A RISK MANAGEMENT APPROACH to ABDOMINAL PAIN in PRIMARY CARE Symptoms Most Predictive of Appendicitis Are Right Lower Torsion

EMERGENCY MEDICINE – WHAT THE FAMILY PHYSICIAN CAN TREAT UNIT NO. 6 A RISK MANAGEMENT APPROACH TO ABDOMINAL PAIN IN PRIMARY CARE Symptoms most predictive of appendicitis are right lower torsion. inammatory disease (PID) and appendicitis can be virtually for a patient with abdominal pain yields little information, aneurysm or a dissection in elderly patients presenting with quadrant pain (RLQ), and migration of pain from the indistinguishable via the anterior abdominal examination, and unless one is specically looking for air-uid levels indicative of ank pain. Up to one-third of patients with abdominal aortic SUMMARY Dr Lim Jia Hao periumbilical region to RLQ. Anorexia, which has been Palpation should begin with light palpation to localise the it will be the pelvic examination that can reveal the true intestinal obstruction in a patient exhibiting obstructive aneurysms may have haematuria, which can further confound classically taught to be useful in diagnosing appendicitis has region of tenderness and to elicit guarding. Deep palpation aetiology. While both conditions can result in painful cervical symptoms. Abnormal calcications associated with gallstone the physician. Detection of vascular emergencies can be dicult e assessment of abdominal pain in the primary healthcare been found to have little predictive value.6, 7 A gynaecological follows for the detection of organomegaly and masses. However, motion and adnexal tenderness, it is the presence of disease, kidney stones, appendicoliths, as well as aortic if the diagnosis is not entertained from the outset. setting will require the family physician to employ the ABSTRACT just as important to recognise the patients that require a referral and sexual history should be obtained when evaluating women, this can be deeply distressing to the patient with severe mucopurulent discharge from the cervix that will allow the calcications can sometimes be seen on the plain lm as well. traditional clinical methods of careful history taking and Abdominal pain is a common presentation to the family to a surgeon and/or admission, as it is to determine an exact physician clinic and emergency departments and although with point-of-care pregnancy testing for those of childbearing peritonism, with limited diagnostic value. Adequate analgesia physician to diagnose PID. Often, the other investigations indicated in the evaluation of It is absolutely reasonable to have a low threshold to refer the physical examination. e investigative resources available to diagnosis. common, it is often a symptom of serious disease, with many age. should be given prior to examination, and palpation should patients with acute abdominal pain such as ultrasonography or elderly patient with abdominal pain to the Emergency the physician can be sometimes limited, and the return of results diagnostic challenges that the physician has to overcome. The progress from the non-tender region to the region of concern. Diagnostic Tests computed tomography will yield more information.12 If the Department for evaluation. Low-risk abdominal pain or can take time. e family physician will therefore have to missed surgical abdomen often results in high morbidity and DIFFERENTIAL DIAGNOSIS AND Other features in the history that should heighten the clinical Well-localised tenderness can generally guide the formulation of In the primary healthcare setting, not every family physician plain radiograph is to be used routinely, one has to appreciate undierentiated abdominal pain can be managed with determine the need of these outpatient tests based on his or her mortality to the patient, and high medico-legal risk to CONSIDERATIONS assessment of the overall clinical picture, and weigh the risks and physicians. In certain patient groups, such as the elderly, the suspicion for a more ominous pathology will be any evidence of a diagnosis, but generalised tenderness can prove to be a will have readily available on-site access to a laboratory where the limitations. admission, or with serial examinations and observation in the benets of performing these tests at the clinic versus referring women of childbearing age and the immunocompromised, Causes of abdominal pain can be due to pathologies from gastrointestinal bleeding (coee ground vomitus, melena), diagnostic challenge. Peritoneal irritation is elicited by looking the results can be processed and returned to the clinic within the ED setting, which can allow for mitigation of risk to the patient. HIGH-RISK CONDITIONS the patient to the emergency department for further evaluation. presentation of abdominal pain can be atypical, and hence various systems. Although the gastrointestinal (GI) and hypovolaemia (postural symptoms, syncope, giddiness), fever, a for rebound tenderness, by performing gentle depression over hour. Similarly, not all primary health centres will have on-site additional caution and consideration should be taken. In order Special attention needs to be given to patient groups where genitourinary (GU) systems are the leading causes of worsening progression of pain, and pain out of proportion to the area of concern and suddenly releasing the hand after 15-30 radiology facilities, and in order for diagnostic imaging to be Always do the urine pregnancy test in women of childbearing age to mitigate risk in the challenging primary healthcare documentation of the information gathered, as litigation the abdominal examination ndings. seconds. e pain of rebound tenderness is worse on release. As done, the patient has to be referred to a radiology unit Acute appendicitis Avoid omitting pregnancy testing based on patients’ reports of there is altered physiology, or impaired perception or environment that the primary physician faces where abdominal pain, it is important to remember extra-abdominal Due to age-related immunological changes (or arising from physicians missing or misdiagnosing high-risk this can be quite a painful test to elicit, some advocate gentle elsewhere, and return to his or her physician with the images Acute appendicitis is the most common cause of the “surgical symptoms. At the emergency department level, the use of the ultrasound. However, the bedside ultrasound machine is not sexual abstinence, contraceptive use or last menstrual periods, as verbalisation of pain. investigative resources can be limited, a careful diagnostic and systemic causes as well (see Table 1). Physical Examination approach with regards to history taking and physical immunosenescence), common physiological responses and diagnoses such as appendicitis and ectopic pregnancy is often percussion over the area of concern instead. Carnett’s sign is and radiology report in hand. is results in a signicant delay abdomen”. However, it is commonly initially misdiagnosed in Alvarado score can provide a guide towards the subsequent widely available to all family clinics or medical centres. If it is missing a ruptured ectopic pregnancy is catastrophic. If the tests REFERENCES examination is used, coupled with good documentation of Of particular importance are 3 patient populations where the laboratory ndings in sepsis — such as hyperthermia, elevated due to deciencies in the history taking and data gathering, as e physical examination rst begins with an assessment of the increased tenderness to palpation when the abdominal wall to the time it takes for the physician to process the data needed up to one-third of cases, with the commonest diagnosis investigations and disposition of the patient, where low-risk available, it is a quick and easily performed test at the bedside. are negative, consider a referral to the appropriate centre for a 5 1. Colucciello SA, Lukens TW, Morgan DL. Assessing abdominal pain findings and patient discussion. spectrum of pathologies can be signicantly dierent from the total white cell counts and elevation of inammatory markers opposed to misinterpretation of data. patient’s general appearance and vital signs. e physician muscles are contracted as the patient lifts his/her legs o the bed for him or her to come to a working diagnosis and management attributed to gastroenteritis. It is important to remember that patients can be observed in extended observation units for serial As always, the utility of ultrasonography to aid diagnosis is pelvic ultrasound to exclude other gynaecological disorders. In in adults: A rational cost-effective, and evidence-based strategy. Emerg majority of patients, which can result in misdiagnosis and — might be blunted. Consumption of certain medications should take note of the patient’s position and movements, facial as you palpate the abdomen – it is indicative of abdominal wall decision for the patient. However, it must be emphasised that the diagnosis of gastroenteritis requires the presence of nausea, abdominal examinations, and patients who are indeterminate in aected by the ability of the user, as well as the patient’s body patients where they have already been diagnosed with Med Pract. 1999;1(1):1-20. Keywords: 2. Rothrock SG, Green SM, Dobson M, et al. Misdiagnosis of appendi- poorer outcomes, and therefore extra attention and caution is that can alter the heart rate due to common comorbidities It is the combination of all the data — history, physical expressions and respiratory patterns. On the other hand, the tenderness, as opposed to abdominal tenderness secondary to there are signicant limitations to blood tests and imaging vomiting and diarrhoea. Patients who are commonly risk undergo further diagnostic imaging studies. e Alvarado habitus.

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