Cope’s Early Diagnosis of the Acute Abdomen

I read this book as an “optional” before my third-year surgical rotation in medical school.  It is now available as an e-book at Google Books.

I am familiar with one of the prior editions.  It is revised by Silen, and said to be well-updated.  But the most important learning point of the acute abdomen is the physical examination of the abdomen.  The history is quite compelling in the sick patient; the examination is strongly confirmatory. The review on Google Books states:

Dr. Silen has again updated the text in a respectful but significant way. He has added a chapter on the increasing disorder of diverticulitis, reexamines the use of analgesics, emphasizes the costs of over-testing, and updates all recommendations regarding trauma, radiologic studies, and therapeutic recommendations.

Like the true expert physicians in any field, this book is instructive to all practitioners who wish to refine their medical arts.  The discussion of diagnosis is well worth study to any internists who solve complex puzzles.

I recommend, first, that the reader look over the first few chapters made public in Google books; and then purchase the paper book for learning, as the entire volume is well worth reading, even if one does not expect to see a surgical belly in one’s practice.

Well after medical school, I encountered a febrile quadriplegic who didn’t feel well.  As you recall, without sensory innervation of the belly and peritoneum, the history of pain is unattainable.

I took the history and physical, and after a sound review of laboratory tests (I had no access to prompt imaging,) I sent the patient to the maw of the inpatient machine.  I did follow the old rules as described in Cope.  I contacted the on-call surgeon with the patient’s identification, my findings, and my diagnosis of an acute abdomen.  Since people can no longer be “admitted to the hospital,” but must be filtered through the ER, he slid onto the conveyor belt, and was hospitalized after a half-day on IV antibiotics for fever.

In the Old Days, this would not happen.  The surgeon would hear about the sick belly, go to the ER on arrival, or send an intern or designee to do a five-minute look-at, and decide what to do straight away.

In one’s discussion with colleagues or the chart – when the chart used to exist as a usable document – an experienced doctor does best with the King’s English, either proper or vulgar.  Use it.

This patient was sick as shit.  That belongs in the chart either literally, or using dignified euphemisms.  Medical experience gives one the capacity to take a global impression of a patient, whether heavily decompensated into schizophrenia or with a rotting belly, and leave a clear snapshot orally and in writing.  In litigation, an attorney will howl over it – “This patient looks sick as shit, and is steadily decompensating.  I fear he’s going to be septic before the sun goes down.”  Listen, nod, and admit that this sounds vulgar and unprofessional.  The longer this fool makes you answer to your written entry, the more the jury’s decision is made.  Any sane adult can understand the phrase; and you have expressed a lot in a few words.  Old Medicine was poetry; New Medicine is – well, I can’t say.  This case was not litigated; I did my job and communicated the state of the patient, at first in plain and simple observation, and then with ever-increasing precise and technical description of the elements contributing to my diagnosis.

He went to the ER, got vitals and labs, had an un-suggestive flat plate of his belly, and was admitted and parked on the floor for a day, hydrated and given antibiotics, struggled to stay homeostatic, and finally perf’ed his appendix.  An emergency lap showed peritonitis; his hospital course was over ten days.

The purpose of this story is not to exhilarate in my being right and everyone else being wrong, although I am proud that by following Cope’s rules, and being diligent and scrupulous, I could diagnose an acute appendix in a quadriplegic man.  That’s a note that goes on my personal refrigerator – good job, Steve!  I did good doctor!

The learning lessons are:  Here is an acute belly.  Every sick patient needs the most precise diagnosis you can muster at the time.  My diagnosis was – sick patient, PROBABLY acute appy.  I could not diagnose acute appy definitively, but well enough to put my chip on that square.  I could say “acute abdomen,” thanks to Cope.

I offer below the introduction to Cope’s, in hopes that people will realize how useful the book is to all practicing physicians.

Before entering into the detailed consideration of the various forms of acute abdominal pain, it is well to lay down certain principles that form the basis of all successful diagnosis in urgent abdominal disease.

Necessity of making a diagnosis

The first principle is that of the necessity of making a serious and thorough attempt at diagnosis, usually predominantly by means of history and physical examination.
Abdominal pain is one of the most common conditions that calls for prompt diagnosis and treatment. Usually, though by no means always, other symptoms accompany the pain, but in most cases of acute abdominal disease, pain is the main symptom and complaint. The very terms “acute abdomen” and ‘·abdominal emergency,” which are constantly applied to such cases, signify the need for prompt diagnosis and early treatment, not necessarily always surgical. The term acute abdomen should never be equated with the invariable need for operation. In some instances the urgent need for operation may be so obvious that the need for transference of the patient to the care of a surgeon is clear. In other cases, the observer may, if in doubt, think it wise to discuss the problem with a fellow practitioner before deciding on any course of action. There are, however, occasions when, with somewhat indefinite symptoms, there is justification to wait for the development of clearer indications to see whether the condition will not improve spontaneously and to temporize as long as the patient is carefully observed at frequent intervals. Though
in some cases it is impossible to be certain of the diagnosis, it is a good habit to come to a decision in each case; it will be found that after a short time, the percentage of correct diagnoses will increase rapidly.

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