In medical school, they teach you about diseases. They teach you who is most likely to get a certain illness. You have to learn what kind of symptoms a person with that condition might have and what is found when examining such a patient. You learn how to put all of that together to make a diagnosis.
When evaluating a patient, the first thing we do is take a history. In appendicitis, we look for a classic story of vague discomfort around the belly button that, over the next few hours, settles into the right lower abdomen. Classic other symptoms are nausea, vomiting and fever. Most people with appendicitis don’t have diarrhea.
Next comes the physical exam. In this case, how does the patient look generally? Does he look sick? Is he tender in just the right place? Is there nothing else that would lead you to think this was something other than appendicitis?
Next come lab tests. The urinalysis should be normal and the white blood count should be elevated.
If there is any question, the last step is a CT scan of the abdomen, which is the test now used to establish the diagnosis. Why not just scan everyone? It is time-consuming, expensive and exposes the patient to a lot of radiation. So, the history, physical examination and laboratory results help us decide who is most likely to benefit from a scan.
I recently had a young man come in who hadn’t gotten the memo on appendicitis. He had left abdominal pain that started in his flank and went up to his upper abdomen. He had abdominal tenderness but not where his appendix is expected to be. His blood count was normal. His pain was gone after some medicine. He was smiling and happy as he thanked me on his way out the door.
The next night, he came back in, sicker. His white blood cell count was very high and he was really tender all over his abdomen. His CAT scan showed appendicitis. I called a surgeon to admit him to get his appendix taken out.
By the time one has been doing this for as long as I have, it is expected that common diseases will present weirdly. Still, this is an unbelievably atypical presentation of a common disease. It is a good example of how challenging and frustrating my job can be.
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