Abd pain

[Clare]

Nothing is medicine is ever 100% but given we are dealing with a child, we're not going to be thinking atypical myocardial ischaemia, leaking aortic aneurysm, pancreatitis, cholecystitis etc. An important point to note is there have been case reports of children spontaneously dying suddenly from aortic aneurysms from undiagnosed connective tissue disorders such as EDS or Marfan's syndrome (although I don't think undiagnosed Marfan syndrome is very likely!). FMHx here is the kicker given both are inherited (if I remember correct). Like most things in medicine, this goes to show that diagnosis usually hinges on the history.

I'd recommend the child is reviewed by a Doctor, preferably his own GP who knows him well provided this can happen today. If it cannot, he should go to an Accident and Medical Clinic (urgent care) provided this can happen the same day. If neither of these options is available, he should be seen in an ED today. It is likely that he will be referred there anyway for an opinion by the duty surgical registrar. I would contact his GP or an A&M to see if they are comfortable seeing him there, no point sending him there if he's just going to go to ED to be s/b the surgical reg!

If the parents do not want this to happen then there is very little we can do it about it, as in nothing. Not really at the level where we could involve the Police or Child, Youth and Family for something this simple. If it was a case of neglect or abuse or something then yes.

At the end of the day his parents have the right to make a informed choice regarding their child's healthcare until the child is at an age he can do it himself.

I wouldn't feel that uncomfortable leaving a kid with a tummy ache with mum and dad.

Nothing to get bent out of shape about.

 

[ERDoc]

While I appreciate this sort of thing to help demystify bedside examination, I am always a little wary of trying to pin sensitivity/specificity figures on physical exam findings (or even components of the history). These are inevitably skill-dependent tools, just like interpreting an ultrasound or an ECG.

As Sapira put it, it's never particularly hard to find somebody who can't do something. (I had a roommate, for instance, who couldn't seem to wash dishes -- yet dishes are intrinsically washable.) This is probably increasingly true nowadays when few clinicians have serious training or experience relying upon their exam in isolation. You don't want to "validate" the sensitivity of Skodaic resonance in the Facebook generation; you want some old crusty fellow who drives a Cadillac and is still skeptical of CAT scans.

Of course, it's easy to take this to the other extreme and pull the old "I don't care what the RCTs say, I've seen this drug work!" Some areas just aren't very amenable to study.

I was just putting it out there to show that despite the dogma that is taught in EMT class, things are never black or white. Not all pts read the textbooks and not all are built the same. Some people have retrocecal appendices and can have llq tenderness. The large majority of pts I have seen with acute appy have not been febrile.

 

[Brandon O]

I was just putting it out there to show that despite the dogma that is taught in EMT class, things are never black or white. Not all pts read the textbooks and not all are built the same. Some people have retrocecal appendices and can have llq tenderness. The large majority of pts I have seen with acute appy have not been febrile.

I guess that's my point. When someone tries to do a study showing that "X finding is Y sensitive/specific for Z!", it's inevitably by trying to dichotomize it into a binary result. Very little of anything we do (that works) is binary; it's a constellation of mutually-interacting spectra of data, and much of the task of interpreting it has to be learned experientially, as it's rather difficult to put down on paper.

As you said, this is why this thread is so unanswerable; we'd have to put our eyes on the actual patient, and even then we might disagree.

This is also the only reason our jobs haven't been replaced by computers yet...

 

[AcadianExplorer1910]

(Based on a scenario or two I have seen, scrubbed to prevent identification; I would like your thoughts).

It's a hot dry day without a cloud in the sky.

A family comes up to you asking for a bottle of water. You send your partner to grab some water and notice a male about 12 y/o who just doesn't look good. He is sweaty, flush red, in a slouching / tired posture, and has one hand on his abdomen. You offer him a seat and he takes it.

The parents advise you that their son was not feeling well so they wanted to get him some water. With their permission, you start asking a few questions. The pt is having a headache (3/10) and sharp abd pain (5/10) with nausea and dizziness. The headache is new and the abd pain, nausea, and dizziness have been worsening since morning. He had a hot dog to eat and hasn't drank much all day. The pt takes no medications and nothing like this has ever happened before.

Examination of the abdomen reveals a diffuse pain, unable to be located by the patient. Palpation does not affect the severity of the pain.

You suggest that the patient be evaluated by paramedics for possible transport, but they end up refusing care. You suggest that the pt be seen by his MD, but he does not have an MD. The parents say that they will take him to urgent care but don't want EMS/hospital because they don't have insurance.

How okay are you with this refusal? Your gut instinct wanted an ALS evaluation / transport unit to be called to the scene, but your partner and supervisor both seemed perfectly okay with this as an ordinary refusal.

i guess since the patient is a minor and the parents say no then do as told but to me it sounds like he ate something that upset his stomach then if he gets even more sick (vomiting) he could get extremely dehydrated