A. Physical Exam Key Points. Most patients can be diagnosed clinically, without need for sophisticated tests. Critical question is: Does patient require urgent surgery or can more leisurely evaluation take place? It is controversial whether analgesics will mask the findings of abdominal disease. Many surgeons maintain they cannot adequately assess patients who have received narcotics, although recent studies suggest otherwise. A compromise may be to administer a single dose of analgesia if it is decided to observe patient and then reassess when medication wears off. If surgery is definitely planned, pain relief may be provided.
1. General appearance. Note overall appearance, how patient moves about, and whether he or she "looks sick." Writhing with intermittent crying and drawing the knees up suggests colicky pain; lying still in fetal position is more indicative of peritonitis.
2. Vital signs. Children with nonperforated appendicitis rarely have a high fever; significant fever suggests a viral syndrome or peritonitis.
3. EENT, lungs. Because abdominal pain, particularly in young children, may be caused by extra-abdominal conditions, check for conditions such as otitis, pharyngitis, and pneumonia.
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