della storia e dell’esame obiettivo?
Dolore addominale in pronto soccorso.
Ha ancora un ruolo il rituale
della storia e dell’esame obiettivo?
Ciro Paolillo
SOC di Medicina d’Urgenza e Pronto Soccorso
AOU S. Maria della Misericordia
Udine
Top 10 reasons for emergency department visitCDC 2003 in milions
Abdominal pain 7.2
Chest pain 5.6
Fever 5.3
Cough 3.0
Shortness of breath 2.9
Headache 2.8
Back symptoms 2.7
Symptoms referable to throat 2.5
Vomiting 2.4
General pain 2.2
Do opiates affect the clinical evaluation of patients with Do opiates affect the clinical evaluation of patients with
acute abdominal pain?
SR Ranji JAMA 2006 296 1764-1774
0
2
5
7
9
Adults
Children
9
3
tot: 1062 pt
Effect of opiates on pt
HISTORY
“admnistering opiates does not
substantially alter the history”
Effect of opiates on the
PHYSICAL EXAMINATION“ significant heterogeneity”
Effect of opiates on potential
MANAGEMENT ERRORSNNH 909
SR Ranji JAMA 2006 296 1764-1774
1.
2.
3.
4.
1. seat at the bedside
2. an unhurried approach
3. careful history-taking
4. patience and warm hands
PF Jones BMJ 1976 2 551-553
15
“Abdominal examination is not complete
without
performance of a rectal examination”
Talley NJ, O’Connor S. Clinical Examination, 2nd edn. Oxford: Blackwell, 1992.
Rectal examination in 97 patients Rectal examination in 97 patients
did not reveal any abnormality.
How did you feel about this rectal examination?How did you feel about this rectal examination?
Unconfortable 89
Painful 19
N Manimaran Ann R Coll Surg Engl 2004 vol 86 pagg 292-295
18
Rectal examination in patients with pain
in the right lower quadrant of the abdomen
JM Dixon BMJ 1991;302:386-8
1204 pt
“ NO information of diagnostic value”
Sn % Sp% LR + LR-
Rebound
tenderness40-95 20-89 2.1 0.5
Percussion
tenderness65 73 2.4 0.5
S McGee Evidence based physical diagnosis 2007 Saunders
K
Massed palpated 0,82
Tenderness 0.42
Distension 0.42
Normal bowel sounds 0.36
Surgical abdomen 0.27
J Pines Am J Emerg Med 2005 23 483-487
“The elderly patient who has abdominal pain consumes
more time and resources than
any other emergency department patient presentation.”
JP Martinez, Emerg Med Clin N Am 2006 24 471-388
Accuratezza della storia e della clinica nella ricerca della occlusione intestinale Sn % Sp %
Addome disteso + Aumento dei rumori + Vomito 23 100
Aumento dei rumori + Storia di stipsi + Vomito 10 100
Addome disteso + Pregresso intervento + Vomito 38 98
Addome disteso + Aumento dei rumori + > 50 anni 19 99
H Bohner Eur J Surg 1998; 164: 777-784
Siediti e raccogli la storia Siediti e raccogli la storia
Riconosci i limiti dell’esame obiettivoRiconosci i limiti dell’esame obiettivo
Non usare scorciatoieNon usare scorciatoie
Tratta bene il doloreTratta bene il dolore
Accuratezza della storia e della clinica nella ricerca
della occlusione intestinaleSn % Sp %
Addome disteso + Aumento dei rumori + Vomito 23 100
Aumento dei rumori + Storia di stipsi + Vomito 10 100
Addome disteso + Pregresso intervento + Vomito 38 98
Addome disteso + Aumento dei rumori + > 50 anni 19 99
Anse distese e ridotta peristalsi all’eco 93,9 81,7
TB Jang Emerg Med J 2011 28: pagg 676-678