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Likelihood Ratio (LR) in Emergency Medicine

4/27/2015

Where is peritonitis?

Clinical Scenario

A 80 YO man with a history of hypertension presents to the ED complaining of abdominal pain. He felt well until 8 hours ago, when he developed diffuse abdominal pain. The patient is afebrile, tachicardic, BP is 180/100 his lungs are clear, ECG shows no changes suggestive of ischemia.  There is diffuse abdominal rigidity.

In another room there is a 22 yo girl with abdominal pain started two days before. She is febrile (38°C) and tachicardic, blood pressure is 120/80, her abdomen is soft. The cough test is positive, but rebound is negative.

In the 3rd room there is a 48 yo patient.  Come in -says the nurse- this abdomen is like a board.

Where is peritonitis?











Conclusion 

Determining the presence or absence of peritonitis is a primary objective of the abdominal examination. All the methods alone are inaccurate. Thoracic inflammatory process adjacent to the diaphragm, a voluntary contraction of the abdominal wall in apprensive patients, a rough painful examination, may be misleading. But what is more interesting is that no test alone is useful in ruling out a diagnosis of peritonitis. Furthermore a gentle percussion is as inaccurate as the rebound test is, but it saves unnecessary pain.  



Bibliography 

R McNamara
Approach to acute abdominal pain.
Emerg Med Clin N Am 2011 29 159-173


S McGee 
Abdominal pain and tenderness
Evidence based physical diagnosis Saunders Ed. 2007.


Ciro Paolillo

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  1. This is very informative .Following this from Kenyatta University school of medicine (http://medicine.ku.ac.ke/)

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  2. I am a Pharmacist and the same problems are seen on every day but the doctor cannot make any decision untill they examine the patient themselves. We used to read scenarios like these when we were in the University and in my opinion the second patient has the problem of Peritonitis. In this case, the patient also feels a lot of pain and he must also be taken to some physiotherapist who ca help the patient out of such pain.

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