Spotlight Case June 2003.ppt

Spotlight Case June 2003 Missed Appendicitis Source and Credits This presentation is based on June 2003 AHRQ WebMM Spotlight Case in Surgery See the full article at CME credit is available through the Web site Commentary by: James Adams, MD, Feinberg School of Medicine, Northwestern University Editor, AHRQ WebMM: Robert Wachter, MD Spotlight Editor: Tracy Minichiello, MD Managing Editor: Erin Hartman, MS Objectives At the conclusion of this educational activity, participants should be able to: Appreciate the variable presentation of appendicitis List complications of missed appendicitis Understand the advantages and disadvantages of CT in diagnosing appendicitis Define anchoring and metacognition and state their impact on missed diagnoses List potential strategies to enhance patient safety in the emergency department (ED) Case: Missed Appendicitis A 37-year-old woman with no past medical history went to ED complaining of vomiting and periumbilical abdominal pain for 6 hours. On physical examination, she was afebrile, BP 110/70, HR 85. Abdomen was soft, with no rebound or guarding. She was diagnosed with gastroenteritis, discharged with antiemetics, and told to return for persistent vomiting, pain, or new fever. Abdominal Pain in the ED Most common chief complaint in the ED 6% of the 100 million yearly ED visits Appendicitis is the most common surgical cause of abdominal pain 7% of population affected over a lifetime Small percentage of abdominal pain is due to appendicitis 1%-3% of ED visits for abdominal pain are appendicitis Challenge of Diagnosing Appendicitis Diagnosis uncommon; clinicians accustomed to ruling out rather than ruling in disease High incidence of missed diagnoses due to low suspicion 20%-40% misdiagnoses in some populations Implementation of diagnostic algorithm may combat this effect Reduce misdiagnosis rates to 6% Challenge of Diagnosing Appendicitis Classic signs of appendicitis increase likelihood of disease Epigastric pain, radiating