I will never diagnose constipation. I will never diagnose gastroenteritis. You have abdominal pain. You have nausea and vomiting. I may have to diagnose viral syndrome, due to the overwhelming crush of well-appearing sniffly children, but I draw the line after that.
To say 'constipation' or 'gastroenteritis' is to say 'there is no chance that you have badness currently occurring'. That is NOT how I have learned to think. This was reinforced a few days ago.
A 14-yo boy w/hx of constipation written suggestively in the nursing notes comes in with RLQ pain for only 2 hours that came on suddenly. I went to see him. His story was correct in sequence for an appy--pain first, central migrating to RLQ, with nausea. One tiny loose stool that did not relieve the pain. His exam was correct; he was tender maximally over McBurney's point, the magic spot for the appy. There was one more detail; there was something behind his eyes that told me he was sick. This is not scientific. It isn't always there. When it is, I have found it very reliable.
I went to staff the patient, told the story, and the attending, who is quite good, said, if you told a surgeon this story, they would laugh at you. No way appendicitis starts and progresses in only 2 hours. But, you're right, he's hooked us with his exam.
We tried a KUB which showed some stool. We tried a fleets enema, and it initially seemed to work. I actually filled out the paperwork for constipation before I went back in to re-examine him on my own, because the nurse said it made him feel better. Just before I went in, my staff went in, and came out. His exam was unchanged. CT showed a 1 cm dilated appendix with peri-appendiceal fat stranding (inflammation) and I called surgery for an acute appy, put in a line, gave him some morphine.
Constipation is a sign and a symptom, not a diagnosis. Yes, there are LOLs who come in with impaction, but it is due to something--inactivity, opioids, or, scary terrible inflammation in the gut that is waiting to kill them.
Gastroenteritis and constipation are dangerous, dangerous diagnoses--moreso becuase they are so common, and usually we will get away with these diagnoses if we are confident, or maybe foolhardy, enough to use them. The author of RENT, 3 days before he died in his apartment of a ruptured aortic aneurysm, was diagnosed with gastroenteritis. Is that common? No, or people would be dying in droves. But COMMON isn't what I'm looking for. I'm looking for 'zebras', what we call rare diseases. For a medicine doc or a pediatrician, that's usually some obscure genetic disorder. I look for enormous zebras with big teeth waiting to kill you--the aortic dissection, the coronary artery aneurysm from KD, the inferior MI that shows up as weakness.
It felt good to be right about this kid. He got helped. But how many have I sent? How many will I send? Only paranoia can save me from the abyss.