TOA vs PID vs Appy

[name?]

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So, I guess I can tell that I'm getting closer to graduation because some panicky thoughts of "what the hell do I do when I'm not at the jumbo academic center when this comes in?" are coming more often.

Had a case last night of a young woman with RLQ pain. Febrile, nauseous, borderline peritoneal with +McBurneys, psoas, Rovsing's. Pelvic has discharge, CMT and right adnexal tenderness. I was leaning towards appy, and scanned her--the CT showed possible appy vs TOA vs PID, with a decent amount of free fluid. I covered her for abdominal bugs and I had both gyn and surgery see her assuming she was going to get a scope done to see what needed to be taken out, and was pending an ultrasound when I left this morning.

So, what do you guys in the community do with your reproductive age women with RLQ pain and equivocal studies? I feel like the academic places with lots of house staff we can get consults easily and push a little bit more to get what we want, but I'm not sure how that plays out in the 'real world.' Thoughts?

Thanks

BR

 

[southerndoc]

I have both gyn and surgery available for consultation. Then again, I practice at a very large community hospital.

If you don't have both services available, you'll probably have to send her out to a place that does.

 

[Jeff698]

I'm in community practice but at a well staffed place. I do exactly what you did.

I think most decent community hospitals have surgery and GYN available. Once you get out into the rural areas you start getting into trouble. Of course, most of those places frequently don't even have the imaging technology available so you'd have to ship them out early anyway.

Take care,
Jeff

 

[docbooboo]

try working somewhere ultrasound is available ONLY 35hrs per week, CT's take 2-4 hours be transmitted and read, surgery is on divert every other weekend, nearest tertiry center is 2 hrs away.

 

[name?]

Thanks for the responses. Comforting to know that the backup is good on the outside.

 

[elwademd]

just curious : more history? (h/o std's for example) studies on the pelvic discharge?

 

[NinerNiner999]

You'll be fine and do what we all do regardless of where we practice - document your thoughts, conversations, interventions, and reasons for your decisions very, very well. You will only be held to the standard of your community. 🙂

 

[txterp98]

I'm basically echoing what everyone else says and what you already know is true...a surgeon and gynecologist need to evaluate the patient.

Just like in residency, though, expect some groaning and "I want the other service to see them first."

Ultimately in these cases, I've found that one of them takes the patient to surgery and the other is ready to scrub in if needed.

 

[pushinepi2]

So glad to see that, "groaning" transcends geographic locale! Bottom line is to always advocate for the patient's best interests. A young woman with peritoneal signs needs to be evaluated by a surgical service. The presence of PID (even if definitively diagnosed) doesn't preclude the diagnosis of appendicitis. The one benefit of working in "community" type hospitals is that you'll have the privilege of speaking with an attending level physician- even at our local community affiliate, a "joint" trip to the OR (GYN/SURG) isn't all that uncommon for sick patients with peritoneal signs.

As an aside, my favorite conflict to emerge out of these cases is the deuling radiology reports:
1) ULTRASOUND: POSSIBLE TOA, CLINICAL CORRELATION SUGGESTED, RECOMMEND CT SCANNING FOR FURTHER EVALUATION
2) CT SCAN: POSSIBLE TOA, CLINICAL CORRELATION SUGGESTED, RECOMMEND DEDICATED TRANSVAGINAL SONOGRAPHY, CANNOT EXCLUDE APPENDICITIS

Still, after all these years, CT scans haven't managed to cure one (1)!!!! damn case of appendicitis.

Sigh.

 

[name?]

As an aside, my favorite conflict to emerge out of these cases is the deuling radiology reports:
1) ULTRASOUND: POSSIBLE TOA, CLINICAL CORRELATION SUGGESTED, RECOMMEND CT SCANNING FOR FURTHER EVALUATION
2) CT SCAN: POSSIBLE TOA, CLINICAL CORRELATION SUGGESTED, RECOMMEND DEDICATED TRANSVAGINAL SONOGRAPHY, CANNOT EXCLUDE APPENDICITIS

Still, after all these years, CT scans haven't managed to cure one (1)!!!! damn case of appendicitis.

Sigh.

The CT read on my patient was great--something to the effect that it's either "a) appendicitis with adnexal inflammation or b) adnexal process with inflamed appy. Recommend US." I also liked the dance the radiologist did trying to avoid calling in the US tech an hour early when I talked to him, and then the CT read that insisted US was necessary to differentiate the two.

As for her pelvic-- she had tons of non-purulent discharge with only a moderate number of WBCs. She ended up having an early ruptured appy in the OR. Taken by surg after the US showed nothing but FF in the adnexa. Good times.

 

[docB]

The "Who's gonna take it to the OR?" dance is always one of my most hated scenarios. Invariably the patient doesn't have any insurance just to make the poison pill that much more bitter. And heaven help you if she's pregnant.

I recently had a 13 week pregnant patient with insurance who had an established OB. In fact the OB sent her to the ER because of her exam. WBC was 22K, no CMT, no d/c, Temp 100.5 and peritoneal RLQ TTP. I happened to get surgery on the phone first and his approach was pretty reasonable. He said he'd head on in and take her to the OR but he wanted the OB to come see the patient too and write a note agreeing that a laparoscopy was indicated. That made sense to me.

Of course the primary OB's partner who was now covering, as the primary OB had accomplished the old "dump to the ER and wait 'til someone else is on call" gambit, threaw a hissy fit and outright refused to come in. It got ugly. I got the chair of OB/Gyn involved. Interestingly he didn't call the jerk OB directly. He called the head of the OB's group who then really brought the hammer down. The last thing you want to hear as the owner of a group is how your on call is refusing to take care of one of the group's patients.

But that's how it usually works out. Fight all you want, the end result is always the same.