General

To scan or not to scan?

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1 Oct 2016 - General
 

Suppose you encounter a patient, Mr Z, 37 year old male who consulted the emergency room due to abdominal pain of 15 hrs duration. On history, he narrates that it initially started in the epigastric region, then eventually migrated to the right lower quadrant of the abdomen. Pain score also gradually progressed from 2/10 to 6/10. On physical exam, vital signs were normal, except for his temperature at 38C. His current pain scale is 6/10. On physical exam, his abdomen was soft, with direct tenderness on the right lower quadrant. No rebound tenderness. He has leukocytosis of 15 with neutrophilic predominance. Upon chart review, the patient does not have a health insurance and works as a family driver. Your presumptive diagnosis is appendicitis. However, there are no signs of peritoneal irritation on your examination. Would you send this patient for CT scan? Why or why not?  Were you put in a similar ethical scenario? Please feel free to relay your experiences. 

Rajinda Asalage I dont see any reason why I should take offense. The reason why I posted this hypothetical case is to prove a learning point for everyone. The practice of “defensive medicine” is becoming increasingly prevalent. I am not sure if this is true for your region, but for mine it is. It is becoming usual practice to request for CT scans prior to performing appendectomy. This is commonly done in private...
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Marinelle Castro Of course. Not only it has been said by us people but the researches and the journals also have proven that it is a clinical diagnosis. In my country in government hospitals, imaging studies are being done for free at all. Usually a CT scan needs around 130- 140 USD to be done in private sector. So the cost of a CT scan must be around that margin. So why do we need a CT scan to diagnose acute app...
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Mahmoud AbdelAziz Rajinda Asalage TALAL HUSSAIN Thank you for your responses. For this case, although the patient presented with a classical history of appendicitis with supporting laboratory data, the absence of clinical sign/s of peritoneal irrit...
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In case of acute appendicitis many Doctors will agree that false positive cases are not uncommon in most hospitals and this does puts the patient under undue risk of anesthesia and abdominal surgery, therefore an important modality like CT scan, especially contrast ehanced which has an accuracy of around 95% is a very good option. But non availability, costs and risk of contrast can be an obstacle. In that case a good clinical examination , reinforced by laboratory reports and ultrasound by a...
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As a medical doctor working in a surgical ward in the world's biggest children's hospital, I have a bunch of experiences about this issue. At the casualty, A huge number of patients are getting admitted to the ward with abdominal pains. Actually acute appendicitis is a clinical diagnosis. What we do is taking the clear history and do a proper clinical examination of the abdomen. And we usually send blood for a full blood count, C reactive protein levels. We send urine sample of the patie...
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As the patient is young male, I don’t see a significant need for requesting CT!. If the patient was older or female, there would be more options to rule out. As the pain has started epigastric /gastric and is ow localized to right lower quadrant, we can for sure suspect acute appendicitis. However there are many absent criteria such as rebound tenderness and other symptoms suggestive of acute abdomen. Also with absence of symptoms suggestive of intestinal obstruction and with continuous passage...
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