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Dr. Andrew Rynne
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Dr. Andrew Rynne

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Suggest treatment for severe abdominal pain with high fever

Answered by
Dr.
Dr. T Chandrakant

General Surgeon

Practicing since :1984

Answered : 13176 Questions

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Posted on Thu, 25 Aug 2016 in Abdominal Pain
Question: dear dr. i have made a previous request.

the hospital decided its inconclusive at this time. can you give a opinion?

Complaint
Localised belly ache - lower abdomen. Upper right part to lower right.

Anamnese
Since last night pain in lower belly. Upper part. Sometimes hurts more. She wanted to lay still and legs curled up.

Pain is getting less.
Fever 38.6 at top. (40.5 was false reading)
After paracetemol 37.

Not hurting when in a bumpy car. Miction? And stool was painfull in upperbelly when pushing. No pain when peeing.

Physical exam:
Temp 38.6. Looks sick. Sat 99% wrist 118/min regular. Rr 118/70mmhg

Abdominal: flexible, peristaltic? + wt?, pressure pain in the lower abdominal upper part with pain when letting it go. No evident resistances. Proassign negative. No hit-pain in the kidneylodges.
Vt: no up-hit or slingerpain

Crp 95

Surgeon said the pain is exactly on the spot of the appendix.

The scan showned no sign of torn appendix or any leakage
doctor
Answered by Dr. T Chandrakant 4 hours later
Brief Answer:
Surgeon's clinical acumen- diagnostic and therapeutic Laparoscopy

Detailed Answer:
Hi.
Thanks for your query and an elucidate history.
Read the history your have posted so well, but could not understand the reports due to language barrier.
I was wondering about one attachment- the date shown is 30-4-1995 - is this report so old?
Well, coming back to the history and findings:
The positive symptoms and signs are:
pain on right side of abdomen
fever
Pulse rate of 118 - too high
She wants to lay still, legs curled up.
Very high CRP
Surgeon's clinical evaluation say - pain at the appendix area.
Scan- Which scan is done? - If only ultrasound scan is done then a CT scan can show better diagnosis.
If CT scan is done, you have to get high resolution ultrasound repeated to see for the internal problems particularly appendix. The scans too have limitations, it is not that every time they will show up something.
Hence it is important to have correlation between the clinical findings and the reports to get a final diagnosis.

I would like to know a few details:
If the patient a female? as you have mentioned male in description and used she in the discussions.
Please elucidate on ''abdominal'' : is there rebound tenderness, meaning whether the pain increases momentarily on gradual pressure but more pain on releasing the pressure of examining palm? pressure pain in the lower abdominal upper part with pain when letting it go.
Meaning of : Vt: no up-hit or slingerpain?

My thoughts:
The clinical evaluation, examination and the sixth sense of an experienced Surgeon is more important than the scan as the scan may not show the positive findings; it is ultimately an interpretation of the images that the screen shows and hence needs repeat and review scans to confirm on day 1 or 2 as it may then show up the more positive thing. Every inflamed appendix may not be picked by the scan.
Hence when in doubt, talk to the Surgeon and discuss about the possibility of diagnostic and well as therapeutic Laparoscopy. In laparoscopy the diagnosis becomes certain as the images on the screen are far more clear and also enlarged on Laparoscopy. You can have certain diagnosis and if there are any positive findings that the scans have missed, the Surgeon can go ahead with a definitive surgery also.

I hope this answer helps you in decision making towards a proper diagnosis and proper management.
Please give feedback.




Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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