Tuesday, January 19, 2010

Appendicitis is a CLINICAL diagnosis

This is a pet peeve of mine. The loss of clinical assessment skills. I have seen over the past 20 years, an increasing reliance on tests of all sorts to evaluate things that might not need a test. I will also say that I have been guilty of this as well. However, some diagnoses are rather straightforward.

I had a patient a few years back who was a younger female patient with RLQ abdominal pain. Her story was classic. Started as periumbilical pain, migrated to the RLQ, complained of fever, nausea with no vomiting, and anorexia (lack of appetite). On exam she had tenderness at McBurneys, and a positive Psoas. She also had rebound tenderness on the LLQ, and guarding with palpation. WBC was around 12. I called our general surgery service and was confronted with the question. All ER docs know this question "What did the CT scan show?" I told the resident that there was no CT scan, and that she didn't need one. The resident proceeded to argue that perhaps it could be ovarian. I explained calmly that it was not ovarian. It was a CLASSIC presentation of appendicitis. Silence. I finally told the resident that I would only order a CT scan if they came DOWN to the ER, and LAID THERE HANDS on the patient. Otherwise, NO way. Resident comes down...not happy. (I don't really care) 5 minutes later she walks out, and says "Yep, we're taking her to the OR". The attending surgeon was so happy I thought that they were going to hug me. I saved that patient around 1700 dollars for an enhanced CT, and unnecessary radiation, which she DID NOT need.

We need to return to a focus on clinical exam techniques, and the development of a clinical gestalt.

Lastly, I would only add, that of course NOT every patient fits this scenario. Many have a mixture of symptoms that makes delineation much more difficult. But when it is clear.....

Sometimes less is more.


terri c said...

YES!!! Thank you. A related pet peeve of mine is an over-reliance on protocols that sometimes means the patient is not really "seen," only the steps in the protocol.

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preciousbabysite said...

I did want to say as well as that your nurse is a line of defense that some Drs do not use, they see the patient and know the history.

Jackie Savi-Cannon

claudette said...

Absolutely. What's interesting is that even if the CT was negative in that case, the patient would STILL be taken to the OR because of the clinical presentation. The test, in some cases, is a waste of time, money and exposure for the patient.