Here was the case. Nine-year-old female comes in with mom, and mom is dressed in scrubs. Chief complaint is abdominal pain. Nine-year-old female with abdominal pain, started that day, and it was early in the afternoon. Pain started this morning, and mom brought the child in. Diffuse abdominal pain. No nausea, no vomiting, no diarrhea, no fever, chills, no urinary symptoms.
I go and see the child. Vital signs are stable. Child’s happy and smiley, hungry, wants to eat. “Would you like a piece of pizza?” She goes, “Oh, yeah.” Big smile on her face. Her abdomen was remarkably soft, as soft as a hotel room pillow.
I talked to mom and I say, “Well, her abdomen is very soft. We could run some labs, but I don’t know if it’s necessary at this time.” It became clear that Mom was a nurse’s aide at a local nursing home, and she was insisting on labs. What would you do? How would you work this up? Would you poke her and do labs? Would you do a urine? Would you do an HCG on this?
What would you do with this case?
Well, mom was insistent on labs. I said, “Mom, her belly is very soft and she’s hungry. I think this is very unlikely anything like appendicitis.” You’ve got to understand that when parents bring their kids in, you’ve got to use that word. You’ve got to use the word appendicitis, because that’s what freaks parents out. That’s what they’re always thinking. I said, “This isn’t appendicitis. The chance of it being appendicitis with the soft abdomen and her being hungry is incredibly low.”
She looks at me and she says, “Well, I want you to do some labs.” Well, I’m glad to do labs, but walking out of the room, I’m thinking, “Come on. You want me to poke your daughter? You want me to put her through the pain of a venepuncture?” I’ll do it, but I had some animosity towards the mom, some contempt for the mom because she’s making me poke her child. It’s going to be absolutely useless. Well, then the labs came back with a 22,000 white count.
I go back in the room and I examine the child again. Very, very soft abdomen. I said, “Are you hungry?” She goes, “Yeah, I’m hungry.” Now, I’m angry at the mom because she’s making me do a CAT scan on her daughter. That’s tremendous amounts of radiation. I said, “You know, mom, her white blood cell count is elevated. I’m going to have to do a CAT scan now.” In my mind, I’m thinking, “I hope you’re happy. I hope you’re happy that you’re exposing your daughter to this radiation.”
Well, we do the CAT scan and acute appendicitis was the CT read. I was absolutely wrong in this case. Acute appendicitis is a sneaky diagnosis. I have made that diagnosis over 100 times in my 17 years as an ER physician assistant. It’s a sneaky diagnosis. The history is unreliable, ladies and gentlemen. The history is unreliable. The classic presentation of malaise, anorexia, maybe repulsion to food, periumbilical pain radiating down to the right lower quadrant. That’s not the common presentation. It’s weird. I’m saying that the classic history of appendicitis isn’t a typical presentation. I’m saying the physical exam can be incredibly blunted. I’ve had this girl, her belly was so soft, and she was definitely in appendicitis. I would have missed this one had mom not been persistent on the labs, no doubt about it.
The thing about appendicitis is this. What’s the most sensitive test for appendicitis? This is really important. A lot of people, when I ask this question at conferences will say, “Well, laparotomy,” or some people say, “Well, only surgical fixing or a CAT scan.” I’m saying, “No, no, no, no.” All those are helpful. Time is the most sensitive diagnostic test for appendicitis, ladies and gentlemen. Give it enough time and you’ll figure it out.
If you have a case of appendicitis, it’s on a timeframe. Let’s say it’s 36 hours from the start of symptoms to the time of perforation. If the patient is five, six hours in, their chief complaints are going to be diffuse abdominal pain, nausea, maybe some diarrhea. They’re going to be incredibly nonspecific symptoms. Nobody can pick that up, and if you scanned every single person that came in with nonspecific abdominal pain and a little bit of diarrhea, you will be radiating a lot of people. The world will be glowing. We’re overusing CAT scans as it is.
Greg Henry, an ER physician who speaks, says, “The way we use CAT scans today is going to be the mesothelioma of tomorrow,” meaning that we’re scanning the crap out of people. Know that if you do a plain film chest radiograph, that’s about 2-1/2 days of solar radiation, but if you do an abdominal CAT scan, it’s 3-1/2 years of solar radiation. It is a massive amount of radiation.
What’s the most sensitive test for appendicitis? It’s time. If you give them enough time, you will find the diagnosis, and you need to communicate that to your patients. That’s why observing them in the ER for 6 hours may be the right thing. That’s why having them reevaluated, whether it’s in the ER the following day or at their primary care doc’s office, is a good way to practice medicine. The most sensitive test to help make the diagnosis of appendicitis is time.
The physical exam and the history is unreliable in appendicitis. Just put that in your bank. Certain patients have atypical presentation and symptoms. I’m telling you, appendicitis presents weirdly. There are two types of people that classically have atypical presentations of abdominal pain. You cannot be fooled by them.
The first one is diabetics. I have said many times before, diabetics were put on this Earth for one reason and one reason only, and that is to burn us in emergency medicine because they present so atypically with infections and cardiac problems and intraabdominal pathologies. They won’t have peritonitis like non-diabetics. If you have a diabetic with abdominal pain, scan their belly. Have a very low threshold to scan.
The second class of patients is people who are on chronic steroids. If they’re on their 10th day of prednisone for their lupus or their rheumatoid arthritis, they will not have the same abdominal physical findings as others. Have a low threshold to scan them.
When it comes to the physical findings of the abdomen, there are three physical findings that you really want to document and cognitively think about. The first one is guarding. Guarding is a voluntary response. It’s when you push down on someone’s belly and they clamp down. Something that I teach at conferences is if you’re a lady and you want to know what guarding is, go up to a guy that you kind of know and grab their bicep. Get a meaty grab of their bicep. We, as masculine men, cannot tolerate women grabbing our biceps, so we immediately flex. We can’t help it. We’ll bring the guns out. That’s guarding. It’s a voluntary response.
Rigidity is where the muscles stay clamped and they cannot relax. Rebound tenderness is where you have the peritoneum. It’s highly innervated with nerves. You have an inflamed appendix. When you push on it and you bounce the peritoneum on the appendix, it hurts like the dickens. That’s why you ask, “How was the ride over,” because if they hit bumps, it hurts. If they’re walking in like they’re wearing snowshoes, they’re not oscillating when they walk, that’s an appendicitis walk or a peritonitis walk.
There are three different physical findings when it comes to abdominal pain: guarding, rigidity and rebound tenderness.
Use the mnemonic PROM. P is psoas sign, not the most sensitive test. R is Rovsing’s sign. That’s where you push on the left lower quadrant and get pain in the right lower quadrant. It’s a good test. When people get positive Rovsing, my experience is 70-80% of the time, they have appendicitis. It is not an absolute. It’s not literature-based. Just my experience in diagnosing over 100 cases of appendicitis in my career. Rovsing’s a good test. O is Obturator sign, which is not the greatest test, either. It’s very similar to psoas sign. M is McBurney’s point, which is a buzzword you want to document in your chart because when you document it, you know that you’re looking at McBurney’s point or that particular right lower quadrant for appendicitis.