I Will Never Diagnose Constipation

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.


medicine girl said...

I was recently (probably correctly) diagnosed with gastroenteritis. I came to the ED after 12-15 episodes of projectile bilious vomiting. No diarrhea & no pain. The ED doc ordered a pregnancy test, CBC, & basic metabolic panel. I got 4 liters of fluids & some damned painful but effective IV Zofran. 8 sleep-filled hours later I was sent on my way and passed out at home for another 16 hours.

I know my case was simple, but I later wondered how they knew at the time that it was definitely gastroenteritis. When & how do you pick up the magic secrets of when it's okay to send someone home and when to keep them?

tyro said...

Although I'm still learning, it's based on clinical exam, how patients respond to therapy, and the story. You didn't have pain--reassuring. You responded to therapy--reassuring. Electrolytes were probably normal--reassuring. They were probably basing their diagnosis on a combination of experience and overall impression.

It's not that people never come to the ED with gastroenteritis and it's always something bad; it's more that things that look OK can turn bad later, or you might miss something, and learning to be paranoid helps me sort out the proverbial needle in the haystack. And I'm guessing they told you to come back if you had increasing pain, worsening fever, couldn't hold down oral fluids, and so on. Letting someone go includes a favorable impression and then advice for if you're wrong and they DO have something bad so they'll come back.

tyro said...

I just re-read that. 4 liters? Wow. That's a ton. And bilious vomiting? I'm guessing the biggest factor in them letting you go was the lack of pain, because otherwise that's a great story for biliary colic.

medicine girl said...

Yep, those instructions sound just like the ones I got. I never had a fever AND at the time a norovirus was ripping through this area like wildfire (tho' unlike ~everyone else I never got diarrhea, which is the one part that doesn't really fit).

I think the bile was mainly due to the violent nature of the vomiting (thank goodness no biliary colic!). I got so much fluid b/c they had trouble getting my systolic BP out of the 80s (normal for me is in the 90s). Good thing, b/c it was another 2-3 days before I could comfortably keep more than a sip or two of fluids down.

I don't think I need much help learning to be paranoid in a medical setting. I realize that common things are common but already I'm terrified of missing something bad. That fear keeps me reading & learning about things that have nothing to do with my current rotation. I do hope that developing good clinical experience & judgment will help me to bring the paranoia to a healthy & helpful rather than disabling level!

tyro said...

I'm sure it will. Now that I've seen a few 'true' cases rather than just read about them, it's easier to distinguish scary from not.

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