Originally published June 2013
Appendicitis is a common clinical disorder. Descriptions of the classic symptoms and signs abound in textbooks and journal articles. However, experienced physicians recognize atypical presentations are common and many patients are difficult to diagnose in the course of their illness.
A review of the CMPA medico-legal cases involving appendicitis during the 10-year period from 2002 to 2011 identified 212 cases, with 78% of the patients being adults and 22% children.
Of the 212 cases, 57% were legal actions, 26% were regulatory authority (College) complaints, and the remaining 17% were hospital complaints, legal threats, or coroner's inquests. Of the legal actions, 70% were either dismissed or there was a judgment in favour of the physician. Family physicians, emergency physicians, and general surgeons were most likely to be involved.
While performance issues (retained sponges, injury during laparoscopic procedures, and leaving a long appendiceal stump) were identified in many of the cases (25%), the most frequently identified issue (50%) was diagnostic delay. Three CMPA cases illustrate the lessons that can be learned.
Case 1: Thorough history and a physical
A 17-year-old female arrived at a walk-in clinic. The admitting nurse noted a 2-day history of dull, lower abdominal pain that was worse when coughing and walking, and was associated with anorexia and vomiting but without diarrhea. Her last menstrual period was 2 weeks previous and her only medication was birth control pills. Her vital signs were normal. The physical exam demonstrated increased pain with extension of the lumbar spine and tensing of the rectus musculature. The only documentation of an abdominal examination in the medical record was a check mark. Urinalysis showed trace hematuria and ketones. She was discharged with a diagnosis of gastroenteritis and strained abdominal musculature. No specific discharge instructions were noted aside from being instructed to follow up with her family physician in 7 days.
The patient's condition worsened and she presented to an emergency department several days later with an appendiceal abscess requiring drainage and resection of the right colon and terminal ileum. Her recovery was complicated by subphrenic abscesses. A short time later the family sued the walk-in clinic physician.
Peer experts who were asked to comment on the care were critical of the brevity of the history taking and the absence of a gynecological history; pelvic examination, pregnancy test, complete blood count, and imaging; documented differential diagnosis; and discharge instructions.
As expert support was absent, a settlement was paid to the patient by the CMPA on behalf of the member physician.
Case 2: Difficult physical examination
A 38-year-old morbidly obese female presented to an urgent care centre with vague complaints of lower abdominal discomfort. Her past medical history was remarkable for schizophrenia treated with injectable antipsychotics. On examination her affect was flat and there was a paucity of speech. Responses to questions were monosyllabic. On physical examination her vitals were normal and there was mild tenderness in the right lower quadrant with very deep palpation. No pelvic exam was performed. Urinalysis and pregnancy tests were negative. She was advised to seek medical attention if she developed fever, vomiting, or worsening pain.
Several days later she was seen in an emergency department and appendicitis was confirmed on a CT scan. Surgery was uneventful. A College complaint was lodged against the urgent care physician alleging inadequate assessment and discriminatory treatment based on her history of mental illness.
The College counselled the physician to exercise greater care when examining and treating individuals whose ability to provide a full history may be compromised by mental illness or other cognitive impairments. The College also reminded the physician that morbid obesity may make accurate physical examination of the abdomen more difficult, and imaging should be considered in such situations.
Case 3: Inadequate discharge instructions
A 32-year-old male presented to an emergency department with a 1-day history of right-sided abdominal pain associated with 2 episodes of vomiting and 1 episode of diarrhea as well as dysuria and frequency. Vital signs were normal. His past history was remarkable for membranous glomerulonephritis with a baseline elevated creatinine of 440 µmol/L. Physical examination demonstrated tenderness in the right upper quadrant and right flank without peritoneal signs. Blood work showed a leukocytosis with a left shift, a creatinine of 515 and an active urinary sediment positive for red and white cells and nitrite. Abdominal ultrasound was unremarkable, although the appendix was not clearly visualized. Contrast CT was contraindicated due to the renal impairment.
A presumptive diagnosis of pyelonephritis was made and the patient was started on an appropriate antibiotic and a narcotic analgesic. The discharge instructions were given verbally and included information that the patient should take the medication for 4 days before expecting significant improvement. There were no written discharge instructions.
Five days later the patient returned and was diagnosed with a ruptured retrocecal appendix. Post-operatively his renal function deteriorated requiring permanent hemodialysis. Litigation followed.
The court did not find the emergency physician negligent in reaching a presumptive diagnosis of pyelonephritis, given the negative ultrasound and the findings on urinalysis. However, the physician was deemed to be negligent in not providing clear discharge instructions, both verbal and written, as evidenced by this quote from the judgment: "A significant component of the discharge instructions is the delivery of information to the patient, to educate the patient regarding the essential factors. This involves the diagnosis, the basis for the diagnosis, plan of treatment, other possibilities and what to do if things go wrong. "
A settlement was paid to the patient by the CMPA on behalf of the member emergency physician.
The bottom line
Patients suffering from appendicitis may not show all the classic signs of the condition, but the following points may prove helpful in reaching the correct diagnosis:
- An appropriate history and physical examination, including vital signs, should be performed and documented on patients with abdominal pain regardless of the clinical setting.
- When there is sufficient clinical index of suspicion, consider further testing.
- Negative affective biases towards a patient may compromise the diagnostic process.
- More vigilance is advisable when the history is difficult to obtain because of the patient's cognitive impairment or inability to communicate well because of language.
- Clearly articulated and documented discharge instructions remain important.