EM Forum Case #94 "Jump Up and Down!"
by Charlene Babcock Irvin, MD, FACEP
My sister called one morning and told me Fred, my nephew, wasn’t feeling well. As the only physician in my immediate family, these calls are not unusual. She said he was complaining of a stomach ache, and didn’t want to eat breakfast.
Fred was 8 yrs old, and had no medical problems. He had no vomiting or diarrhea, and had already had a normal bowl movement today. He didn’t feel feverish (thermometer could not be found).
“Have him point to where it hurts.” I asked.
“He points to his right lower side.” She answered.
“Have him jump up and down three times.”
“Aunt Char said jump up and down 3 times!” I heard her ask him.
“Ow, ow, ow!” I heard in the background.
Questions:
1. What is the Rovsing sign? The Obturator sign? The Psoas sign? How reliable are they?
2. How often is appendicitis missed on the patients first health care provider visit?
3. On arrival in the ED, Fred’s temp was 99F. He had not vomited (my sister had kept him NPO), but he still had no appetite. He had no history of
peri umbilical pain migrating to RLQ (“I just woke up and it hurt here!” pointing to the RLQ). Exam revealed RLQ tenderness and localized rebound. He also had voluntary guarding on palpation of the RLQ. His Rovsing sign was positive (He noted RLQ pain on palpation of the LLQ). Otherwise exam was unremarkable. Acute abdominal series showed a RLQ localized ileus (no appendicolith). WBC was 18,000 with 90% PMN, and urine was negative. Surgery was consulted and ordered a CT scan. What do you think?
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