Estoy desilusionada.

This is a story of modern American medicine. You can take from it what you will. Good or bad, it’s reality. From it I am trying to weed through and decipher what lessons to take home. 

Nine year old female, has strep throat. A few days later she develops nausea and vomiting. Really unable to keep anything down. Then she develops lower abdominal pain and at some point starts having diarrhea, and intermittent fevers are reported. Mom takes daughter to urgent care. They send her to the Emergency department concerned about her gallbladder. On presentation lab work is obtained, her white count is normal and her CRP is barely a smidge elevated (inflammation markers). Based on lower abdominal pain rather than upper, ED requests imaging concerned more for appendicitis. An MRI of the pelvis is obtained which shows a normal appearing air-filled appendix. Without an answer for mom and dad, they proceed with obtaining a CT scan of the abdomen and pelvis. Once again not only is a normal appearing air-filled appendix appreciated but the study is actually negative for any sign of inflammation in the abdomen or pelvis. The patient is sent home with no answers for mom or dad. Unfortunately the child’s abdominal pain persists. Mom takes her to their family doc, and an ultrasound is obtained, negative findings. Mom obtains a meeting with a Gastroenterologist, who listens for a half second, hears that the girl has pain in her right lower quadrant and sends her back to the Emergency Department telling mom it has to be appendicitis. Girl and mom present back to the ED for reevaluation as instructed. On presentation lab work is obtained. Her inflammatory marker of white count is once again normal and her CRP is now also within normal limits. An MRI of the pelvis is obtained, again showing a normal appearing air-filled appendix, negative appendicitis. This little girl is admitted to the hospital, still with no diagnosis. At this point the patient is no longer nauseous or vomiting, actually is able to tolerate a regular diet, pears and pasta to be exact. Her diarrhea has resolved and bowel function returned to normal. Her fevers have also abated. Yet she still cries about an abdominal pain that insists on persisting. Therefore, due to demands from the mother, surgery is consulted to “rule out appendicitis.”

In general and brief, there are three main modalities of diagnosis. 1) Clinical presentation 2) Lab work 3) Imaging.  In the United States we are blessed with all three, and with fairly easy access I might add. Around the world, that is not always the case. Perhaps a diagnosis of appendicitis is made based purely on clinical presentation and patient taken to the operating room. Does that mean a normal appendix is taken out from time to time? Yes. So when all three modalities are available and obtained, a case for or against appendicitis can be made with both incredibly high sensitivity and specificity. And, in the case described above the patient’s clinical presentation, lab work and imaging are all NOT consistent with acute appendicitis.

I then ask you, in a world where appendicitis can be diagnosed solely on clinical presentation, did this case justify 2 MRIs, 1 CT scan, and 2 ultrasounds? Did it justify repeated lab draws? And did it justify a surgical consultation?

Much Love.