?A 24 year old healthy female in her usual state of health presents with acute 10/10 diffuse abdominal pain, anorexia and nausea. On physical exam she exhibits peritonitis, with rebound tenderness in the right lower quadrant, reproducible with palpation in the left lower quadrant.? A typical summary of a patient one might see in the emergency room. There I was, a week into my second clinical rotation of my third year of medical school, getting asked by the surgeon on-call about the differential diagnosis for such a presentation. Only, it was me who was dressed in the unflattering hospital johnnie, and the patient I was talking about was me.
I had woken up the night before my third day on my internal medicine rotation with a sharp abdominal pain that I had never experienced before. A typical medical student, I browsed some medical literature about my possible diagnosis. I was restless, unable to sleep, and suspicious that this acute abdominal pain was not some bug I d caught from last night s dinner. Falling into a pain-induced sleep, I returned to the hospital the following morning, bleary-eyed yet eager to learn, hoping to ignore the nausea and the pain.
As medical students, we learn about different types of pain. There s the chest heaviness or tightness associated with angina, the tearing pain described in an aortic dissection, and the writhing pain seen in patients who are passing a kidney stone. Abdominal pain comes in all flavors ? colicky pain (which is crampy and tends to wax and wane), visceral pain (arising from internal organs, or viscera, and is difficult to localize), and peritoneal pain (when inflammation begins to irritate the parietal lining of the organ; this pain is usually extremely localized).
In between our daily ritual of rounding on patients, the resident on my team tested my symptoms with a seemingly simple movement: he asked me to bounce forcefully on my heels, which immediately exacerbated the pain. Ultimately, he was the first to recognize my pain as peritoneal, and to diagnose me. ?I think you have appendicitis. You should probably go to the ED.?
As a third year medical student, I have already spent more than two years learning how to elicit a patient?s medical history, and am still in the process of mastering the art of the physical exam ? a skill-set that takes a physician countless years before being able to claim expertise. There are thousands of maneuvers a physician can perform (and often named after the physician who invented it), and the outcomes of these tests are supposed to guide our diagnosis and management of a patient s condition.
Appendicitis is considered classic bread-and-butter medicine, largely because it is traditionally a diagnosis made on the basis of the physical exam. There are several key diagnostic maneuvers that, when positive, are highly indicative that the patient has appendicitis. For instance, tenderness at a particular spot in the right lower quadrant (RLQ) McBurney s sign has a specificity up to 86 percent [1]. Rovsing s sign, which is pain in the RLQ with palpation in the left lower quadrant has a maximal specificity of 96% [2]. I had both of these signs.
Additionally, I had rebound tenderness pain that is greater when the examiner releases pressure on palpation which is another indication that I had some type of peritoneal irritation. As a medical student, I could recognize and name these signs something which was both reassuring and inherently frightening at the same time. While I could precisely describe the physical feelings I was experiencing, I also knew too much about the potential complications I could experience.
Not a century ago, my acute abdominal pain combined with these positive signs might almost certainly have been enough to take me to the operating room, albeit with a high rate of negative appendectomies (where the appendix is found to be normal at operation). But today, medicine has moved towards trying to become far more accurate at diagnosis with the use of technology and what is known as evidence-based medicine.
In his book Evidence-based physical diagnosis [3], Steven McGee summarizes the most effective physical exam findings based on their correlation with the actual disease. In the case of appendicitis, there is something known as the Alvarado Score, which takes into account these different symptoms and spits out a likelihood that a patient in question will have appendicitis based on these symptoms. Essentially, the score takes a physician s clinical suspicions of a diagnosis and converts them into an algorithmic scale.
Interestingly, my own Alvarado score was 5/6 a value which is non-significant in the diagnosis of appendicitis. What this translated to, in a practical sense, was that the physicians became extremely doubtful that I had appendicitis. I underwent about 7 physical exams (including a pelvic exam), an ultrasound, and was tested for all gynecologic manifestations ranging from ectopic pregnancy to pelvic inflammatory disorder before being given the ultimatum to leave against medical advice (and return if the pain worsened), or to get a contrast CT. I had initially deferred obtaining a CT, not wanting radiation were it unnecessary, and with the conviction and perhaps naivet ? that, if I really had appendicitis, our collective medical knowledge would have sufficed to diagnose me based on my physical exam findings.
Ultimately, I did give in. I was finishing the oral contrast CT solution a milky-appearing viscous fluid when the surgery resident on-call came to see me and made me present my case. I remember that conversation vividly, since not 15 minutes before my CT, he was trying to convince me that I didn?t have appendicitis. ?I?d say that maybe 1 in 20 people with appendicitis would be sitting up at a computer like you are,? he joked with me ? referring to the patient notes I was typing up from earlier that morning (ever the dedicated medical student).
And looking back, I can t really blame him. He was going off of the collective available evidence, which was not definitively pointing to anything. I remember feeling relief when I saw my CT, moments after it was taken (the benefit of being able to look up my own medical record). I could see the appendicitis, documented for eternity. At least my pain was real and explainable ? in spite of being persistently dissuaded that I in fact did not have appendicitis. Before being prepped for my operation, I humorously paged that surgeon, ?I guess I?m the 1 in 20?.
I knew what would come next because I had spent the previous three months alongside patients except that I had been at the other end of the scalpel. The amnesic anesthetic agent I received has erased my memory of my entire time in the operating room a limbo in my life where it s as though I didn t even exist. Seeing as I ve witnessed patients talk after waking up from the anesthesia, I am taunted by the curiosity of what words I mumbled after being aroused something that only the others in the room would remember.
I remember waking up in excruciating pain and waiting hungrily for the painkillers to set in. And as I recovered over the ensuing weeks, I noted how the dull constant ache that had me hunched over and prevented my walking upright morphed into occasional pain; evolved into an internal discomfort that allowed me to walk slowly; changed to a tightness that signalled my insides were healing; taunted me with itchiness of the nerve regrowth; and finally, faded from my constant consciousness as the scars themselves became less visible.
Susan Sontag, in her book Illness as Metaphor [4], has eloquently described the dual citizenship that everyone holds in the worlds of the well and the sick. Personally, I wouldn t necessarily have chosen to become privy to the patient s world of surgery just a few days after completing my three-month surgery rotation. However, the tiny piece of stool that spontaneously became lodged in my appendix clearly had its own plan in mind. As I joke with my friends: Apparently I really liked surgery, because I had to have one myself.
Now that I have returned to daily life in the hospital less a vestigial structure I have become even more finely attuned to a patient s physical clues that can guide me in a diagnosis. There will be cases where the patient s diagnosis will be straightforward, and the laboratory and/or imaging tests I order will confirm an expected diagnosis.
But there will be even more patients whose symptoms are more complex, more esoteric, perhaps less classic and in whom the physical exam will either be not as helpful, or will leave room for hesitancy. What I am striving towards what all medical students and young physicians aspire to is to develop an intuition, a gut instinct, that will aid me in figuring out what disease is afflicting a patient, when the ailment is not obvious and equally as crucial when it should be crystal clear.
[1] Andersson R.E., Hugander A.P., Ghazi S.H., et al: Diagnostic value of disease history, clinical presentation, and inflammatory parameters of appendicitis. World J Surg 1999; 23:133-140.
Golledge J., Toms A.P., Franklin I.J., et al: Assessment of peritonism in appendicitis. Ann R Coll Surg Engl 1996; 78:11-14
Lane R., Grabham J.: A useful sign for the diagnosis of peritoneal irritation in the right iliac fossa. Ann R Coll Surg Engl 1997; 79:128-129.
[2] Izbicki J.R., Knoefel W.T., Wilker D.K., et al: Accurate diagnosis of acute appendicitis: a retrospective and prospective analysis of 686 patients. Eur J Surg 1992; 158:227-231.
Jahn H., Mathiesen F.K., Neckelmann K., et al: Comparison of clinical judgment and diagnostic ultrasonography in the diagnosis of acute appendicitis: experience with a score-aided diagnosis. Eur J Surg 1997; 163:433-443.
Alshehri M.Y., Ibrahim A., Abuaisha N., et al: Value of rebound tenderness in acute appendicitis. East Afr Med J 1995; 72(8):504-507.
Jahn H, Mathiesen FK, Neckelmann K, et al. Comparison of clinical judgment and diagnostic ultrasonography in the diagnosis of acute appendicitis: experience with a score-aided diagnosis. Eur J Surg. 1997;163(6):433.
[3] McGee, Steven R. Evidence-based physical diagnosis / Steven McGee. 3rd ed. 2012; Saunders, Elsevier Inc.
[4] Sontag, Susan. Illness as Metaphor and AIDS and its metaphors. 1990; Picador.
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