'By the way,' says the attending, 'she doesn't have guarding. So in your note, no guarding, no rebound. Got it?'

'But she did have guarding', I said.

'What's guarding?'

'Involuntary contraction of the abdominal muscles with palpation', I said without hesitating. I had felt it, although it was brief.

'She didn't have guarding. If you distracted her, she didn't do it. It's a peritoneal sign. Maybe you're just a such a terrible brute,' he said, in fun.

'True guarding is rare', said the other resident, a year ahead of me.

This is why we have residencies. This is why Osler said that seeing patients without reading was going to sea without a rudder, and reading without seeing patients was like never going to sea at all. The 'true' signs we read about are dramatic and real. Guarding is a peritoneal sign; that is, some abdominal catastrophe is occurring. This lady either had reflux or gallstones. Neither one is a catastrophe. Annoying, painful. Not a full-blown catastrophe. I got schooled, but I can take it easily from that attending. He was taking night call on the floors at Beth Israel when I was still eating crayons and pureed carrots.


medicine girl said...

I write "tender to palpation with voluntary guarding (TTP c/voluntary guarding" when the guarding is strong but clearly voluntary. It may be voluntary b/c the patient wants to show you it truly hurts or b/c the patient is simply averse to someone digging into their abdomen. Not sure if this notation would appease your attending, but it allows me to document what happened without implying an acute abdomen.

tyro said...

Not a bad way to do it--but the attending's point was that guarding goes with a surgical abdomen. Did I really think it was a surgical abdomen? Nah. I've never seen voluntary guarding used.

This is a bit similar to rebound when you ask, and rebound that makes them wince involuntarily. I don't count it unless it's involuntary, will even distract them. Each true peritoneal sign probably means a belly scan.

medicine girl said...

Thanks for the tips. Good comparison to rebound. If the person has to consider whether they have rebound tenderness then they don't. Which isn't to say they won't develop it later, but I won't be putting in my ultra-thorough student H&P!