werner@aecom.UUCP (12/14/85)
<> For those who forgot the question: > History of present illness: Two weeks ago the patient had a bout of > severe epigastric (that's directly underneath the belly button) pain and > nausea that lasted a little more than 12 hours and then went away. However, > two days after that he felt a little tired, and has had a continuous headache > ever since, and sweating and chills (and presumably fever) at night. However, > he feels fairly good, albeit fatigued, and his physical exam reveals > nothing remarkable, and routine tests are normal. > > Contained in the above is a Classic symptom of a disease. It should be For those who didn't get it, one other piece of information should prove relevant. On physical examination, pressing on the left side of the abdomen was painless but upon sudden release there was pain on both the left and right side (this is known as rebound tenderness). If you still haven't recognized it, here's the answer: Burst appendix -- the acute pain underneath the belly button is a Classic sign of acute appendicitis in its early stage. The reason it is central is because all visceral pain is referred to the navel in that area of the body. Appendicitis can progress either of two ways: it can go to the parietal (outside) surface, with the pain localizing to the right side where all of you were taught the appendix lies -- OR it can do what it did here - burst, whereupon the pain goes away but there is spillage of the gut contents into the abdomen (peritoneum). The various contents can try to wall off the infection (specifically the Greater Omentum) but its kind of like Napoleon's retreat from Moscow. The nightly headache and sweats are due to fever caused by Sepsis -- bacteria in the blood. However, it was a small amount, since the blood culture taken was negative for bacteria -- a sign that the infection was being contained fairly well. Now for the unhappy part: this is an actual story (from 1970). The only change was that the patient waited 8 weeks before seeking treatment. The diagnosis -- obvious from the history and rebound tenderness -- was actually missed by the treating physicians for three days because of the unusual (8 week delay) presentation. His appendix was eventually removed, and antibiotics were given, but the patient died of peritonitis and septic infection two weeks into the hospitalization. They give this case to us because this should not have been missed, and they wish to see it never happens like this again. The happy ending: in the last fifteen years, at least (that have been reported back) four cases of missed burst appendix have been diagnosed by Einstein Medical students, with survival of all four. -- Craig Werner !philabs!aecom!werner "What do you expect? Watermelons are out of season!"