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Hello everyone-
I'm a cardiolgoy fellow that moonlights in an urgent care, and wanted your opinion on a case I saw last night regarding acute appendicitis:
The patient was an otherwise healthy 42 y/o male who came in complaining of abdominal pain radiating to the RLQ x 1 day. The patient had voluntary guarding on exam, so I sent him to CT to r/o appendicitis. I also sent a CBC to evaluate for a leukocytosis, and white count was only 7. The patient was afebrile, had bowel sounds, was not rigid, and tolerating PO, however the CT demonstrated an "acute non-ruptured appendicitis" (radiology read). I immediately contacted the surgeon on call (resident), who arrived with a senior attending to evaluate the patient. They reviewed the CT, and felt that they would prefer conservative management and that the patient could be sent home on PO antibiotics. Both the attending and resident left notes attesting to this. I reluctantly sent the patient home on PO Cipro/Flagyl x 10 days, with a follow-up appointment with his PMD today.
My questions are:
1. I was always taught that acute appy required surgical intervention unless their was evidence of phlegmon or abscess in which case there is sometimes a period of antibiotic therapy. Have you ever seen a patient like this sent home before?
2. Should I have pushed for admission anyways for observation? I read up on this a bit last night after the fact (couldn't sleep for some reason). Apparently the mortality from a *ruptured* appendix is only 1.7%, but there is only an 8% likelihood that a conservatively managed case like this will not recur within a year (based on case series).
3. Can I face legal ramifications if a bad outcome occurs, despite doing everything within my power to get the patient's appendix out?
Thanks in advance for your responses.
I'm a cardiolgoy fellow that moonlights in an urgent care, and wanted your opinion on a case I saw last night regarding acute appendicitis:
The patient was an otherwise healthy 42 y/o male who came in complaining of abdominal pain radiating to the RLQ x 1 day. The patient had voluntary guarding on exam, so I sent him to CT to r/o appendicitis. I also sent a CBC to evaluate for a leukocytosis, and white count was only 7. The patient was afebrile, had bowel sounds, was not rigid, and tolerating PO, however the CT demonstrated an "acute non-ruptured appendicitis" (radiology read). I immediately contacted the surgeon on call (resident), who arrived with a senior attending to evaluate the patient. They reviewed the CT, and felt that they would prefer conservative management and that the patient could be sent home on PO antibiotics. Both the attending and resident left notes attesting to this. I reluctantly sent the patient home on PO Cipro/Flagyl x 10 days, with a follow-up appointment with his PMD today.
My questions are:
1. I was always taught that acute appy required surgical intervention unless their was evidence of phlegmon or abscess in which case there is sometimes a period of antibiotic therapy. Have you ever seen a patient like this sent home before?
2. Should I have pushed for admission anyways for observation? I read up on this a bit last night after the fact (couldn't sleep for some reason). Apparently the mortality from a *ruptured* appendix is only 1.7%, but there is only an 8% likelihood that a conservatively managed case like this will not recur within a year (based on case series).
3. Can I face legal ramifications if a bad outcome occurs, despite doing everything within my power to get the patient's appendix out?
Thanks in advance for your responses.
