Chief Complaint)

“I have a 48 year old, FEMALE with a past medical history of INSULIN DEPENDENT DIABETES, AND NO HISTORY OF ABDOMINAL SURGERY, who presents with ABDOMINAL PAIN“

a Typical demographics statement

Age

The reason age is so important (especially with abdominal pain) is because it adds additional (frequently forgotten) items to your basic differential. For example…

• Pediatric Patients
  • Intussusception
  • Necrotizing Enterocolitis
  • Henoch Schonlein Purpura
  • Testicular and Ovarian Torsion
• Geriatric Patients
  • Abdominal Aortic Aneurysm
  • Mesenteric Ischemia
  • Volvulus
  • Myocardial Infarction

Interesting Fact: In some studies, geriatric abdominal pain has a mortality of almost 10%!!!

Gender

The reason gender is so important (especially with abdominal pain) is because ECTOPIC PREGNANCY is the most important life threatening diagnosis in women of child bearing age.

Pertinent Past Medical and Surgical History

This is the only place in your presentation when the patient’s medical and surgical history is included. Keep it focused on the most important items.

• Always include previous abdominal surgeries (or say “no history of abdominal surgery”)
• Always include an overview of previous GI workups
• Diabetes, immunosuppression, active cancer, and blood thinners are almost always pertinent medical conditions regardless of chief complaint
• Obvious GI diagnoses should be included such as inflammatory bowel disease, peptic ulcers, cirrhosis, etc

At Least 4 Descriptors (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors)

“She describes it as a SEVERE, GENERALIZED, abdominal pain that STARTED LAST NIGHT and has been GRADUALLY WORSENING since then”

An example of giving 4 Descriptors

Most attendings think about (and document) the history of present illness as a list of descriptors. This is for billing reasons. A “level 5” chart requires 4 “HPI Elements” to be documented.

Red Flags/Pertinent Positives and Negatives

“She has had some subjective FEVERS but NO HISTORY OF AFIB, and NO VOMTING, DARK TARRY STOOLS, URINARY SYMPTOMS, or VAGINAL BLEEDING OR DISCHARGE

An example of Giving red flags and pertinent positives/negatives

Abdominal pain is not typically a complaint known for having a big list of “red flags” that need to be asked. In my opinion, examples of true red flags with abdominal pain would potentially be the following…

• History of Atrial Fibrillation
• History of Bariatric Surgery

However, it is generally expected that you give a thorough list of pertinent positives as well.

• Fever, Chills, Malaise
• Chest Pain, Shortness of Breath
• Nausea, Vomiting, Diarrhea
• Vaginal Bleeding/Discharge
• Dysuria, Urinary Frequency/Urgency, Hematuria
• Melena

Additional Reading

• Geriatric Abdominal Pain Mortality and Clinical Overview (PubMed)
• Basic Approach to Pediatric Abdominal Symptoms “Tummy Ache” (EM Clerkship)