Christmas 2012: Research

Pain over speed bumps in diagnosis of acute appendicitis: diagnostic accuracy study

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8012 (Published 17 December 2012)
Cite this as: BMJ 2012;345:e8012

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Prior to the advent of the speed bump, my colleague the late Dr Frank Heelan of Tipperary, Ireland, confirmed the diagnosis of acute appendicitis by eliciting pain on shaking the patient's bed!

Competing interests: None declared

Charles Dupont, Consultant Dermatologist

Baggot Street Hospital, Dublin 4

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The authors' excellent observation that being driven over bumps in the road will aggravate the pain of localised peritonitis is very well taken. They correctly ascribe this phenomenon to rebound tenderness. This reminds me of my methods of eliciting rebound tenderness in the clinical scenario, having had to modify the traditional method for eliciting the sign, due to far too many raised eyebrows during a process that is guaranteed to make the patient at the very least wince in pain.

May I suggest the following techniques instead: If pain is exacerbated on pumping up the bed for examination, then rebound tenderness is present. Naturally, motorised beds cannot reproduce the same effect. Additionally, pumping up the bed to height is an essential step, and a far milder way to flex the inflamed peritoneum. In children, an excellent and often humorous way to achieve the same is to gently shake the child from side to side with one hand on each side of the pelvis.

If both of these methods fail, then percussing over the affected area, or McBurney's point in acute appendicitis, is a more direct, but still a gentler method of eliciting the sign of rebound (percussion) tenderness, which is indicative of underlying localised peritonitis.

Competing interests: None declared

Nicholas RF Lagattolla, General surgeon

Independent, Corscombe Dorset

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We wonder if the diagnostic accuracy may be improved by an illness severity measure that we have called the 'too ill to text' scale.

During a recent illness I gave my mobile phone to my partner because I felt so unwell. I spent several hours without electronic contact with the outside world. This led us to propose a new illness severity scale - the 'Too ill to text scale' - a simple scale that grades use of Facebook, twitter, SMS and email as a percentage of normal use. Of course, it will need to be adjusted for poor mobile reception in some of our hospitals. In my case, it was 12 hours at 100% reduction, followed by a rapid return to normal texting frequency but a gradual return over 36 hours to normal activity. A welcome side effect to my 'too ill to text' state was that my partner's contact with friends increased exponentially, as did his SMS response time. Sadly, this has had no medium or long term effects on his own chronic condition.

Competing interests: None declared

Vicci Owen-Smith, Consultant in public health

Robin Johnson, Melvyn Newton

NHS Stockport, Regent House, Heaton Lane, Stockport, SK4 1BS

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