The case of the atypical appendix

[ghost dog]

I saw a 19 year old patient 4 weeks ago, who presented with malaise and anorexia.
2 weeks prior she had a 3 day episode of vomiting and diarrhea , which had resolved.

However, her grandmother was quite concerned in regards to her anorexia.

On exam, she exhibited quite significant orthostatic hypotension. She did not complain of abdominal pain.

As a result of the clinical picture, I sent her to the ER, where it turned out she had a ruptured appendix and a WBC of 30. This was treated with percutaneous drains for the abscesses, and the patient was admitted for approximately 3 days.

I saw the pt again today in reassessment post drains. This time the pt complained of fatigue and mild malaise. She had eaten that day, was tolerating fluids, and passing flatus.

On exam she exhibited the following:

Oral Temp: 37.5 / 37.7 C ( 2 readings taken)

BP: 130 / 80
HR: 120 / reg
Sitting

BP: 120 / 75
HR: 134 / reg
Standing ( pt complained of mild presyncope)

Her abdominal exam failed to show peritoneal signs, although she did exhibit moderate tenderness in the drain regions. She had bandages over her abdo where the drains had been removed.

I ordered a stat CBC, creatinine, etc. with reassessment tomorrow.

How many peeps would have sent her to the ER versus close re-assessment ?

and why?

Using the retrospectospcope, I believe I made 2 mistakes here:

1. Considering her abnormal vitals: I should have sent this pt to the ER. I did not , as I believe I was influenced by the fact that I had previously sent the pt and her GM to the ER 4 weeks ago.

I did counsel the pt and her GM that she should immediately attend the ER should she get worse ( i.e. abdo pain, vomiting, fever, etc.). At this point, the GM complained about
the significant wait experienced in the ER 4 weeks ago. I indicated that this was immaterial in the care of her grand-daughter, as this could be a potentially life-theatening problem.

2. In retrospect, I should have at least talked with surgery and obtained specialist feedback.

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[lowbudget]

I would need more data. What was respiratory rate? Did she have subjective/measured fevers within last 24 hours? Was she discharged with antibiotics? What did the area around the drain looked like? Most importantly, were the drains draining?

Agree at minimal with the order CBC and basic metabolic panel. I would have added ESR and C-reactive protein to trend as inflammatory markers because your febrile response could be blunted by pain meds.

If her respiratory rate was high in the office, she would have met SIRS criteria and I would have directly readmitted her (bypass the ER) to the floor with blood cultures and another CT scan of the abdomen and pelvis with and without contrast to see if the abscess is back.

If she wasn't tachypneic in the office, I would have bolused her with 1 liter of NS in the office, maybe 2, to see if orthostasis and symptoms and/or supine tachycardia improved. And, I would want to know if she felt the urge to urinate. Because 19 year olds can hang on hemodynamically pretty well until the end and then fall off the cliff, if she had no improvement in those hemodynamic markers (HR, BP, urine output), I would directly admit her with the plan per above. Are we looking at SIRS/sepsis or are we looking at volume depletion due to malaise/fatigue?

If she responds to bolus, I would feel pretty good that, if she can tolerate orals and have no peritoneal signs, that she's probably going to be good until tomorrow when the CBC and labs come back.

If she's not on antibiotics now, I think it's a separate decision altogether. If you're worried or if the community you live in have you practicing defensive medicine, I would draw blood cultures and start her on something that covers gram-negative and anaerobes until more data is known.

If the drains aren't draining, I would flush them with sterile water/saline in the office and only if they don't drain would I call the surgeon.

I'm unlikely to send her to the ER because she's currently not experiencing any emergency. It would be a waste of resources, the patient's time/money, and may even delay care if you already have a plan for her. What we're worried about is a potential emergency, so what you need right now is more data and monitoring to see which direction she is moving, which I think can be achieved with some things you do in the office and on the floor.

 

[newdude2009]

The tachycardia is a bit confusing. I would have expected it to resolve since she is tolerating fluids now.
It could also be related to uncontrolled pain as well, so that is something to keep in the back of our minds.

 

[deleted87716]

Abscess/infection would be my main concern. I definitely would've gotten her surgeon on the phone to let them know what was going on, and to set up an urgent eval in their office. I'd only send her to the ED if that was the only way to get her checked out by a surgeon. An abdominal US wouldn't be a bad idea, either.

 

[ghost dog]

Abscess/infection would be my main concern. I definitely would've gotten her surgeon on the phone to let them know what was going on, and to set up an urgent eval in their office. I'd only send her to the ED if that was the only way to get her checked out by a surgeon. An abdominal US wouldn't be a bad idea, either.

I saw her in follow up today. She didn't die, which is always nice.

She's currently on 2 abx ( can't remember the names off the top of my head).

She was feeling better - less fatigue / malaise ( whatever the hell that means).

O/E:

Oral Temp: 37.2 C

RR was normal ( can't remember exact rate)

sitting
BP: 115 / 80
HR: 110

standing
BP: 120 / 70
HR: 120
( no complaints of presyncope today - a good thing)

abdo was WNL - no peritoneal signs.Areas around drain sites were pristine. The percutaneous drains had since been removed as of around 2 weeks ago.

Her bloods: Hgb 79
WBC: 14
Neurophils: 11

Compared to 1 month ago: her Hgb was around 100
and WBC was 35

I called up the surgeon's office, and couldn't get a hold of him,The admin tried to shuffle me around to another surgeon ( bunch of d-bags). I faxed the baseline and recent bloodwork, along with my physical findings. You don't want to talk with me ? That's fine. I documented on the paper that I faxed to your office , and that this was the case.

The patient has an appointment with this d-bag of a surgeon tomorrow.

I started her on iron pills.

 

[Hamhock]

From an EM perspective:

Send to the patient to the ED.

CRP and other stuff unnecessary. A lactate and Cr would be nice, as these will change management: CT and modified EGDTx.

Also, ultrasound would do little in this situation....not sure what you would be looking for except for maybe cutaneous/superficial abscess, which would still require CT in this clinical setting.

I feel like we get a lot of nonsense sent from outpatient clinics and I like to complain about it, but this seems like a slam dunk transfer to the ED.

If you or the GM are worried about the "wait", a phone call to the ED is likely to help (our clerks can't say we aren't there!).

HH

 

[ghost dog]

From an EM perspective:

Send to the patient to the ED.

CRP and other stuff unnecessary. A lactate and Cr would be nice, as these will change management: CT and modified EGDTx.

Also, ultrasound would do little in this situation....not sure what you would be looking for except for maybe cutaneous/superficial abscess, which would still require CT in this clinical setting.

I feel like we get a lot of nonsense sent from outpatient clinics and I like to complain about it, but this seems like a slam dunk transfer to the ED.

If you or the GM are worried about the "wait", a phone call to the ED is likely to help (our clerks can't say we aren't there!).

HH

Yes, I should I have sent her to the ER in retropect. I sent her home today, as her vitals seemed to be trending downwards ( but of course, she is still tachy, and has a white count and is anemic - she meets the SIRS critieria - which I realize now). I rarely ,if ever, see cases like this as don't do ER work ( and thus the reason for my call to the surgeon).

It really pisses me off that the general surgeon wouldn't speak to me on the phone. His goddamn administrator actually said that " it wasn't his responsibility " until the patient came to his office tomorrow. Well, gee, I'm sure the patient will really appreciate that if they die from septic shock tonight.

I just documented my concerns in a very formal manner, and faxed off a note to this jackhole's office.

 

[cabinbuilder]

Damn surgeons, I feel your pain. Sounds like the time I had an elderly osteoporotic patient who fell and had multiple fractures of the pubic rami. Do you think I could get hold of a local surgeon in Oregon just to talk to about management? Hell, No. I called my ortho guy in Texas who helped me out and said all those local guys really suck. Gotta love rural medicine.

 

[ghost dog]

Yes, I should I have sent her to the ER in retropect. I sent her home today, as her vitals seemed to be trending downwards ( but of course, she is still tachy, and has a white count and is anemic - she meets the SIRS critieria - which I realize now). I rarely ,if ever, see cases like this as don't do ER work ( and thus the reason for my call to the surgeon).

It really pisses me off that the general surgeon wouldn't speak to me on the phone. His goddamn administrator actually said that " it wasn't his responsibility " until the patient came to his office tomorrow. Well, gee, I'm sure the patient will really appreciate that if they die from septic shock tonight.

I just documented my concerns in a very formal manner, and faxed off a note to this jackhole's office.

The saga continues today :

After I sent my formal and quite comprehensive note to this consultant ( including the definition of SIRS), he sent me quite an elaborate reply.

Sure enough: pt sent to ER today for CT scan to rule out a psoas abscess.

His excuse for not answering my call:

1. He hadn't seen the patient yet.
2. His fellows don't have admitting privileges at the local hospital.

I still don't see why he couldn't have fielded my question in regards to this patient. I mean, hey douche, it's called being collegial. You : expert, me: generalist.

I thought we were on the same team, and the goal was to keep the patient alive ( as opposed to seeing how close to the brink of death we can get them before bringing them back).

He left a message on my machine at 7:30 AM, indicating that he wouldn't be in the office today.

Further update on this case:

Pt admitted to hospital, and underwent an unspecified abdo / surgical procedure. In hospital stay for 3 days, then discharged home. Doing well.