Professor and Class:
Patrick is a twenty year old, Caucasian male, well- groomed and of medium height and build, who presents to the emergency room with complaints of RLQ abdominal pain, fever, and nausea X 5 hours. He is notably anxious, diaphoretic, guarding and holding pressure to the area described.
Some questions I would ask Patrick include the following:
When was the onset of your pain? Was there anything that provoked the pain? What is the quality of your pain? Is it sharp, stabbing, dull, aching, throbbing? Does it radiate anywhere? On a 1-10 scale, and 10 being the worst, what is the rate of your pain? How long has the pain lasted? Does it come and go, or is it constant? Do you have now, or have you had any nausea or vomiting with the pain? Are you hungry? Do you feel like you could eat something now? Are there any recent changes in your diet? What has your diet consisted of in the past week? Have you ingested any unusual foods or non-food items, intentionally or unintentionally?
Any history that may be associated with his symptoms may include previous episodes of RLQ or periumbilical pain, nausea, vomiting, and anorexia. Risk factors include a stool blockage, an ingested foreign body, such as a coin, cancer that can lead to infection, bacterial or viral infection, parasitic infection, or lymphoid hyperplasia where the appendix produces an overabundance of normal cells that create a blockage in the appendix. Other factors include age less than twenty years, a WBC count of greater than 10,000 that can approach 20,000, hypoactive or hyperactive bowel sounds, rebound tenderness, or presence of a positive Psoas sign, Obturator sign, or Rovsing’s sign, any delay of surgical intervention, or presence of an appendicolith.
Physical examination techniques would include positioning of the patient, then inspecting the area visually, and performing palpation to include the above tests that are telltale signs of appendicitis. A Hamburger sign is simply asking the patient if he thinks he could eat something. If his response is yes, then this is not appendicitis. I notice he is applying pressure to the area of pain, and by doing this he states it is relieving his pain, but when he lets go he experiences rebound tenderness, also a classic sign. Assessing for the point of reference of pain is McBurney’s point, which is directly in the middle of the iliac crest and the belly button. If I palpate or push on his LLQ and he experiences pain, this is known as a positive Rovsing’s sign. If I have Patrick cross one leg over the other while lying on his back causing flexion and internal rotation, and this causes pain, this is known as a positive Obturator’s sign. Then, if I have him raise one, then the other leg while I provide resistance with an opposing force and this causes him pain, this is known as a positive Psoas sign. Our text states, “Normally, there is no abdominal pain associated with this maneuver…Pain during this maneuver is indicative of irritation of the psoas muscle associated with the peritoneal inflammation of appendicitis” (D’Amico & Barbarito, 2012). Besides his low grade temperature, he may present with an increased blood pressure and heart rate, his bowel sounds may be hypoactive or hyperactive, and his abdomen distended. In educating Patrick, I would inform him that if his appendix bursts, is found to be perforated, or spilling infectious materials into his abdominal cavity, this condition can be life threatening, and can cause complications of peritonitis and sepsis. There is usually a 24 hour window rule of thumb, from the onset of symptoms until surgical intervention. Diagnostic testing usually is obtainment of a CAT scan. (If the patient is pregnant, an ultrasound or KUB are other diagnostic tools). Lab values may include an increased WBC count with a left shift and neutrophil banding. Also, a urinalysis may also show increased RBC’s and WBC’s. Besides surgical intervention with a laparoscopic appendectomy, treatment may include the antibiotics, IVF’s, and making him NPO to promote bowel rest. He would be held overnight for observation, and possibly discharged the next day if no complications arise. Oral and written discharge instructions would include keeping the area clean and dry, and inspecting the site for any signs or symptoms of infection or complaints of pain. A small amount of blood or serous oozing from the site is normal for the first few hours. Keep steri-strips in place for a week or until they fall off. Call PCP for increased pain, drainage, swelling, redness, or increase in temperature greater than 101 degrees F.
Patient is a 20 year old, well-nourished and well-groomed appearing Caucasian male. He presents to the emergency room very anxious with complaints of RLQ abdominal pain=10/10 pain scale that is sharp and constant which began approximately 5 hours ago. He has a LGT of 100.2 degrees F and is diaphoretic and pale in color. His B/P=150/96, HR=110, RR=22, and oxygen saturation=100% on R/A. He is notably guarding and applying pressure to the RLQ, McBurney’s point area, and states this helps to relieve the pain. A&OX3, LCTA A&P, BS present X 4 quadrants, hypoactive and with slight abdominal distention. Positive peripheral pulses, capillary refill < 3 seconds, no edema. He has rebound tenderness and a positive Rovsing’s sign. Patient verbalizes extreme pain, refuses further examination at this time, and yelling for pain medication. Dr. Fine called to room and here to see patient.
Reference:
D’Amico, D., & Barbarito, C. (2012). Health & physical assessment in nursing. (2nd ed., p. 541). Upper Saddle River, NJ: Pearson Education, Inc.