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A 42-year-old male comes to the emergency department with left lower quadrant and suprapubic abdominal pain which has become progressively worse over the prior two days. The day of presentation he noted mild chills prompting him to come in for evaluation.

The patient states that he has had nearly identical symptoms twice in the past six years. On both occasions he was evaluated by a surgeon in the office, lab testing and a CT of the abdomen were performed, and diverticulitis was diagnosed. In both previous cases, the patient was given a two-week course of oral ciprofloxacin and metronidazole and made an uneventful recovery. He attempted to see the same surgeon for this episode of pain, but the surgeon had closed his practice and moved out of state. The patient has no other medical history and takes no other medications.

On examination, the patient has normal vital signs and is afebrile. His abdomen is moderately tender to palpation in the left lower quadrant and suprapubic region. There is minor localized left lower quadrant rebound tenderness present. Rectal examination is normal. No other abnormalities are present on physical examination.

The patient does not want lab testing or radiographic studies performed. Instead, he requests a prescription for two weeks of ciprofloxacin and metronidazole. He also requests the name of an on-call surgeon with whom he can follow up as an outpatient.

After some discussion, the patient agrees to a CBC and urinalysis in the emergency department, which are both normal. A check of the old medical records confirms the patient’s history of sigmoid diverticulitis.

The physician then discharges the patient with prescriptions for antibiotics and pain medications, along with a follow-up appointment at the on-call surgeon’s office in 48 hours. The patient also receives strict instructions to return to the emergency department if he gets worse.

Without knowing the patient’s outcome, did the emergency physician’s actions meet the standard of care?

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Comments   

# DiverticulitisR Thompson, M.D. 2009-05-02 13:29
I believe the care provided was that which a reasonable practitioner would provide under the same circumstances
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# jb 2009-05-02 18:52
I've encountered this before. If it is made clear to the patient and it is documented that this is not your typical practice, but is a unique circumstance whose risk the patient is willing to accept, I believe it is okay.
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# Acceptable CareMatt Everett 2009-05-03 00:31
I believe that the details given in this scenario make the care provided wholly acceptable. The patient was competent and the history he relayed in addition to the physical exam made a strong case for the presumptive diagnosis. The only caveat is that given his level of tenderness a 12 hour follow up for repeat abdominal exam may have been pursued.
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# emergency physicianPatrick Connell 2009-05-04 14:51
And just how tender was this patient??? Rebound??? This does not meet the "standard of care." Patient should be advised that without appropriate imaging some very critical issues can be missed. If the patient still refuses, he could be discharged with ABX and close follow-up but I would want him to sign something that states "I hereby refuse further imaging and studies as recommended as recommended by my ED physician, and I have been advised that there are potentially serious or life threatening conditions that could be missed. I am willing to accept those risks." BTW, was there a bruit?
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# David Whitten 2009-05-04 21:50
I agree with Dr Connell - should have a 12 to 24 hour followup and should sign a release as he indicates.
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# EM PhysicianJim Mensching, DO 2009-05-05 14:14
Sounds reasonable and meets standard of care. Review of medical records confirmed similar presentation in the past. Appropriate antibiotics were prescribed and timely follow up was arranged, with instructions to return if worse. Documenting clearly the discussion with the patient (and his ability to understand and accept responsibility) regarding the differential diagnosis and the inability to confirm the diagnosis or exclude others without testing also should be enough.
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# ER physicianpushpa bisarya MD 2009-05-05 16:07
other diagnosis must be considered as triple A , appendicitis.
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# MDSteve Richards 2009-05-05 17:58
Standard of care met. This patient has already been radiated twice in 6 years to diagnose diverticulitis. With normal vitals and normal WBC and identical presenting symptoms I would not repeat the CT.
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# ED PhysicianChazz in Texas 2009-05-05 19:29
With the significant tenderness and rebound, I believe this patient warrants a followup exam in 12 hours and if that falls on a weekend, a return to the ED for repeat evaluation. IV Cipro and IV metronidazole started up in the ED with an rx for outpatient treatment (for 2 weeks) would give this patient better opportunity to improve within the 12 hour wait. Documenting in the chart that the patient did not want imaging would be sufficient as long as this includes the patient acknowledging that the diagnosis is not clearcut and could represent other causes. The normal blood pressure and tenderness to the left of midline mitigates any obligation to rule out a AAA if indeed the patient has not been a smoker nor suffered from hypertension. Furthermore, 2 prior CT's of the abdomen within the past 6 years did not show aneurysmal changes. Certainly waiting 48 hours for reexamination does not meet the standard of care.
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# Rebound present = peritoneal sign = high risk = surgical consultationwingate 2009-05-06 14:16
Simple heuristics keep you out of court. Drs and nurses need to respect any degree of peritoneal findings on PE that persist. Their presence while not 100% specific means high probability of an impending surgical problem warranting at minimum a surgical consult to arrange disposition. Pt should be told of the complications of diverticulitis (perf, abscess etc...) can start out subtle but ultimately develop peritoneal signs and require surgical evaluation (heal with steal). Documenting "minor local left lower quad rebound tenderness" is like documenting "minor positive HCG" in a female with lower ABD pain and sending them out without the next step in the Dx w/u a pelvic US. If rebound or guarding absent (in nurses notes too), it is clearly reasonable and safe to DC with close f/u. The literature is clear that a maximum 12 hour follow-up is safe.
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# Emergency PhysicianMark Eich 2009-05-08 14:57
Not what I would recommend, but meets the standard of care if the patient refuses additional tests. DOCUMENT DOCUMENT DOCUMENT. Having the patient sign a refusal is a good idea.
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# Just another case of diverticulitis?Dan Mayer 2009-05-08 15:25
I think that the standard of care was met in this situation. The patient had no “danger signs” associated with his diverticulitis. I assumed that there was no other medical history meaning that he had normal appetite, was able to eat ok, no nausea, vomiting, diarrhea, or constipation, no light headedness no fever or chills, and the only symptom was pain in the left lower quadrant. His vital signs were all normal and his abdominal examination was relatively normal with only minor localized left lower quadrant direct and rebound tenderness. Also, the patient had a previous episode of diverticulitis that was successfully treated with oral antibiotics. He would therefore know what to look for if complications developed.

Certainly a trial of oral antibiotics with a close follow up appears to be very appropriate for this man. The converse, of course is that had any of those “danger signs” been positive, he most likely would have required imaging, admission, consultation or all of those.

The only fault that I can attribute to the care provided is that with a diagnosis as serious as diverticulitis it would have been appropriate to make a phone call to the patient’s primary care physician to “hand off” the patient and make sure that they were set up for follow up. Whether that crosses the line of practice below the standard of care is a little bit tenuous and unrealistic.

Dan Mayer
Professor of Emergency Medicine
Albany Medical College
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# Depends on the communityJohn Frey 2009-05-14 20:08
If this is a small community with close followup and good communication, it would be appropriate to prescribe, discharge, and document conversations with the primary md and patient. If this is a large community, like Las Vegas, with poorer followup and a strong propensity for lawyer involved communications, it would be prudent to make the patient go AMA. You have to know the terrain you practice in.
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