Family Practice Grand Rounds A Clinical Correlation Conference on Appendicitis

Willis W. Willard, MD Donald A. Kennedy, PhD

Hershey, Pennsylvania

The Clinical Correlation Conference ed 90 minutes and was recorded on A discussion of this case is consis­ at The Milton S. Hershey Medical Cen­ color videotape. tent with our educational objectives ter of The Pennsylvania State Univer­ The central person in the case pre­ because it illustrates several concepts sity is a teaching method originated by sentation was Mike Snyder who was important to your training. First, we the Department of Family and Com­ recovering from appendicitis. Four out would like to demonstrate that com­ munity Medicine in 1967. In recent of five members of the Snyder family mon problems are not necessarily years, Correlation Conferences have were present. The mother, father, and simple problems. In dealing with a been presented on a weekly basis dur­ a younger brother, Greg, were seated common problem, we should have a ing two of the three academic terms. in front of the amphitheater. The high index of suspicion or concern to The conference is designed to en­ oldest son, Douglas, could not be compensate for familiarity with the hance the relevance of basic science present. The physicians making the problem. Second, we would like to material for first and second year presentation included Dr. Hiram Wiest, trace the natural history of this prob­ medical students. An attempt is made the Snyder’s family physician for 7 lem as it developed and to emphasize to present future clinicians with realis­ years, Dr. Donald Bley, the family the relationships among our staff, and tic and practical clinical situations medicine resident on call at the time the relationships within the family which, of course, do not always follow Mike became ill, and Dr. Willis Willard, group. Third, we want to discuss textbook presentations or outcomes. the faculty consultant on call at the abdominal pain in general, for this is a Interpersonal relationships within the time of initial contact with the pa­ very common problem in most family family and among health care provid­ tient. Dr. Rugh Henderson, a member practice settings. Fourth, we want to ers are important to medical care out­ of the teaching faculty, helped orga­ show that common problems, even come1 and are regularly included in nize the Conference and provided the when they are conscientiously the Correlation Conference. The illness introductory statement. approached by both the physician and process and the relationships between the family, can result in complications. the patient and the health care provid­ Introduction This case is a clear demohstration that ers are viewed in as close to their natu­ DR. HENDERSON: The situation in the real world everything does not ral state as possible. that we are presenting today is similar turn out exactly as we would wish. This paper illustrates this educa­ to a type of problem that you will With that introduction, I turn the con­ tional method and represents an edited come across in the office of the family ference over to Dr. Wiest and Dr. Bley. account of a conference on “Appendi­ physician if you elect a primary care DR. WIEST: We certainly appreci­ citis” that was held in a large amphi­ preceptorship. Before getting started, I ate the fact that nearly all of the theater in The Hershey Medical Center want to thank the Snyder family for Snyder family were able to come on October 11, 1973. The class was agreeing to participate at a time when today. The oldest son, Douglas, who is composed of first and second year they are in the process of coping with 17, is absent, but we are glad that the medical students. The conference last- their son’s illness. We can appreciate rest of you could come. Mike, if you the fact that this is not the easiest time get too tired and want to leave at any to discuss this problem before a group time, please speak up. First I should of medical students. We also appreci­ say that I have known the Snyder trom the Department of Family and Com- family for the seven years that I have munity Medicine, The Milton S. Hershey ate the willingness of faculty members Medical Center, The Pennsylvania State and a resident physician to participate been practicing in Hershey. They have University, Hershey, Pennsylvania. Requests also played a part in the education of for reprints should be addressed to Dr. Willis in careful analysis of this case. The W- VUillard, Department of Family and Com­ course of events has been complicated medical students. Dr. H. Theodore munity Medicine, The Milton S. Hershey Medical Center, Hershey, Pa 17033 and not without some surprises. Harcke, a member of our first class,

59 th e JOURNAL OF FAMILY PRACTICE, VOL. 2, NO. 1, 1975 was assigned to the Snyder family at the right side. He had vomited three what happened in the office’ the time Mrs. Snyder was pregnant times and had a very low-grade fever. MIKE SNYDER: I got real bjd with Greg. She developed diabetes dur­ He had not had his appendix out and chills and I guess I had a fever in the ing her pregnancy, so Ted had the this was a consideration. Knowing that morning. opportunity to see Greg delivered by we were undergoing an epidemic of DR. WIEST: Initially, his tempera- cesarean section. Mr. Snyder and I viral gastroenteritis in the community ture was recorded at 100 F, but whip have been in frequent consultation at the time, I thought Mike might be the nurses were preparing him for about a bad back. But, today, we are experiencing an attack of gastro­ examination, he did start having! here to discuss Mike’s abdominal pain enteritis. Mrs. Snyder asked whether shaking chill. When I walked into the and appendicitis. she should give her son a laxative or room, I felt his forehead and thought enema and I cautioned her against this. that he felt hotter than 100 F. When Case Presentation I told Mike to restrict his oral intake, we checked his temperature again it DR. WIEST: Mike, would you like to rest, and to let me know later that was actually 103.6 F by mouth. | to tell us when your pain started? day if the pain got worse. Later in the examined his abdomen and by that (Mike is wearing pajamas and is sitting afternoon, and again the next day, I time he did have classical signs of in a wheelchair. He is receiving intra­ discussed the case with Dr. Willard. He appendicitis. He had no peristaltic venous fluids through equipment was a little concerned that this had sounds when we listened to his abdo­ attached to the wheelchair.) been going on so long and suggested men. On deep palpation in the right MIKE SNYDER: On Saturday that I call to find out how Mike was low er side, he did have rebound night it started to hurt around 8pm. doing. Mike told me that he was still tenderness. I thought, because he was DR. WIEST: Were you the only one experiencing discomfort, but felt so sick and because he was having in the family who was sick at that perhaps a little better. Later in the chills and probably going to have sur­ time? afternoon on Monday he became gery, that I would not do a rectal MIKE SNYDER: Yes. much worse and he came in to see Dr. examination. We contacted a surgeon DR. WIEST: Had anyone else been Wiest. and sent him over to the emergency having this type of pain? DR. WIEST: Do you remember room where he was seen in surgical MIKE SNYDER: No. how things changed that Sunday consultation. DR. WIEST: What did you do when night? Were you able to sleep? DR. WIEST: How long did you the pain started? MIKE SNYDER: No, not at all. wait in the emergency room? Do you MIKE SNYDER: Nothing, I just lay DR. WIEST: Did the pain change remember? down. I took some Pepto-Bismal, but any during the night? MIKE SNYDER: I guess maybe an that didn’t help any. MIKE SNYDER: During the night hour, I don’t really know. DR. WIEST: Where did the pain it shifted to the one side. MRS. SNYDER: It was an hour and start? Do you remember where it was DR. WIEST: Where did it shift to? a half because the doctor had gone out when it first began? MIKE SNYDER: To the right side. the door. It was about an hour and a MIKE SNYDER: Just all over my DR. WIEST: And did you tell your half. “belly,” just all over. mother and dad that things were get­ DR. WIEST: What were you think- ! DR. WIEST: When did you finally ting worse? Sometime Monday, did ing then? decide that you better get something you tell them that you thought things MRS. SNYDER: I didn’t knowhow done about your “belly” pain?* were not doing so well? long it would be. The anesthesiologist MIKE SNYDER: That was on Sun­ MIKE SNYDER: I guess it was assured me that everything was under day afternoon, I think. around 2 o’clock. control and that they were definitely DR. WIEST: And what did you do DR. WIEST: Monday afternoon? going to operate. then? What were your parents’ thinking at DR. WIEST: At surgery they found MIKE SNYDER: We went to the this time? Dad, what were your a distended and inflamed appendix. doctor. thoughts at this time? They also found some fecaliths ob­ DR. WIEST: And which doctor did MR. SNYDER: Well, he made me structing the lumen of the appendix you see? mad. and a small hole where perforation had MIKE SNYDER: Dr. Bley. DR. WIEST: Why? occurred. There was a small amount of DR. WIEST: Dr. Bley, do you want MR. SNYDER: Oh, he was getting pus and an inflammatory reaction to tell us what happened next? up more, and throwing up often, and secondary to that. It was a retrocecal DR. BLEY: Mrs. Snyder said that complaining about the hurting. We appendix which means it was tucked her son was having abdominal pain and asked, “How bad are you?” I said, up in back of the cecum. What is the I suggested that she bring him in. I saw “Do you want to go to the doctor or next thing you remember Mike? him about 12:30 Sunday afternoon. should we call?” He said, “No.” He MIKE SNYDER: I really don’t He did have diffuse abdominal tender­ didn’t make up his own mind. Finally know what happened. ness but no real localizing signs. His I said, “It’s time.” DR. WIEST: The next day you pain had not shifted significantly to DR. WIEST: Do you remember remember feeling better or worse? your visit to the office on Monday? MIKE SNYDER: It was a lot bet­ 'Technical terminology is usually avoided in Do you remember much about it? ter, I think. these conferences so that the family and the first year medical students will be able to MIKE SNYDER: Yes. DR. WIEST: And what did they do follow the discussion. DR. WIEST: Do you remember for you in the hospital during the first

60 THE JOURNAL OF FAMILY PRACTICE, VOL. 2, NO. 1, 1975 admission? DR. WIEST: Would anyone in the DR. WILLARD: Sunday the pain mike SNYDER: What do you audience like to ask any questions at was more diffuse and that’s the day this point? you called Dr. Bley for the first time. mSpR WIEST: How did they treat A STUDENT: How old are you? Then Sunday night you did not sleep you1? Remember intravenous fluids? MIKE SNYDER: Fifteen. because of pain and then Monday MIKE SNYDER: Yes, they did that A STUDENT: Do you do your morning you described the pain as and I was supposed to walk. I couldn t schoolwork while you are in the having shifted. drink or eat anything. That is about it. hospital? MIKE SNYDER: Yet, it was Mon­ DR. WIEST: But you did feel grad­ MIKE SNYDER: I didn’t make up day morning. ually stronger and better? any work yet. I’m not really worried DR. WILLARD: When the pain MIKE SNYDER: Yes. about it, I’ll make it up when I get shifted, did you seem to feel better, DR. WIEST: And how many days out. the pain less discomforting, and did after the operation did you go home? A STUDENT: You said you had you think “maybe this will blow MIKE SNYDER: I guess six or trouble walking. Is that because you over”? seven. I am not sure. had weakness in your legs? MIKE SNYDER: Yes. DR. WIEST: Seven days later, just MIKE SNYDER: My legs were DR. WILLARD: When? one week later. You were then free of okay, it’s just that I couldn’t straight­ MIKE SNYDER: It was Monday fever and feeling good. Your bowels en up right. I couldn’t stretch out the morning. Then as the day went on, it were moving and you were eating a muscles very well and it was really sore got worse and in the afternoon we regular diet. What happened next? I when I stretched them. called Family Medicine. am not sure I know this next part of DR. WIEST: Was it both legs or just DR. WILLARD: You saw Dr. Wiest the saga. one leg? then? MIKE SNYDER: I went home and MIKE SNYDER: Just the one leg, MIKE SNYDER: Yes. I was feeling a little bit better. I the right leg. DR. WILLARD: Early afternoon? couldn’t walk very well, though, and A STUDENT: Were you feverish at MIKE SNYDER: Yes, around 2 then the next day I noticed a swelling that time? o’clock. on top of the cut (incision) and I had a MIKE SNYDER: No, I don’t think DR. WILLARD: At that time fever. so. No. things were getting to feel a little DR. WIEST: And you were seen by DR. WIEST: I think that Mike is worse? the surgical resident on Tuesday night? describing a common situation after MIKE SNYDER: Yes. MIKE SNYDER: Yes. abdominal incision. He probably put DR. WIEST: Mike wants to know if MRS. SNYDER: About 11 P M. tension on the skin and this hurts until we know how much this is going to DR. WIEST: And he was again the wound knits together well enough. cost. admitted to the hospital. The wound People with abdominal surgery are MR. SNYDER: No, I don’t. Just had a lot of pus draining out of it since pretty tender. like everyone, it is covered by insur­ an abscess developed following the MRS. SNYDER: I might add one ance - all but seven dollars which we appendectomy. Do you feel better thing. He was worried that he was have to pay. now since the thing has started drain­ lopsided. We tried to explain to him MRS. SNYDER: We keep a little ing? that he was favoring one side because joke between us every time we come up to see Mike. We say it is costing us MIKE SNYDER: A lot better. of the pain. This was making his body DR. WIEST: How do your mother lean over. He couldn’t understand this seven dollars a day and is going to be taken off his Christmas present. The and father feel? because he felt as if his whole body first time it was $49. So each time it is MRS. SNYDER: I knew something was just twisted. just taken off his Christmas present. In was not right, when he came home DR. WIEST: Was this before truth, the insurance pays for most of Monday - the way he walked and the surgery? pain, even while he was sitting or get­ MRS. SNYDER: No, this was after it. DR. WIEST: I think we have kept ting up, he had pain in the rectum and he came home. Mike here long enough. We certainly just looked so pale I knew something DR. WIEST: Did you have trouble walking before you were admitted appreciate having Mike and his family was not right but we let it go. I guess come to participate in this conference. Tuesday night is when he said he really because of pain in your right side? MIKE SNYDER: Yes. Let’s give Mike and the Snyders a nice thought he was worse and right then round of applause. (The Snyder family he had a fever. I called the emergency DR. WILLARD: Going back to the leaves the amphitheater.) service right away. First I called original illness, Sunday night through DR. WIEST: I would like Dr. Bley Family Medicine and they said to take Monday, you described the shift in to tell a little about the outcome of him over to the surgeon on call. your pain. As the pain shifted, and the situation and what this has meant DR. WIEST: Greg, did you miss after it shifted, do you recall a period to him as a physician. your brother when he went back to when the pain seemed to be a little the hospital? better? DR. BLEY: When I first met you, your head was shaking and you were GREG SNYDER: Yes, sometimes. MIKE SNYDER: Let me see. It saying something to the effect that DR. WIEST: Do you fight with shifted over and it wasn’t really bad you had just learned Mike had been each other? Or are you good friends? and that’s when I felt better - but admitted to the hospital and had had GREG SNYDER: Yes, sometimes. then it got worse.

61 THE JOURNAL OF FAMILY PRACTICE, VOL. 2, NO. 1, 1975 this “middle of the night” surgery. quent and there is often less abdomi­ has had some discomfort for f0Ur , Yes, I agree that I did not pick it up nal wall guarding. Twenty-six percent five hours. She will remind you tw on Sunday. Looking back on it, his of acute appendicitis cases are retro­ Suzie had trouble last year when she signs were not clear cut. Perhaps I cecal.2 That means that a quarter of first went to school, but then she got should have personally called him Sun­ the cases we are dealing with are along fine. Suzie had also been in to day evening and asked him how he was subtle. In the best of hands, the cor­ see you last week for her annual doing and asked his mother how he rect preoperative diagnosis is made physical and you said everything Was was doing. But I had told them quite only 50 to 85 percent of the time.3 I just fine. Again, you will be asked emphatically that if things got worse think this supports Dr. Henderson’s what can be done to make Suzie feel or if they were sure things were not assertion that common problems are better. This is the initial stage 0f getting better to please call me back. not necessarily simple. Appendicitis communication with patient or paren: Having not heard anything throughout occurs in this country about 200,000 We have a saying in medicine that the rest of Sunday afternoon and times a year. The rate may be even when all else fails, we should examine Sunday evening while I was on call, I greater because it is increasingly evi­ the patient. It is important for youto assumed that everything was doing dent that many people recover spon­ convey this requirement to the patient well. I think one of the interesting taneously from a mild case of or to the family. If pain has been going things that came up was that this was appendicitis. In terms of age and sex on for six hours or more, you must such a hectic time for the family them­ spread for this disease: 18 percent of examine.5 Knowledge of intercunent selves; they were managing a busy cases of appendicitis occur all the way illness in the community is often help­ campground at the height of the from in utero to 12 years of age, 69 ful, but taking a careful history and season. They had a lot of things going percent of cases between the ages of doing a careful physical is essential. on, and they were quite preoccupied 13 and 39, and 12 percent of cases A STUDENT: When you do get with their business along with the occur over the age of 39. Between the someone with a little stomach pain, problem of having a sick son. ages of 15 and 25, the male pre­ how concerned should you be about A STUDENT: Would it be safe to dominates two to one.4 the possibility of appendicitis? assume that most people in a similar Some comments about doctor- DR. WILLARD: In our own prac­ situation would tend to underestimate patient communication are relevant tice, we see about one case every two the severity of their own problem or here; how does the patient get into perhaps hesitate a little bit in getting months. When you see something that your care? We are often limited by often, it is considered common and back to the physician? when the patient asks for help, and DR. BLEY: Are you talking about you develop a strong index of suspi­ this a serious limitation because pa­ cion. Features of the patient’s history the patient — would he tend to under­ tients frequently wait a long time. estimate? will tend to raise or lower this index of Patients will ask many other people suspicion. A STUDENT: Right, he said he for help before us. Only when the thought it would go away. I think that A STUDENT: I just wonder what condition persists or gets worse do you would include in the list of alter­ would probably be the reaction of they decide to “bother” a physician. I most people. native possibilities. think it is important for us to recog­ DR. WILLARD: Dr. Bley com­ DR. BLEY: I don’t know. I would nize this natural and personal consulta­ imagine so. I can tell you from per­ mented that he was thinking of some­ tion sequence that precedes contact thing very common in the community sonal experience that I waited 36 with the physician. hours with a ruptured spleen before I and that was viral gastroenteritis. We If a condition persists or worsens, had anything done with it. I was wait­ have a lot of this here. So this condi­ initial contact with the physician is ing for it to go away too. And this is tion also had a very high index of usually by telephone. First, the secre­ suspicion. Appendicitis can be a com­ what he was doing on Monday when I tary answers and asks what the prob­ called him back. plication of viral illnesses due to lem is. The patient or another member lym phoid tissue obstructing the DR. WILLARD: And you just of the family will then describe the appendiceal lumen. Really, appendi­ caught him when things were momen­ difficulty. Mrs. Jones may say that her citis can mimic just about any other tarily better. I think we all expect daughter Suzie has not been feeling disease or problem in the abdomen or these events to subside and this is the well and complains of pain in her in the chest. Pneumonia can present as approach we frequently use. Also, I stomach. The pain has been going on an acute abdomen. A gall bladder think this points out the fact that for three or four hours and she wants down in the right iliac fossa mimics events taking place in the family situa­ to know what she can do to make appendicitis. Any acute gynecologic tion may be influencing the patient’s Suzie feel better. Hopefully the secre­ disorder must also be considered. response to his problem. tary or nurse will ask some further Porphyria, a metabolic disorder, can Discussion questions about the problem. Has mimic appendicitis. Basically, the Suzie been vomiting; has she had any­ physician should be sensitive to: the DR. WILLARD: This young man thing like this before; is anybody else history given by the patient; the physi­ had a very difficult problem. A retro­ sick in the family? A brief message is cal exam; the patient’s age and sex; cecal appendicitis is notoriously diffi­ written and a request is made for you, and the family history. Remember, cult to discover early because the the physician, to call Suzie’s mother. appendicitis tends to run in families." patients have relatively nonspecific, When you call the patient back, Mrs. This disorder illustrates the extreme mild pain. Vomiting tends to be infre­ Jones is going to tell you that Suzie relevance of understanding certain

62 THE JOURNAL OF FAMILY PRACTICE, VOL. 2, NO. 1, 1975 facts from embryology, anatomy, nature of the discomfort that often when potentially serious symptoms physiology, and pathology. From the characterizes the very early symptoms persist and before you recommend standpoint of embryology, as you of appendicitis - a very vague, almost treatment. I can assure you that there know, the intestine is derived from im perceptible crampy discomfort. will be all kinds of reasons why you a disk of entoderm on the roof of Because this represents true visceral will be asked to prescribe by phone: the yolk sac. It reaches its final place­ pain, the discomfort radiates to the “My husband has the car, I don’t have ment through a complex mechanism periumbilical area or to the low epigas­ any transportation. I was in just a of counterclockwise rotations. The trium. The patient does not perceive week ago, everything was fine then. appendix, as part of the intestine, the pain down where the appendix is Can’t you just prescribe something for “flops” down counterclockwise from actually located. This stage in the me?” You have to take a firm stand above. This is what happens 96 per­ development of appendicitis can last and help this person appreciate that cent of the time. In a small fraction of anywhere from several hours to several you must see what is happening. cases, roughly 4 percent, the rotation days. The literature describes an aver­ Occasionally, a patient will choose to is not complete and the cecum and age of one to four hours for this go elsewhere or telephone another appendix end up in the right upper process.8 I followed a patient once physician. You have to learn to accept quadrant of the abdomen. In a very who was in this first stage for seven and live with that prospect if you are small number of cases, about .03 per­ days before there were indications we going to practice the sort of medicine cent, the cecum and appendix are over could use to make a diagnosis. The your patients deserve. in the left lower quadrant. In less that diagnosis of appendicitis was con­ Let me give you another case in 1 percent, the appendix lies in the left firmed during surgery. abbreviated form. Say you see Mrs. upper quadrant. Some .004 percent of Once a true visceral pain pattern Jones and her daughter, Suzie, in the patients have two appendices, and has developed, the patient will often office late in the morning. You exam­ .008 percent have none at all.7 Of have some anorexia or loss of appetite. ine her. She has a soft abdomen and course, when you are dealing with a Frequently we learn that breakfast or has lost some of her appetite, but given person, you have no way of supper was skipped because the there is no nausea or vomiting. She has knowing about the presence or patient just did not feel hungry. This no fever. Her pulse is normal. You get absence of these statistically rare seems to be the symptom that pre­ a blood count because it is wise in case events. You certainly do not know cedes the actual perception of nausea, of later problems to have a base-line about these characteristics at the and the nausea may or may not lead to blood count. The blood count comes beginning of the disease process. But vomiting. Very often there is a loose back normal. The patient has diffuse you do have epidemiological informa­ stool the day or two before, but not abdominal pain but when you examine tion for estimating probabilities. necessarily. Very often there is consti­ her, there is pain in the right lower The appendix itself then can lie in a pation, but not necessarily. This may quadrant. There is no rebound, but variety of positions. The appendix can depend in large part upon where the just pain on deep palpation and during lie over the pelvic brim as well as in appendix is located. If it is retrocecal, some of the other maneuvers that are the retrocecal position. The location the patient may have some diarrhea done to help identify the location of of the appendix is going to determine because the cecum and the ascending the appendix. All these findings are the character and the type of pain that colon are irritated. It it is located away essentially negative or equivocal. So occurs after there is parietal peritoneal from the bowel, there may be consti­ you ask Mrs. Jones to bring Suzie back irritation around the appendix and the pation. If it is lying right over the later in the afternoon. You tell the visceral peritoneum. A large variety of ureter, the patient may have increased patient not to eat anything, maybe a pain patterns are possible. I have yet urinary frequency, and you may few sips of water, and to come back to to see two identical cases of suspect that this patient is developing be examined again at about 4 o’clock. appendicitis. a urinary tract infection. The third Suzie comes back and at 4 o’clock her The appendix usually becomes stage of pain in appendicitis is known temperature is 99.4 F, her pulse rate is inflamed due to obstruction. I think as the peritoneal cutaneous reflex pain 86 per minute. The pain is a little appendicitis illustrates beautifully the of Morley. This means that the pain more intense in the right lower quad­ pathophysiology of hollow tube ob­ begins to localize where the appendix rant. You then call a surgical consul­ struction. Any time you take a hollow is actually situated and thus reflects tant because you now suspect the viscus and obstruct it, a number of the area of the parietal peritoneum patient of having appendicitis. things happen. If it has a blind end, directly involved.9 The case I just gave you actually there will be an increase in intra­ Now I would like to give some happened in our office two weeks ago. luminal pressure. This, then, begins to general comments about how you This young girl had her appendix out shut off the flow of capillary blood should approach the patient with that evening. The point to remember is resulting in ischemia. In the appendix, abdominal pain. We made the point the importance of careful and repeated such a condition results in edema that the patient does have to be ex­ examinations of the patient. You will formation and accumulation of mucus amined. I would urge you to remem­ have some families where you can and secretions inside the appendix. ber this rule. There is an additional trust a telephone follow-up. If you Any time a hollow viscus is obstruc­ principle: “If you don’t know what is know the family well and they are ted, distension increases peristalsis in wrong - don’t treat.” If you are going reliable in taking temperatures and an attempt to propel out the obstruct­ to be responsible for the care of the reporting changes, you may not need ing objects. This produces the crampy patient, you must examine the patient several office visits or house calls to

63 th e JOURNAL OF FAMILY PRACTICE, VOL. 2, NO. 1, 1975 monitor a developing illness process. If neutrophil morphology. But this of various kinds. Tumors and congenj. there is any doubt in your mind, you occurs later on. You often call a con­ tal bands are also among the causes^ should do an examination. This can sultant in when the blood count is still obstruction which set off the who’; mean three or four exams in a course normal. process of stasis and infection. Whet of several days. A STUDENT: Can we go back to ever a hollow tube is obstructed, there A STUDENT: I understand the cost the physical exam? Dr. Wiest said he is a serious possibility of infection of emergency room visits is $20. Does did not do a rectal exam. Would you This principle also applies to the pari. the cost of a return visit influence please comment on when to do a nasal sinuses, the biliary tract, the ur­ your decision? rectal exam. nary tract, and the pulmonary bron­ DR. WILLARD: All you can do is DR. WILLARD: If you have an chial tree. This is a principle to keep® advise. As a physician, it is not your appendix that hangs over the pelvic mind when you are dealing with vari­ fault that the patient got ill, and it is brim into the pelvis and you can touch ous organ systems of the body. not your fault that emergency room this appendix with your finger, you visits cost $20. It is your responsibility may be able to palpate a mass that is to try to help this patient get the best exquisitely tender. This must be Acknowledgment We wish to express our appreciation to I care possible. If your professional distinguished from merely painfully Mike Snyder and the members of his family I judgment indicates that the patient distending the peritoneum by using for their willingness to participate in the I conference and to give consent for the pub 1 needs to be reexamined and it is going the examining finger. Appendices can lication of this case report. to cost money, that’s the way it is. I range in length anywhere from 2.5 to appreciate your concern about costs. 22.5 centimeters and they can be It is a valid concern. It is something we located anywhere.1 0 I have seen them References all think about. 1 believe that an located under the ascending colon 1. Conn H F, Rakel RE, Johnson TW I examination for this disorder is much approaching the liver. The lumen (eds): Family Practice. Philadelphia, W B I more valuable than a $50 battery of ranges from 5 to 15 millimeters in Saunders Company, 1973 2. Bockus H L: Gastroenterology, ed2. I laboratory tests. diameter and can become obstructed Philadelphia, WB Saunders Company, 1964, | vol 2, p 1090 Twenty-five percent of all white readily. The method of obstruction is 3. Bockus: op. cit. p 1 100 blood counts in acute appendicitis often a fecalith which is a combination 4. Bockus: op. cit. p 1092 5 . Cope Z : The Early Diagnosis of the cases are normal. In the 75 percent of of food particles, mucus, and bacteria. Acute Abdomen, ed 14. London, Oxford I cases with elevated blood counts, the In the first recorded case of appen­ Medical Publications, 1972, p 3 6. Bockus: op. cit. pp 1092-1093 elevation is often a very modest dicitis in 1736, a common pin caused 7. Bockus: op. cit. p 1090 11,000 to 13,000 total white blood 8. Bockus: op. cit. p 1097 the perforation. Pinworms may ob­ 9. Ibid count with a “shift to the left” of the struct the lumen as well as concretions 10. Bockus: op. cit. p 601

64 THE JOURNAL OF FAMILY PRACTICE, VOL. 2, NO. 1, 1975