MEDICOLEGAL PEARLS – ACUTE APPENDICITIS
-Fifth most common cause of successful malpractice claims against emergency room physicians.
-57% of children younger than age 6 and 49% of patients older than age 60 with appendicitis are initially misdiagnosed.
-Atypical presentations are common in children and elderly (approximately 60-80% perforation rate).
-The total WBC count can be normal in up to 80% of cases in the first 24 hours.
-Fever and chills are present in 20% of patients with acute appendicitis.
-An abnormal urinalysis (>5 WBC’s or RBC’s per hpf) may be present in up to 30% of cases of appendicitis.
-Gastroenteritis is the most common discharge diagnosis when appendicitis is missed and is the discharge diagnosis that appears in more ED medicolegal cases than any other.
-There are false negative CT scans.
Recommendations:
The temperature is helpful only if febrile.
The WBC count is significant only if elevated. Normal WBC does not exclude the diagnosis of appendicitis, especially in the elderly.
Don’t be misled by an abnormal urinalysis. This does not exclude the possibility of appendicitis.
An adequate observation/repeat exam is extremely important.
If diagnosis is unclear on initial visit and patient is discharged, re-examine within 6-10 hours to avoid perforation.
Discharge instructions:
impression: acute abdominal pain, cause unknown
definite referral ( i.e. appointment arranged)
Re-examine in 6 – 10 hours
Abdominal pain written instruction sheet
Return sooner if worse.
