Ok people, I sure would appreciate it if you would take the time to read the textbook prior to coming to see me. Some of you have definitely been slacking of late — like with appendicitis. If you had read beforehand you’d know you’re supposed to show up with vague abdominal pain beginning at the belly button and later migrating down to the right lower quadrant with development of a low grade fever and some associated vomiting and anorexia. Your white blood count would be elevated, your urine negative, and your CAT scan confirmatory although maybe we wouldn’t have even gotten one since you presented so freaking classically. (Ha, kidding, who operates without a scan?)
Instead, here’s how the last three patients I’ve diagnosed with appendicitis have presented.
1. Lady in her late 30’s stocks shelves at a local grocery store. She lifts a heavy box and feels a twinge in her right lower abdomen. It’s mild but persistent for the next 4 hours so she presents to have it checked out. No fever, no vomiting, good appetite. On exam, she’s tender right over McBurney’s point. Hmm, I tell her, well you’re right it’s probably just a muscle strain but let’s check your blood and urine, give you some toradol, and let you hang out with us for a while.
Urine came back negative, white count was at the upper limits of normal. Repeat exam was pretty much the same. Well ma’am, we better run you through the scanner. Ok, crazy doctor, if you want to get a cat scan of my muscle strain, fine by me. Back it came as acute appendicitis, and I still don’t think she could believe it even as she was being wheeled to the OR.
2. Guy in his mid 30’s with a day and a half of abdominal pain. No fever, no vomiting, and had some bacon and pancakes just a couple of hours before showing up. Exam showed tenderness again right over McBurney’s point. White count was 6.1 (normal) without a left shift. Again because of the exam I scanned him, and again it came back as appendicitis. He reacted just the opposite, he was pretty sure that’s what it was all along.
3. Lady in her early 50’s with 3 hours of abdominal pain, pointing to her left upper quadrant. She vomited just prior to making the trip to the ER. No fever, no appetite. On exam mild tenderness just below her rib cage on the left with no right lower quadrant tenderness. White count was elevated at 23. I reexamined her about an hour and a half later, and now she was really tender five centimeters or so above McBurney’s point. To the scanner she went, and back she came with appendicitis.
Then some of you read the textbook, more or less, but show up without appendicitis. Instead you come with gastroenteritis, or mesenteric adenitis, or colitis, or some other nonsense.
Tricky, tricky, appendicitis.
December 10, 2007 at 6:05 am
In classic cases of appendicitis we do operate withouth a scan.
December 10, 2007 at 7:24 am
This one scared me. Number one I would have sent home without any workup (but with a strict “Call me if you’re not better or getting worse”). Number two I would have scanned and done bloodwork. Number three? Come on, LUQ pain? That’s not even fair…
Again I say, this is why “overtesting” in the ER is a good thing.
December 10, 2007 at 11:26 am
amen on the overtesting, Dr. Smak. Ten, do you ever see appendicitis w/o tenderness at McBurney’s point? And if there hadn’t been that particular symptom in each of these cases, would you have still known you should order the scan?
Bruce
OMS-1
December 10, 2007 at 3:54 pm
Bruce,
There is almost always tenderness to palpation over the right lower quadrant on exam, even though they may complain of pain somewhere else, it may not be there initially, and it may not be right at McBurney’s point. Rarely they are tender elsewhere, like in a pregnant patient (uterus pushing the appendix up) or with a retrocecal appendix (an anatomic variant).
My basic algorithm is if I’m pretty sure it’s appendicitis I’ll scan right off the bat (the surgeons are not interested in operating without a scan). If I’m less sure, like in these cases, I’ll order some tests, give some fluid and pain meds, and let time be my friend. If their stuff comes back normal and they feel better I usually send them home with instructions on what to look out for. If something comes back abnormal (white count of 23) or their exam is the same or has progressed, I’ll typically scan. There are always exceptions, but for the most part that’s pretty much how I roll
December 10, 2007 at 4:11 pm
A couple of weird ones I’ve had recently:
54 year old woman with syncope, no abdominal pain initially, negative syncope workup, but, “now I’ve got this pain down here…”
33 year old woman with a chief complaint of depression for 3 months since her divorce, and also a few days of abdominal pain (normal white count).
December 10, 2007 at 5:58 pm
I am hoping that in the future we will be able to prophylactically laser-ablate the appendix on every school-age child.
In the meantime, it is extremely difficult to get anyone to operate on classical presentations without a catscan in my hospital. Worse yet, is the contrast-waiting game when the scan comes back as “appendix not visualized”. Surgery tends to admit and sit on those at our place and see if their abd exam changes.
December 10, 2007 at 8:23 pm
I got one the other day who c/o LLQ abd pain, but –oh–when you push on the left side, it makes the right side hurt, but palpating the right side didn’t really hurt that much. Eventually, she got out her textbook and decided the right side hurt more.
December 10, 2007 at 9:18 pm
Hmmmm. Which one of these three would have been included in the 30% of CT scans that are “overordered” by emergency physicians?
Oops. Right. They were all appropriate because they showed something. Its the other dozen or so normal scans in patients with RLQ pain that we’ll get bashed for.
Sorry about bringing my rant to your blog. It’s just cases like this that scare me and people telling us that we order too many tests that just tick me off.
December 10, 2007 at 9:28 pm
[...] actually believe that 30 percent of CT scans are “unnecessary,” on how many of the above cases would you have prospectively ordered CT scans? All of them, right? After all, they were all [...]
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December 11, 2007 at 12:36 pm
Nurse K — Rovsing’s sign.
WhiteCoat — Feel free to drop by and rant anytime. People have got to realize that a test is not validated by its result.
December 13, 2007 at 1:24 am
I was sooooo close to being discharged with appendicitis. C-scan was negative; intense pain & vomiting relieved after my co-occuring impaction was dealt with; no fever. The only thing was my damned’ high wbc. So the other ER doc on call goes: “Well, hell, she has insurance and if it’s going to happen, it’ll happen to a doctor’s kid. Take her to surgery.” My appendix ruptured as the surgeon was taking it out. :O
May 10, 2008 at 1:51 am
Great blog!
Indeed appendicitis is tricky. 2 weeks ago I was forced to go to the doc’s. Presented with mild fever, sever pain in RLQ, loss of appetite, and pain behind belly button. Every time the doc pushed my belly I would scream. Off to the lab I went to get a UA, CT scan, and a CBC.
All the tests came back normal. No one knows what happened. The tests saved me from surgery that day.
Fast forward to now…sudden pain in RLQ again and screaming pain when belly is pushed on. Who knows what it is. Maybe I’ll get told I have virus again.
December 18, 2008 at 10:12 am
14 year old presented with sudden onset RLQ pain and nausea. The first US neg, CT with contrast with a questionable 2mm vague finding on CT scan, radiologist can not decide if fecalith or contrast since so small, otherwise, normal CT. Surgical team will not consider surgery since US and CT look to be normal except for nonspecific findings Second US obtained appendix not visualized. WBC neg, UA and HCG neg. Is is still possible the 14 year old could have appendicitis? She continues to have RLQ pain over Mc Burney’s point and intermittent nausea.