Films and Scans
You are called to ED triage to evaluate a 30-year-old with stomach pains. “I think he has a kidney stone,” his mother volunteers by way of introduction. “You know his father had them also, and he just won’t settle down.”
The patient in question is a well-appearing male who makes poor eye contact but is ambulating without difficulty in the triage bay. “You know he has autism, and so it’s hard to tell sometimes what is wrong,” she continues. “But he is just not himself.” That explains why you are giving me the history, I think. But OK, I get it. The patient has some lower abdominal, R flank and RLQ pain without guarding but is not in any distress. He has vomited once today and maybe has been sick for a day or two (not clear). Vitals are normal.
After about a nanosecond of deliberation, you ask the triage nurse to start the basic stone study protocol and you head back to the main ED for more distractions. A while later, the CT is done, and you pop over to see it (by now you’ve learned the hard way to look at most of your own critical CT scans). What does it show?
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Another case illustrating that it is better to be lucky than good. The CT shows a beautiful, well-matured case of appendicitis, with lots of inflammation in the RLQ & free fluid (arrows) and an appendicolith just for good measure (circle). It is getting late in the evening, so you call the surgeon. “What is the white count?” he queries. You briefly consider making one up (“uhhhh . . . sixteen thousand”) with a plan to beg forgiveness later (“Oh, you know that was Mr. Jones’ WBC, I’m sorry”), but you refrain. After all, doctors are not supposed to lie or be sarcastic. After some minor delay-of-game to get all the labs back, the case is posted and the appendix removed in a timely fashion.
Fourth generation 64-slice CT scanning (now becoming universal) without contrast is a wonderful screening study for significant abdominal pathology, as well as for renal colic. We use it routinely for suspected kidney stone, and it is frequently positive for other entities such as appendicitis. The exceptions are the very thin, young patient or child (avoid) or an appendicitis that is less than 12 to 24 hours old. In addition, adding oral contrast to CT scanning for abdominal pain may add very little to its diagnostic accuracy. Despite increased use of CT scanning for appendicitis, the negative laparotomy rate is still about the same. We are scanning more for appendicitis, finding a “positive scan,” and still NOT finding appendicitis.
This case also illustrates the communication barriers and challenge of patients with developmental impairment in the ED. Adults with autism, MR and behavioral problems can be difficult to assess in the case of suspected abdominal pathology (not to mention just about everything else). Make full use of the family, who know the quirks of their loved ones, and have a low threshold for more serious illness or injury.
John Dallara, MD, practices emergency medicine in Virginia and North Carolina and directs the EM PREP Course. www.emprepcourse.com