Appendicitis

[BadVB750]

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Appendicitis, sure is a weird beast.

18 y/o F c/o gas pains for two days, last BM 2 days ago, -n/v/f/c, +PO intake,
VSS
Well develop F, NAD
The only + on exam was RLQ pain on serial exams and hypoactive BS.

AAS showed TB (Turd Balls)

On further questioning she said that it started off as diffuse abd pain and now it hurts sometimes in the RLQ.

I almost D/C the girl with a stool softener but I couldn't get rid of that nagging feeling that there was more to her "gas pains" so I order the CT.

CT showed early appendicitis with appendicolith

 

[GeneralVeers]

females + abdominal pain = irritating

 

[HokiMD]

Appendicitis, sure is a weird beast.

18 y/o F c/o gas pains for two days, last BM 2 days ago, -n/v/f/c, +PO intake,
VSS
Well develop F, NAD
The only + on exam was RLQ pain on serial exams and hypoactive BS.

AAS showed TB (Turd Balls)

On further questioning she said that it started off as diffuse abd pain and now it hurts sometimes in the RLQ.

I almost D/C the girl with a stool softener but I couldn't get rid of that nagging feeling that there was more to her "gas pains" so I order the CT.

CT showed early appendicitis with appendicolith

Any lab abnormalities?

 

[bulgethetwine]

Appendicitis, sure is a weird beast.

18 y/o F c/o gas pains for two days, last BM 2 days ago, -n/v/f/c, +PO intake,
VSS
Well develop F, NAD
The only + on exam was RLQ pain on serial exams and hypoactive BS.

AAS showed TB (Turd Balls)

On further questioning she said that it started off as diffuse abd pain and now it hurts sometimes in the RLQ.

I almost D/C the girl with a stool softener but I couldn't get rid of that nagging feeling that there was more to her "gas pains" so I order the CT.

CT showed early appendicitis with appendicolith

Good call on the CT. I can tell you agonized over the decision (as did I as a junior resident).

I've had enough of these turn out to be positive such that I don't even hesitate anymore to order the CT in this type of scenario. That is, after I convince myself that it couldn't possibly be torsion, and exclude ectopic with a neg hCG

 

[kungfufishing]

Although we probably over-CT a lot of people, as far as I can tell (and read) females with unclear etiology abd pain buy CT scans.

 

[BadVB750]

Any lab abnormalities?

Her WBCs were 11.1 just 0.1 elevated and +Leu and WBC on her UA (but no symptoms). She did spike a fever (101.9) after I told her the DX.

 

[Painter1]

Her WBCs were 11.1 just 0.1 elevated and +Leu and WBC on her UA (but no symptoms). She did spike a fever (101.9) after I told her the DX.

medicine is an art. at least in my limited experience, the more seasoned attendings are more conservative with workups and imaging. i'm assuming they've been around enough to hear that dreaded: 'remember that patient? well they came back and . . ."

 

[deleted109597]

She did spike a fever (101.9) after I told her the DX.

You should have told her more gently then. Don't they have a communications course at your place?

 

[tkim]

You should have told her more gently then. Don't they have a communications course at your place?

He's getting better - he no longer wears a gorilla mask when entering patient rooms.

 

[BadVB750]

My face was painted like a warrior though

 

[tkim]

My face was painted like a warrior though

Ah, that would explain why you were yelling 'I am William Wallace" just before entering the room.

The upcoming PD face-to-faces should be interesting.

 

[canjosh]

My face was painted like a warrior though

Did you do the haka?

 

[BadVB750]

I had my second appendicitis with nebulous signs and symptoms and just a + UA.

So, I started thinking that a lot of the classical clinic presentations were written well before the advent of CT. Over the years a lot of people were probably sent home when they had questionable symptoms and then diagnosed once they perforated or just got really sick. My question is now that we have CT is it unacceptable to send someone home with an early appendicitis? Should the classic presentation be re-written and the pathway always end with CT?

 

[southerndoc]

I had my second appendicitis with nebulous signs and symptoms and just a + UA.

So, I started thinking that a lot of the classical clinic presentations were written well before the advent of CT. Over the years a lot of people were probably sent home when they had questionable symptoms and then diagnosed once they perforated or just got really sick. My question is now that we have CT is it unacceptable to send someone home with an early appendicitis? Should the classic presentation be re-written and the pathway always end with CT?

Just be cautious with CT's. I fear we're going to have a wave of malignancies floating around and another flurry of lawsuits by ambulance chasers (which will become CT chasers).

 

[EctopicFetus]

Ab pain without Fever, white count, vomiting, diarrhea get no CT after that it is an art. How much do they bother me. If they dont they get a 24 hour recheck.

 

[leviathan]

Just be cautious with CT's. I fear we're going to have a wave of malignancies floating around and another flurry of lawsuits by ambulance chasers (which will become CT chasers).

Lose-lose situation!!! 🙁

 

[roja]

Experience definately helps. Do not be afraid of that nagging feeling. Do not be afraid of serial exams either (good call).

When you have less suspicion and the pain doesn't go away, watch em and do what you did. Sure you will get a high negative rate, but still.


And don't be afraid of good discharge instructions. (saving grace in EM)


Appy can be vague, weird and decidedly NONTRADITIONAL.


Great catch.

 

[DrQuinn]

I think it was my third week as an EM attending, I had a restaurant waitress come in with n/v/d. No abdominal pain, mostly just cramping from vomiting. I figured it was a sure GE'itis, given IVF, antiemetics. Got better afte rthe first liter and 90 minutes in the ED. another check 1 hour later had more abdominal pain. I was about 2 hours to the end of my shift and figured it was time to send her out. I go recheck her, and now she's got RLQ pain. mild rebound. I CT her, and she's got an appy. Go figure.

Q

 

[EM OR BUST]

females + abdominal pain = irritating

only because you hate pelvic exams😀