A child with a history c/w acute appendicitis, RLQ tenderness, leukocytosis, and an abnormal appendix on u/s has previously been a classic, unambiguous indication for its removal. Things are changing and there seems to be a tendency to rely only on labs and imaging rather than considering the value of the H&P. There also seems to be pressure now to make early appendicitis a medical disease, something the surgeons are either uninterested in managing or excluded from involvement until the patient is in trouble. I would add concern as to the nuances of hospital culture in the management of such cases. Maybe their surgeons don't do pediatric cases or the particular surgeon on call is a piece of work. I am a general surgeon. I can't think of any surgeon who thinks a negative exploration in cases like this is worse than a missed appendicitis. This is an easy consult for us. Man up. Just call.
I do believe the PE is extremely important in patient care. I often hear from patients that the ER provider did not examine them. In this case the Physical Exam could have been critical. If the exam was negative and the labs and imaging were inconclusive, discharge and follow up may have been appropriate. If the PE was suggesting appendicitis, observation with serial exams or a Surgical Consultation would be warranted. If there was still concern, a CT scan could have been ordered.
Bottom line, a good History and Physical Examination may have prevented the serious complications.
Alvarado score is likely appendicitis. Be wary to send this home.
US didn’t mention compressibility, which needs mention. Also US should not be used to rule out appendicitis, just avoid CT on a classic appendicitis. Typically the surgeons want a CT anyway though and the parents get tired of waiting, yet another quagmire.
She should not have been sent home with her appendix still in.
I find it absolutely amazing that was no mention of a physical exam. Regardless of the imaging, the exam may have show evidence of RLQ tenderness, guarding, rebound tenderness and even possibly a Rosvings sign. Appendicitis is a diagnosis made by a History and a Physical exam. It is supported by lab and X-ray.
Physical exams really don't make much of an appearance in most med mal cases. Attorneys love to use radiology reports and labs, but don't really appreciate the significance of the exam. Do you mean CT, not x-ray for the diagnosis of appendicitis?
I do believe that although the case seemed obvious in retrospect, as the diagnosis is being worked out, things don't seem as obvious, especially for an ER physician with limited time and surgical training. When it comes to appendicitis, girls are tricky. Of course, he/she could have just consulted a surgeon. However, it is not clear the practice setting/location of this ER. I am amazed at how the "expert" physician mentions that the ER doctor should have ordered a CT or MRI. Really? With the push towards limiting radiation in children or costly imaging, this suggestion seems laughable. I think that in this case, there was enough information where surgery would be justified, with an Alvarado score of at least 5. Hospital observation is also reasonable. She appeared septic too.
I agree. I’m not sure what additional imaging would have added in this obvious scenario. We hardly get appendicitis cases this clear cut. In some more ambiguous cases though, which seems to be all I get, I do think that imaging, particularly CT, helps clarify diagnoses and prevent unnecessary surgeries.
Its always interesting to see how practice patterns vary on this. The ER doctors always joke that if you don't order imaging, the surgeon will just ask to get the CT before taking them to the OR. And if you do order the imaging, they'll say "why'd you order a CT? This is a clinical diagnosis and I would have taken them straight to the OR!"
A child with a history c/w acute appendicitis, RLQ tenderness, leukocytosis, and an abnormal appendix on u/s has previously been a classic, unambiguous indication for its removal. Things are changing and there seems to be a tendency to rely only on labs and imaging rather than considering the value of the H&P. There also seems to be pressure now to make early appendicitis a medical disease, something the surgeons are either uninterested in managing or excluded from involvement until the patient is in trouble. I would add concern as to the nuances of hospital culture in the management of such cases. Maybe their surgeons don't do pediatric cases or the particular surgeon on call is a piece of work. I am a general surgeon. I can't think of any surgeon who thinks a negative exploration in cases like this is worse than a missed appendicitis. This is an easy consult for us. Man up. Just call.
I do believe the PE is extremely important in patient care. I often hear from patients that the ER provider did not examine them. In this case the Physical Exam could have been critical. If the exam was negative and the labs and imaging were inconclusive, discharge and follow up may have been appropriate. If the PE was suggesting appendicitis, observation with serial exams or a Surgical Consultation would be warranted. If there was still concern, a CT scan could have been ordered.
Bottom line, a good History and Physical Examination may have prevented the serious complications.
Alvarado score is likely appendicitis. Be wary to send this home.
US didn’t mention compressibility, which needs mention. Also US should not be used to rule out appendicitis, just avoid CT on a classic appendicitis. Typically the surgeons want a CT anyway though and the parents get tired of waiting, yet another quagmire.
She should not have been sent home with her appendix still in.
Its also odd that they saw an appendicolith on ultrasound, I've see them on CT reads but not on ultrasound.
I find it absolutely amazing that was no mention of a physical exam. Regardless of the imaging, the exam may have show evidence of RLQ tenderness, guarding, rebound tenderness and even possibly a Rosvings sign. Appendicitis is a diagnosis made by a History and a Physical exam. It is supported by lab and X-ray.
Physical exams really don't make much of an appearance in most med mal cases. Attorneys love to use radiology reports and labs, but don't really appreciate the significance of the exam. Do you mean CT, not x-ray for the diagnosis of appendicitis?
I do believe that although the case seemed obvious in retrospect, as the diagnosis is being worked out, things don't seem as obvious, especially for an ER physician with limited time and surgical training. When it comes to appendicitis, girls are tricky. Of course, he/she could have just consulted a surgeon. However, it is not clear the practice setting/location of this ER. I am amazed at how the "expert" physician mentions that the ER doctor should have ordered a CT or MRI. Really? With the push towards limiting radiation in children or costly imaging, this suggestion seems laughable. I think that in this case, there was enough information where surgery would be justified, with an Alvarado score of at least 5. Hospital observation is also reasonable. She appeared septic too.
I agree. I’m not sure what additional imaging would have added in this obvious scenario. We hardly get appendicitis cases this clear cut. In some more ambiguous cases though, which seems to be all I get, I do think that imaging, particularly CT, helps clarify diagnoses and prevent unnecessary surgeries.
Its always interesting to see how practice patterns vary on this. The ER doctors always joke that if you don't order imaging, the surgeon will just ask to get the CT before taking them to the OR. And if you do order the imaging, they'll say "why'd you order a CT? This is a clinical diagnosis and I would have taken them straight to the OR!"