FIRST AND FOREMOST, GO BRONCOS!
Today's POTD is a shoutout to Dr. John "Fearless Leader" Marshall, as brought up at last weeks CQI.
ABDOMINAL EXAMS AND A COMMON PITFALL
There was a recent case of a PERFORATED VISCOUS (of course he presented with SOB, but that's another story). The XR was extremely clear. Of course it was missed. The patient had no abdominal TTP, no rebound/guarding/rigidity. Completely non surgical. The free air was missed because they weren't looking for it. (Even the radiologist only read this obvious free air as "possible free air")
HOW THE HELL WAS HE NON-TENDER!?!?!?!?!?!? THESE PATIENTS ABDOMEN'S SHOULD BE A BOARD THEY'RE SO RIGID
CHRONIC STEROIDS (*ominous sounds*)
- Patients on long term steroids (for asthma, auto-immune dz, etc...) can mask a surgical abdominal exam. They may have no tenderness, nothing.
- Again, patients on long term steroids may have a completely normal abdominal exam, even with having surgical pathology.
Don't believe me? While there may be no true RCT, or even a retrospective trial, there are case studies and anecdotal cases (such as the one above). The best one I found is linked right below.
From Medscape: "Remember that the presentation and the findings on clinical examination may be entirely inconclusive or unreliable in patients with significant immunosuppression (eg, severe diabetes, steroid use, posttransplant status, HIV infection)"
So Be DILIGENT. Have a HIGH-LEVEL OF SUSPICION.
And as Dr. Marshall would say, "Anoscope, Anoscope, Anoscope"