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SSL lecturing
recommends Cope's Early Dx of the Acute Abdomen, says read it often
(I have a copy; it's excellent)
see copy of the acute abdomen form that was in earlier editions of the book
mc surgical emergency esp in children: appendicitis
this lecture is focussed in appendicitis with slight overview of DDX

DDX
biliary colic, Murphy's pt pn may radiate to flank or scapula, tends to writhe
perforated gastric or duodenal ulcer-->chemical peritonitis-->shock
acute intestinal obstruction, volvulus, intussussection, strangulated hernia, fecular vomitus
acute perforative appendicitis, or dx before perf!
acute pancreatitis, epigastric pain radiating to lower thoracic back
acute diverticulitis usu LLQ, abscesses, small perforations, sx like L sided appendicitis
PID, ectopic pregnancy, torsion, salpingitis
lower lobe pneumonia may irritate diaphragm and present similarly

APPENDICITIS
GENERAL
20% of the time healthy appendixes are removed when they thought it was appendicitis
better to remove a beautiful appendix than to have perforation??? erring on side of caution???

SX
1st usu anorexia, sudden loss of appetite in previously well patient
constipation, indigestion, for a few days (dt tightened iliocecal valve)
pain starts epigastric and move to periumbilical or to RLQ, McBurney's pt
pain worse movement
(this pattern only if gut is arranged normally)
nausea, vomiting
need to pass gas, but it doesn't help with the pain

SX DEPEND ON LOCATION OF APPENDIX
BEFORE PERFORATION
ascending or celiac appdx: pain mb in flank or epigastric, more anorexia, N/V
retrocecal: less pain, local, less rigidity, earlier distension, less anorexia
pelvic: epigastric, periumbilical, rectal pain, mb no reigidity, late distension
AFTER PERFORATION
fever up to 104.5, more masses
pelvic may cause diarrhea, dysuria
*chart with location information will be posted for us to print

PE
local tenderness where appdx is
tender to percussion, don't do rebound if rigid gut
positive psoas sign (extension @ hip, lengthening muscle)
obturator sign (+ with pelvic appendix)(internally rotate bent leg by taking heel out to side)

PATELLA
pain
anorexia, n/v
tenderness
elevated temperature
leukocytosis (WBC over 10.5-11K, may have only L shift not numbers yet)
lying still, avoiding movement, gentle walking, no jarring
asleep (these last two added just so he could make a good word and not because they're imp)
(order matters)

SOMATIC PAIN
--originates from ligaments, tendons, bones, blood vessels, and even nerves themselves. It is detected with somatic nociceptors. The scarcity of pain receptors in these areas produces a dull, poorly-localized pain of longer duration than cutaneous pain. ...
www.newworldencyclopedia.org/entry/Pain
--occurs with irritation of the parietal peritoneum. This is usually caused by infection, chemical irritation, or other inflammatory processes. Sensations are conducted by the peripheral nerves and are better localized than the visceral pain component. ...
www.mdconsult.com/das/book/bbmap

SIGNS OF SURGICAL EMERGENCY
shifting pain-->suggests surgical emergency

VOMITING
reverse peristalsis starts mid-jejunum
it is possible with obstruction to vomit stool

CASE
34yo female
a few years ago had "stomach virus" x 1wk
later developed severe RLQ pain
WNL abd US and CT were normal at first
a day later called and told she had appendicitis
it didn't hurt that day, sent home
most foods give her "a lot of bad gas"
w/o probiotics she has 1-4 stools/day, changeable
accompanied by oil on water sfc
probiotics -->more consistent stool but still oily
beans-->gas and D
chicken-->gas
milk-->severe D and cramps
bread-->??
beer-->gas and D
at 25 she drank 2 pints at a time 2x/week
formerly had no sx when avoided beer, now avoiding beer doesnt' eliminate sx
anxious person, nervous, hypervigilant-->indigestion dt
in Jan noticed tight abd w/ walking/exercise so quit exercise
out with dad rotated to R and felt as if falling, passing out
was taken home and continued to experience dizzy episodes
HR pounding, SOB, NP dxed with BPV, gave meds for vertigo, she didn't take
episodes of severe nausea over next week
went to DC who found RLQ tenderness to palp
sent to surgeon who did CT showing no appendix issue
found multiple follicular cysts on L ovary
dizzy disorient low grade fever abd pain continued
had surgery to remove cyst on L ov, none had ruptured
a week later came to see SSL
don't know if healing ov will fix nausea, pain, dizziness
SSL did some labs
DDX: chronic appendicitis? IC valve problem? lactose intolerance? pancreatic insuff?
GI HEALTH PANEL
+2 candida albicans (+3 is max, +2 called "light" but he disagrees with that)
moderate alpha hemolytic strep
abundant non-pathogenic E.coli but these are expected
sIgA less than 11 (very low)
alpha anti-chymotrypsin is low (so no lg or sm intest inflam)
intestinal lysozyme normal
chymotrypsin under 3 (-->pancreatic insuff)
nonreactive to foods except possible gliadin when correcting for low SIgA
no worm ABs

CASE
14yo female
after hours call cc: severe abd pain
began 4 nights ago
gags self to vomit yellow fluid but no relief from V or passing gas
2 days ago vomited all dya
periumbilical pain worse press on RL!
hasn't eaten in days
dizzy when upright
feels warm
moves slowly or is carried
denies sexual activity
O: decr BS4Q, pulse 90, temp 99.8, BP 100/70, RR12
+rebound tenderness at McBurneys
trouble moving R leg, uses legs to raise it
pelvic exam reveals "possible" mass on R
DISCUSSION DDX
appendicitis
obstruction (but passing gas), volvulus, intusussception
gastroenteritis
mesenteric lymphadenitis may cause all these sx (oft follows Yersinia infx)
perforated duodenal ulcer (slow leaker)
ectopic pregnancy, torsion, ruptured ovarian cyst
abscess in psoas muscle
WANT CBC AND BHCG
ASKED TO DRAW BLOOD AND PT SAID NO
she'd never been to doc
talked her into it
CBC showed 14,000 WBCs with L shift
ADVISED TO GET CT, MIGHT NEED SURGERY
answer: she'd rather die than go to hospital
she never got imaging
SSL's TX
he gave Belladonna
(didn't have most specific homeopathic: Iris tenax, Boericke says under iris versicolor to compare, dry mouth, deathly sensation at point of stomach, pain at IC region, pain from adhesions after appendicitis)
(for homesickness besides bry also for ear infx to mastoid: Capsicum, also for florid face, alcoholism)
EFFECT
SSL didn't sleep well that night
mom called in morning, kid was up all night in pain but it went away in morning
started to eat and drink again, all was fine
came in for skin problems at 17, the abdominal pain never recurred

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