I had a thought the other day when I was walking out of the hospital, although I am most of the way through my 3rd year I have almost never seen a pt who was a "classic presentation."
If you read Cope you would be left with the impression that the qualities of pain, locations of referred pain, timing of onset etc will give you the correct dx. But I consistently read journal articles that describe the wild variation in presentation of even simple cases, there was that recent paper in AEM about appendicitis is peds that basically concluded that there was no "classic picture."
So the question for the higher-ups here is do you ever trust the story? I mean, a 55y/o obese dude complaining of RUQ pain that sounds clearly biliary with a +Murphy's aren't you always going to get the amylase/lipase and ROMI?
Is this a) the philosophy of EM, b) the fault of the attorneys, or c) the result of "getting fooled" by pts presenting in variable ways?
Remember that "classic" presentations were described by "classic" physicians working generally between 1850 and 1920. They had limited diagnostic tools. They could spin a crit, use a hemacytometer to do a white count, do a Schilling count (differential) and a gram stain. Their imaging consisted of none until the 1890s and plain films with or without barium. The way they knew they were right was at autopsy or operation.
Not surprisingly, they probably got the obvious stand outs and these became the "classic" descriptions. Usually, however the classic description is not the common one. Think of migraine classic vs common as the perfect example.
As to your specific question, I don't have enough info. For some 55 yo Ms I do the lipase and romi, others perhaps not. It's called judgement and it takes a while to get good at it (>10 years?)
I absolutely recommend memorization of Cope. I use less diagnostics then I used to, but a CT in hand is worth all of the clinical judgement and lab together and then some.
Am J Emerg Med. 2005 Oct;23(6):709-17.
Related Articles, Links
[SIZE=+1]
Derivation of a clinical guideline for the assessment of nonspecific abdominal pain: the Guideline for Abdominal Pain in the ED Setting (GAPEDS) Phase 1 Study.[/SIZE]
Gerhardt RT,
Nelson BK,
Keenan S,
Kernan L,
MacKersie A,
Lane MS.
Department of Emergency Medicine, Brooke Army Medical Center/San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX 78234, USA.
[email protected]
OBJECTIVE: The purpose of this study was to identify a clinical guideline for the evaluation of nonspecific abdominal pain (NSAP) using history, physical examination, laboratory analysis, acute abdominal series (AAS) radiographs, and nonenhanced helical computed tomography (NHCT) clinical predictor variables (CPVs). SETTING: The setting of this study was at an urban emergency department (ED) with 70,000 yearly visits. METHODS: This is an institutional review board-approved, prospective, observational study. The primary outcome variable was urgent intervention (UI), defined as a diagnosis requiring surgical or medical treatment to prevent death or major morbidity. Subjects underwent prompted history, physical, laboratory studies, AAS, and NHCT and were followed up to 6 months for ultimate diagnosis and outcome. CPVs were subjected to classification and regression tree analysis. RESULTS: One hundred sixty-five subjects were analyzed. Thirteen percent of subjects required UI within 24 hours of presentation; an additional 34% underwent elective interventions that mitigated morbidity or mortality. Four guideline models were generated. Model 1 consisted of history and physical, with a sensitivity of 25%, a specificity of 92%, a positive likelihood ratio of 3.17, and a negative likelihood ratio of 0.81. Model 2 consisted of model 1 with laboratory, with a sensitivity of 39%, a specificity of 88%, a positive likelihood ratio of 3.25, and a negative likelihood ratio of 0.69. Model 3 consisted of model 2 with AAS, with a sensitivity of 56%, a specificity of 81%, a positive likelihood ratio of 2.94, and a negative likelihood ratio of 0.54. Model 4 comprised all inputs, including NHCT, with a sensitivity of 92%, a specificity of 90%, a positive likelihood ratio of 9.2, and a negative likelihood ratio of 0.089. NHCT was the single most accurate CPV for UI. CONCLUSIONS: No clinical guideline was identified exclusive of NHCT that possessed adequate sensitivity for exclusion of UI. NHCT is a rational choice for decision support in the evaluation of NSAP and is likely the single most useful diagnostic adjunct available to augment the clinical evaluation.
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PMID: 16182976 [PubMed - indexed for MEDLINE]
