rcdavis Posted August 31, 2011 Share Posted August 31, 2011 Okay. Here's what happened. Was gonna post a teaching case, but frankly, am too tired. But the lesson is interesting. 32 y/o wf, healthy, on no Meds, non smoker, non drinker, works as a secretary in an office comes to a local urgent care where I was moonlighting complaing of flank pai. Awoken last night with colicky sharp stabbing RT flank pains radiant circumfrentally to the ruq, and then caudal towards the pelvis. Pains at worse are 9/10. last 5-15 minutes. Then stop. Completely pain free except more maybe a dull ache. Some nausea when pains worse, better when pains go away. No vomit. No aggravating nor relieving factors. Worsening to point that, despite no insurance, comes to office. No local PCP . No headache, other belly pain, cough, shortness of breath, dyspnea, fever, chills, night sweats, Mellana hematachezia. Normal stools. No gross hematuria, Dysuria, or urethral symptoms. no jaundice. No sore throat. Before the colic, she felt " bloated" Fm hx neg for anything x Htn. PE entirely normal vitals. Uncomfortable wf who, during colicky spasm while giving hx, doubles over for 2-3 minus until passes 50% then eases off enough could sit still and talk. PE entirely normal except RT flank percussion tenderness and abdominal wall tenderness laterally to ruq. ( percussion duplicates colicky pain). Neg murphys. Neg lloyds. Neg mcburney's tenderness. pelvic nl CBC 11.9 WBC, else normal Upt neg. UA 2+ ob, 50-75 rbi/hpf Because of sx( and no injectable narcs), toradol 60 mg I'm given--> mild to moderate relief. D/t finances, PT really really does not want xray nor any further imaging. Had long talk with her. My clinical impression, based on years of EM experience , the hx and the PE was ureter colic. I was concerned about a high grade obstruction. And I wanted to document stone size, position and Hydro- ureter or hydronephrosis. She finally acquiesced and let me get a NCCT for the above reasons.... 60 minutes Katerina, I get a call from the radiologist. Any thoughts? .... .... .... .... .... .... .... .... .... .... ..... Yup. No stone. .... .... ... .... ... ... .... ... High riding retrocecal appendicitis : inflammed swollen, with fatty inflammatory changes. Surgery confirmed. efff me!!!!! Long talk with her... Clinically believed she G2p2 lnmp 4 days ago ( just finishing, entirely normal) Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 1, 2011 Moderator Share Posted September 1, 2011 that's fooled me before too. had one 2 weeks ago. older guy(70's) looked very much like an sbo. distended belly, generalized abd pain x 2 weeks, burping foul smelling stuff, n/v post meals, no fever, wbc around 11(which I guess I discounted due to n/v), nl urine, nl cmp. no recent bm's, etc upright abd film c/w sbo. quick turf to medicine with surg consult with order for f/u ct from the floor . yup, he had an sbo but he also had a ruptured retroceccal appendix....radiologist thought it was a "chronic appendicitis with eventual rupture". Link to comment Share on other sites More sharing options...
polarbebe Posted September 7, 2011 Share Posted September 7, 2011 Thanks for the teaching point. Link to comment Share on other sites More sharing options...
pahopeful Posted September 9, 2011 Share Posted September 9, 2011 Good case. Thanks for posting. Link to comment Share on other sites More sharing options...
Emerson Posted September 15, 2011 Share Posted September 15, 2011 I had a similar case of RUQ/Epigastric pain in a 50 y/o M with a history of bowel resection, secondary to CA. I was quite certain he was obstructed, came back as a positive appy. Goes to show, the appendix is where the surgeon finds it. Link to comment Share on other sites More sharing options...
delco714 Posted September 15, 2011 Share Posted September 15, 2011 Wow! surprise. Was thinking of the same/similar horse. What a twist. Good stuff here. Thanks Link to comment Share on other sites More sharing options...
quirkymedic Posted September 17, 2011 Share Posted September 17, 2011 I had this same scenario last week, but it was on a 30 yo f. UA shows +leuks,+heme, treated earlier in the day at her PCP office for uti. Came into the er with R flank pain that radiated around to her RUQ. No fever, Normal VS.. WBC count 12.2. No bands. All other labs normal. 30 toridol iv (she was refusing narcs as she was in a recovery program) with significant relief. She is begging me to let her go home. I run it by my SP. Not finding anything lab or exam wise, my SP and I agree to send her home with very specific return instructions. Comes back 12 hours later looking like he!!. CT shows retrocecal appy with microperf. ends up getting an abscess, stay in hospital is 11 complicated days. Now I feel like absolute crap. Just got my *** chewed in M&M for it on thursday, am really wondering if EM is for me. I am VERY new (9 mos out of school, 6 mos on the job) this really scared me. I try to be very thorough on my exams, but sometimes stuff like this throws you. It is not feasible to CT everyone with belly pain. In fact, I have to practically beg for CT scans where I'm at. (now I just order them if I think I really need them.. and ask for forgiveness rather than permission... it's just easier that way) .. It's been a really rough week.... sorry about the venting Link to comment Share on other sites More sharing options...
delco714 Posted September 18, 2011 Share Posted September 18, 2011 Don't beat yourself up over it. It happens. As you see here, there are just times where the presenting case is not obvious. Sometimes the patient doesn't read the book. Live and learn and don't make the same mistake twice! Link to comment Share on other sites More sharing options...
bobuddy Posted September 18, 2011 Share Posted September 18, 2011 Had a very similar case in our FP office last week. 45 year old AA woman with history of extensive crohn's - 12 hour h/o RUQ pain, negative murphys. Neg psoas and neg heel tap, etc. UA normal. No fever. White count - 4.5 with NO left shift. CMP/amy,lpse normal. ONLY due to h/o crohn's do I get a CT with contrast - YEP - appendicitis. I could have been burned bad if I didnt look. Link to comment Share on other sites More sharing options...
sk732 Posted September 19, 2011 Share Posted September 19, 2011 The average lay person thinks that appendicitis is such an easy pick up - it isn't at all. I've seen maybe 3 cases that were textbook classical - the rest were weird at best, out in left field somewhere at worst. We had a small run of them in our ER here this week - all presented weird with vague symptoms. If someone chewed you out at M&M rounds, well why wasn't your SP as well - after all, they cleared them for DC. Don't forget, more often than not, the asshat that did that to you wasn't the one that saw that patient, so their hindsight is an awful lot clearer with ALL the facts in front of them. Besides, you *** was covered by the fact you did this with the chart: "D/W with SP and advised patient S&S for immediate return to ER" (I'm hoping that anyway :smile: ) or words to that effect and that's what that patient did. Remember - the only patient that reads the textbook has Muchausen's Syndrome. SK Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted September 19, 2011 Administrator Share Posted September 19, 2011 Remember - the only patient that reads the textbook has Muchausen's Syndrome. Ooh, I'm stealing that one! Link to comment Share on other sites More sharing options...
quirkymedic Posted September 19, 2011 Share Posted September 19, 2011 The average lay person thinks that appendicitis is such an easy pick up - it isn't at all. I've seen maybe 3 cases that were textbook classical - the rest were weird at best, out in left field somewhere at worst. We had a small run of them in our ER here this week - all presented weird with vague symptoms. If someone chewed you out at M&M rounds, well why wasn't your SP as well - after all, they cleared them for DC. Don't forget, more often than not, the asshat that did that to you wasn't the one that saw that patient, so their hindsight is an awful lot clearer with ALL the facts in front of them. Besides, you *** was covered by the fact you did this with the chart: "D/W with SP and advised patient S&S for immediate return to ER" (I'm hoping that anyway :smile: ) or words to that effect and that's what that patient did. Remember - the only patient that reads the textbook has Muchausen's Syndrome. SK yep you are absolutely right. The doc that chewed my A$$ never saw the patient. I did document that I discussed with my SP and to have the pt return to er immediately if symptoms continue... which the pt did. My SP remembered the case and was actually the doc who saw the pt when she came back in. My SP did back me up that it was a very odd presentation of an appy. So I had that... but they were out to crucify someone. In fact, the director chewed my a$$ further for "not recognizing SIRS criteria" based on the patients heart rate and resp rate. Apparently the triage nurse wrote on her scrap paper hr of 92, and rr of 20, which is SIRS criteria for us, but the EMR had completely different vitals- heart rate of 86 and RR of 16. Of course I only had access to the EMR vitals. Of course the director went by the nurse's scrap paper notes, and not what was in my EMR note- where the VS are imported over from the triage EMR nursing notes... It was just a nightmare and no matter what I said, even bringing up the discrepancy in VS, it just fell on deaf ears. It just sucked all around. It was my first M&M and hopefully the last. It definitely makes me more aware of what I write in my note, how thorough my exams are (or are not) and how important it is to DOCUMENT EVERYTHING! if anyone has any suggestions for a better "appy exam", I would love to get some opinions. Of course I do the exams.... Psoas, rebound, mcburneys, heel tap... even checking for CRP... but if there are any subtle tips for making you tune into appy- rather than ovarian cyst or renal stones, etc... I would love to hear it. I do NOT want to miss another one. also, I just want to say thank you to everyone on here, seeing things from an experienced practitioner's perspective is very helpful to us newbies! :) Link to comment Share on other sites More sharing options...
sk732 Posted September 21, 2011 Share Posted September 21, 2011 History - I think one thing that always tunes me into having it high up the differential list is appetite...funny how APPEtite and APPEndicitis seem to have the same prefix, lol. I also ask about the drive over - they don't like bumpy roads and will feel every little pebble. But I think the thing that sends me really down that road is appetite - they really don't like eating, and it's often brewing for awhile before stuff sets in. Positive stethoscope sign as well - listen over McBurney's or around the umbilical region and push a bit on the stethoscope. They'll react to that...I also use that to suss out malingering too, as they think you're listening vs actually doing a subtle palpation. SK Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted September 21, 2011 Administrator Share Posted September 21, 2011 In fact, the director chewed my a$$ further for "not recognizing SIRS criteria" based on the patients heart rate and resp rate. Apparently the triage nurse wrote on her scrap paper hr of 92, and rr of 20, which is SIRS criteria for us, but the EMR had completely different vitals- heart rate of 86 and RR of 16. Of course I only had access to the EMR vitals. Of course the director went by the nurse's scrap paper notes, and not what was in my EMR note- where the VS are imported over from the triage EMR nursing notes... It was just a nightmare and no matter what I said, even bringing up the discrepancy in VS, it just fell on deaf ears. Don't let that stand indefinitely. If there's an error somewhere in the system, document it. NEVER sign a report that assigns you blame inappropriately; the right way to do that is to make sure the entire picture is painted properly, and owning up to everything that was really your fault, AND everything that you could have done better. This isn't for your ego, or your career--this is for the next patient to whom this will happen. Mind you, an M&M is the worst place to deflect criticism. If you get blindsided unfairly, sometimes the best thing you can do is to defer, and then get your facts together and quietly address the matter with the director (or whomever was busy chewing on you) in a private setting where you can focus on the problem without threatening a public loss of face if he admits that he was unreasonable. Never forget, that one of the unwritten rules of any job is "make your boss look good", but that can be a really hard balancing act: you need to not talk back to him in front of his peers, but you also need to fix the underlying system for the sake of patient safety. Link to comment Share on other sites More sharing options...
skyblu Posted October 14, 2011 Share Posted October 14, 2011 I just had a retrocecal appendix yesterday! I discussed with the radiologist because I wasn't sure, stone (infected) vs retrocecal apply. Patient looked like crap, white count of 22.2 (!!), so we went with the non-contrast CT but keeping in mind the possible apply, and sure enough, there it was! Not sure if it is easily seen without contrast normally, but I guess the radiologist was looking for it after our discussion. Very cool case! Link to comment Share on other sites More sharing options...
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