Acute Abdomen

[ouLUSH]

asked a patient if it hurt more when I pressed in or upon release. she says "Both". so how would I document that? is that still + for rebound?

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[Winged Scapula]

asked a patient if it hurt more when I pressed in or upon release. she says "Both". so how would I document that? is that still + for rebound?

You say the patient is unable to ascertain a difference; try shaking/jiggling their abdomen and see if there's a difference there.

 

[ACSurgeon]

asked a patient if it hurt more when I pressed in or upon release. she says "Both". so how would I document that? is that still + for rebound?

Ask them to cough or shake the bid.

 

[Trauma Surgeon]

Or you just document "pain upon palpation" and proceed with your radiology (CT?)!
Now a days I don't even know what difference it makes if there is a pain on on release since just on pain on palpation you would have sent the patient for radiology.
There is a difference in frank peritonitis and trauma situations where you maybe would go for ex lap without radiology verification of an intraabdominal pathology.

 

[TypeADissection]

You say the patient is unable to ascertain a difference; try shaking/jiggling their abdomen and see if there's a difference there.

Somehow this is the first thing that came to mind when I read "shaking/jiggling."

 

[Winged Scapula]

Somehow this is the first thing that came to mind when I read "shaking/jiggling."

LOL...mesmerizing isn't it?

I had an acute abdomen once; palpating my abdomen didn't pick it up but jiggling my (somewhat less Homer like) gut did.

 

[AdmiralChz]

The "not-so accidental and pretty obvious" bumping of the ER stretcher is a personal favorite to assess for true pathology vs some sort of secondary gain/dramatization/malingering.

 

[LucidSplash]

I like the bumping the stretcher but also the "I'm just going to listen with my stethoscope" and then palpating with it. Its amazing how many people don't have the same symptoms when you apply the same amount of pressure with that instrument vs your hands.

 

[TypeADissection]

I like the bumping the stretcher but also the "I'm just going to listen with my stethoscope and then palpating with it. Its amazing how many people don't have the same symptoms when you apply the same amount of pressure with that instrument vs your hands.

This x 1000. I remember watching my chief resident do this while I was just a young, directionless intern. She also taught me the high-five trick when we get peds appy rule-outs. Now I do it and interns look at me like I'm all-knowing. Oh the beautiful cycle of residency training.

 

[LucidSplash]

Oh and I always made a point of telling interns that "anorexia" for appendicitis wasn't really a thing for boys and young men. Or basically any men except old men. It is my experience that young men will eat unless they are actively dying and sometimes even then. Most frequently I would ask if they could eat a pizza and they would say something like "well maybe only half a large pizza right now because I don't feel great" and then you could expect a belly full of pus.

 

[vhawk]

Oh and I always made a point of telling interns that "anorexia" for appendicitis wasn't really a thing for boys and young men. Or basically any men except old men. It is my experience that young men will eat unless they are actively dying and sometimes even then. Most frequently I would ask if they could eat a pizza and they would say something like "well maybe only half a large pizza right now because I don't feel great" and then you could expect a belly full of pus.

Nice. I learned the same thing about the obese. We had a lady transferred in from OSH after they'd been sitting on her for 2-3 days. They had done a scan showing some pneumatosis and ischemic bowel but no free air. When she got to us, wbc was like 18 but hd ok and really only moderately tender on exam. We sat on her for another day and then actually let her eat. She was on her 4th pb&j when she started to get a little tachy and hypotensive so we bit the bullet and explored her. She had about 140cm of....well to call it dead bowel would be an understatement. It was like liquefied, mummified bowel. Like it had been dead for a week.

 

[ACSurgeon]

Or you just document "pain upon palpation" and proceed with your radiology (CT?)!
Now a days I don't even know what difference it makes if there is a pain on on release since just on pain on palpation you would have sent the patient for radiology.
There is a difference in frank peritonitis and trauma situations where you maybe would go for ex lap without radiology verification of an intraabdominal pathology.

My abdominal exam is especially helpful when CT is equivocal. My exam determines how the CT is read.

But yea, most patients aren't going to the OR for peritonitis diagnosed based on physical exam alone.

 

[Jolie South]

I like the bumping the stretcher but also the "I'm just going to listen with my stethoscope" and then palpating with it. Its amazing how many people don't have the same symptoms when you apply the same amount of pressure with that instrument vs your hands.

Stethoscope? What's that?

 

[LucidSplash]

Stethoscope? What's that?

That thing you use to listen to carotid bruits. 😀

 

[Jolie South]

That thing you use to listen to carotid bruits. 😀

Carotid bruits don't actually correlate with level of stenosis.

 

[LucidSplash]

Carotid bruits don't actually correlate with level of stenosis.

No but they are still nice to document on exam.

 

[vhawk]

Stethoscope? What's that?

I believe its pronounced "stethamascope"

 

[VincentAdultman]

"orthopedic center of auscultation".....you can listen to the heart, lungs, and bowel sounds at the same time.