Page 1 of 2
You just heard a great lecture on minimizing radiation exposure from diagnostic testing and your next patient may give you the opportunity to put the lecturer’s plan into practice. The patient is a 19-year-old male who thinks he may have food poisoning due to the fact that he developed abdominal pain last night after eating a burrito at a local “Roach Coach”. He said it tasted fine, but soon after developed abdominal pain in his right lower abdomen. He denies any fever, vomiting, nausea or diarrhea, but did say he hasn’t been hungry this morning. The pain is constant, non-migratory and is gradually getting worse. He motions to a specific localized area with two fingers as he describes the pain. The pain has been present for about 14 hours. He tried some Pepto-Bismol but it didn’t help, but at least hasn’t caused any dark stool or salicylate induced duodenal ulcers.
On exam the patient has normal vital signs with a temperature of 98.2°F. There is no scleral icterus and his exam is essentially normal except for some tenderness to palpation in one small area in the right lower quadrant. Rovsing’s sing is negative. You check a psoas sign to check for retrocecal appendix inflammation and it is also negative. Thinking back to the lecture you just heard you wonder if this is a patient that your surgeon might take to the OR without the almost obligatory CT scan of the abdomen. You order labs and even consider adding a sed-rate, hoping if it is high it might buff your argument to skip the CT if the white count happens to come back normal. Finally, you place a call to your surgeon. You explain to the patient that you plan to give him some pain medication, but if the pain is only mild, it might be better to wait until you talk to the surgeon. You also briefly explain the risks and benefits of having surgery versus having a CT scan first. You don’t want him to think you are cutting corners or rushing so you make sure to tell him that it is always safer for you as a doctor to do more tests and you are more than happy to do it if he wants, but that you think it is safer for him to dodge the radiation bullet in this instance.
You weigh things in your head. The history and exam are not necessarily “textbook classic” but they are pretty suggestive, and you don’t really suspect any alternative diagnosis. The history of progressively worsening right lower quadrant pain, focal RLQ tenderness and the absence of ovaries are, in your mind, the most important elements of the true triad for acute appendicitis, even if the patient doesn’t have many associated symptoms. As you are mulling all of this over in your head, the on-call surgeon calls back. You make your case, emphasizing that this is a young patient and that avoiding radiation is therefore more important than in an older patient. The surgeon agrees with your reasoning, but states that he recently read a study that shows that CT scans decreases the risk of a negative laparotomy. (No duh, you think to yourself). He says, “Hold off on the CT for now. I’m upstairs. I’ll be down in fifteen minutes.”
Your labs come back ten minutes later showing a white count of 12.1 with 75% PMN’s. Unfortunately, you wish you hadn’t ordered the sed rate because it was only 5. The surgeon waltzes in just then, says hi, and sees the patient. Your optimism barometer takes a small dive when he comes out of the room and requests a CT scan. “Why try?” you think to yourself. It’s easier to just do what everyone else does; it’s harder to do the right thing. With your bubble burst, you walk back to your desk and your white coat accidentally catches on one of the handles of the ED ultrasound machine, catapults it across the floor right into the room the surgeon came from. The plug flies off the holder and miraculously makes a flawless entry into the wall outlet and turns itself on. You look down at the floor and see the bottle of ultrasound gel spinning at your feet. Could this be some sort of a sign?
“Hey Steve,” you say to your surgical colleague. “Have you ever used an ultrasound machine before to look for appendicitis?” You know his answer – neither have you, but maybe today is the day. You log onto EMresource.org to refresh your memory (shameless plug) and get some quick tips and then obtain the image shown above.
The surgeon is standing right next to you as you obtain the image. What does he say? Conclusion on NEXT page