clinical
abdominal Assessment and diagnosis of appendicitis
Ruth Higgins describes a consultation process between a practitioner and a patient who has suspected appendicitis
typical healthcare consultation involves gather To assess pain symptoms, the OPQRST system Aing information, inferring a diagnosis and of history taking (Box 1) was used (McGillion formulating a management plan. and Watt-Watson 2007) because this offers an However, consultations can also be regarded in-depth systematic assessment of individual as two-way social interactions, whose outcomes signs and symptoms. However, this model depend on the information that patients disclose, does not address specifically the relationships and on whether they comply with the advice or between individual signs and symptoms, such as hotodisc P treatments they are offered. Consultations are that between pain and nausea (McGillion and Ruth Higgins affected therefore by the actions and choices of Watt‑Watson 2007). BSc(Hons) is a their participants. Open questions were used to gather as much student physician This article explores and evaluates communication, information from the patient as possible. examination and management methods in clinician- By using open rather than closed questions, assistant at the patient interactions by describing a consultation case and listening attentively to the answers, ENPs University of study involving a patient with severe abdominal pain encourage patients to describe their symptoms and Wolverhampton who was admitted to an emergency department express their emotions fully, and, by doing so, reveal (ED) in Birmingham. significant information (Griffith et al 2003). The history-taking process revealed that the Case study patient’s pain, which he described as a vague, Observation central abdominal discomfort around the ‘belly A 19-year-old man presented to the ED complaining button’, had started two days before he attended of severe abdominal pain. the ED. He said that this pain had come and gone Before starting the consultation, an emergency in waves, and that he attributed it to a stomach nurse practitioner (ENP) observed the patient’s upset. Over the first 24 hours however, the pain posture for clues about aetiology. This was because had radiated to his right groin and had become patients who are in pain often adopt positions that persistent and severe. afford them the most comfort. For example: Other associated symptoms identified during n Patients experiencing parietal pain from peritoneal the history-taking process were a loss of appetite, irritation often adopt a fetal position. a reduction in bowel movement frequency, a fever n Patients experiencing visceral pain often lie supine of at least 38.7°C, and vomiting. The patient had with their legs outstretched. no haematemesis or rectal bleeding, which made n Patients with an occlusion in a hollow organ, a differential diagnosis of peptic ulceration unlikely. such as a bowel obstruction or one involving a gallstone or kidney stone, are often restless and Appropriate language and eye contact prefer to be upright (Liang 2005). The language used by the patient, such as ‘belly In this case, the patient had drawn his knees button’, was noted by the ENP, who therefore up to his chest, indicating the presence of used this and similar phrases, such as ‘lower groin’, peritoneal irritation. rather than clinical terms, such as ‘umbilicus’ or ‘right iliac fossa’. History taking In such cases, professional jargon should be To confirm the ENP’s initial suspicions, and before avoided because it emphasises the expertise of diagnosis and treatment were undertaken, clinicians over that of patients concerning patients’ This article has been a systematic consultation was made involving full health. Use of the patients’ own terminologies also subject to double history taking and the appropriate examinations of assures them that they are being understood fully blind peer review the patient. (Jucks and Bromme 2007).
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Appropriate eye contact is one of the most Positioning and observation important non-verbal skills for ENPs (Bensing et al Before undertaking examinations, it is important to 2005) and, in view of this, note taking while gain permission from, and explain procedures to, patients are speaking is an inefficient way of the patients concerned (Parrott 2004). conducting consultations. When clinicians look at To examine a patient’s abdomen properly, both their notes, patients tend to offer information more the patient and clinician must adopt the correct slowly and less completely, their fluency tends to position (Bickley and Szilagyi 2007). deteriorate, and the information they give becomes Patients should be placed supine, as flat as they more easily missed or forgotten (Griffith et al 2003). can tolerate and with their arms at their sides, while Poor eye contact can also be misinterpreted practitioners should sit down or bend at the knee by patients as a lack of interest in them, which so that they can apply an even pressure with the can also inhibit them from communicating fully flats of their hands. (Bensing et al 2005). In this case, observation of the patient’s abdomen In this case, appropriate eye contact was made revealed no scars or pulsations. It was distended with the patient throughout the history-taking however and, contrary to convention, inspection process, and note taking was postponed until the was followed directly by auscultation to avoid any patient had finished giving his history. distortion of bowel sounds caused by pressing on the abdomen (Estes and Cauthorne-Burnette 2005). Sequence of onset The patient’s abdomen was examined quadrant The sequence in which patients’ signs and by quadrant with the unaffected, left side being symptoms begin is significant in that it indicates palpated first. underlying causes. This approach gives a baseline measurement, In this case, the patient’s vomiting may have been allows for more effective comparison and prepares a reaction to peritoneal irritation caused by an patients for the examination of the affected side inflamed appendix. (Bickley and Szilagyi 2007). Irritation of the peritoneum in such cases can develop over 48 hours (Wright 2001) and, during Rebound and guarding this time, people often experience pain followed Deep palpation of the left iliac fossa was performed by vomiting. In contrast, gastroenteritis, a more for rebound tenderness, also known as Rovsing’s common and generally less serious complaint than sign. As expected, pressure over the descending appendicitis, causes inflammation of the stomach colon produced rebound pain in the right lower lining and the intestinal wall, which leads to acute quadrant, which indicated that irritation was vomiting followed by pain (Liang 2005). spreading across the peritoneum (Rovsing 1907). The patient confirmed that he had pain first The site of maximal tenderness is described as then vomiting, which meant that gastroenteritis McBurney’s point, and it lies typically two thirds of Box 1 was unlikely. the distance between the umbilicus and the anterior The OPQRST system superior iliac spine (Naraynsingh et al 2003). for history taking Pain According to Chung (2005), this point is where the The patient’s pain was exacerbated by coughing, appendix base is attached to the caecum. Each of the following sneezing and deep inhalation, and was eased by It was important to assess the patient’s muscle should be described: reduced motion and shallow breathing. tone because peritoneal irritation causes abdominal O Onset These experiences are characteristic of pain pain and involuntary tightening of the abdominal in the right iliac fossa caused by appendicitis wall muscles. This tightening, or ‘guarding’, was P Palliating and (Liang 2005). noted in the patient’s right iliac fossa. provoking factors Asking patients to assess their pain by using a Many clinicians regard digital rectal examination systematic approach can produce useful information, (DRE) as standard for confirming appendicitis Q Quality although pain perception and tolerance can vary (Martinolli et al 2007). Others argue that DRE is an R Region or site unhelpful and non-evident diagnostic tool, and that according to patients’ ages, cultures and moods of symptom (Baker and Green 2005). findings from the procedure should be treated with The most widely used pain assessment scale is caution (Sedlak et al 2008). S Severity the Universal Pain Assessment Tool (Rutledge and Digital rectal examination was not performed in T Timing of onset McGuire 2004), in which pain severity is recorded on this case, partly because of its minimal predictive and duration of a 0-to-10 numeric scale where 0 indicates no pain value and partly because of the associated symptom at all and 10 indicates the worst pain imaginable. discomfort for the patient. The patient had no Adapted from The patients’ perception of the severity of their testicular tenderness and elevation of the testicle Bates et al (2002) pain was assessed using the OPQRST model. did not increase pain, as would occur in a case of
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testicular torsion, or decrease pain, as would occur system for pain from appendicitis (McKay and Box 2 in a case of epididymitis (Turgut et al 2008). Shepherd 2007) and can reduce the proportion The Alvarado of appendectomies that are unnecessary to scoring system Confirming diagnosis 0.5 per cent (Lamparelli et al 2000). Scores are provided for Migration of vague peri-umbilical pain to the right In this case, the Alvarado score was seven out of each of the following lower quadrant and the presence of pain followed ten, which indicated that the patient had appendicitis. signs or symptoms: by vomiting are classic signs of appendicitis It was important to act quickly because untreated (Liang 2005). The likelihood of this diagnosis being appendicitis can lead to serious complications. M Migration to correct is increased by the presence of rebound Once appendicitis is diagnosed, appendectomy right iliac fossa tenderness and guarding on physical examination. should be undertaken, ideally within 24 hours A Anorexia Differential diagnosis of appendicitis depends of presentation (Howie et al 2003). If treatment largely on the age and sex of the patient does not begin within 36 hours of onset of signs N Nausea or vomiting (Crystal et al 2005). Moreover, young men with and symptoms of appendicitis, there is a risk of testicular problems, such as torsion or epididymitis, perforation, and therefore of sepsis and peritonitis, T Tenderness of can present with abdominal pain, so these a widespread and serious abdominal inflammation right iliac fossa diagnoses should also be considered. (Bickell et al 2006, Coor 2006). R Rebound pain In this case, the patient was male so gynaeco There is no evidence that analgesia affects logical aetiology could be ruled out. In addition, the clinician’s ability to diagnose appendicitis (Thomas E Elevated patient reported no testicular tenderness. and Silen 2003). Antibiotics are not given in the temperature The diagnosis of appendicitis was confirmed ED, however, because they confuse diagnosis by L Leukocytosis using the Alvarado scoring system (Alvarado masking the signs and symptoms of appendicitis 1986), in which scores between zero and seven (Crabbe and England 2006). S Shift left, or rise in number, are given for each of the system’s eight signs or In this case, therefore, the patient was made of leukocytes symptoms, identified by the MANTRELS acronym, nil by mouth and given pain relief. He was then and an average score is calculated (Box 2). This referred to a general surgeon and transferred to an Alvarado (1986) is the most widely used, clinical-based scoring emergency assessment unit for appendectomy.
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