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

358 pt con dolore addominale

244 dimessi entro 6 ore (68%)

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

The bedside evaluation:ritual and reason

A. Verghese Ann Intern Med 2011 vol 155 pagg 550-553

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

IspezioneAuscultazionePalpazionePercussione

15

“Abdominal examination is not complete

without

performance of a rectal examination”

Talley NJ, O’Connor S. Clinical Examination, 2nd edn. Oxford: Blackwell, 1992.

16

N Manimaran Ann R Coll Surg Engl 2004 vol 86 pagg 292-295

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

21

Addome silenzioso = peritonite

Addome rumoroso = occlusione intestinale

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

AAA > 4 cm LR + LR-

8,6-28,5 0,31-1.02

JAMA 1999 281 (1) 77-82

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

usa la sondausa la sonda

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