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Likelihood Ratio (LR) in Emergency Medicine

8/24/2013

Is it a subtle appendicitis? How to make time your friend


Clinical Scenario

Mr. Smith is a 39 yo man with abdominal pain. He has been visited, few hours ago, by his primary care doctor who sent him to you for a surgeon consult. He refers abdominal pain, fever and nausea since the day before. The pain was previously in the midabdomen, than it migrated to the right lower quadrant (RLQ). 
Temperature is 38°C, he is tachicardic, he has a moderate pain in RLQ, there aren’t signs of peritonitis.  Appendix  Is not visualized at US examination.  
Laboratory evaluation reveals WBC count 12.000 (cells/microL)  and CPR 7 (mg/L) . 
Patient’s presentation is suggestive for appendicitis but not clearly diagnostic. Let’s see what the surgeon advices.
“He is not yet ready for the operating room” he says “it’s better to repeat a laboratory evaluation, please call me in four hours”. 
The patient is admitted to observation unit. 
How will the change of laboratory tests help you after four hours?  









Conclusion 

Observation unit is ideally suited like a place where the time is the best test!
The patient with equivocal findings requires few hours for better define a diagnosis of appendicitis. The pictures above evidence how the change of laboratory and temperature in 4 hours is little useful. 
“Tincture the time” said Louis Graff. 

But how to make time your friend?


Bibliography 

RE Andersson
Repeated clinical and laboratory examinations in patients with an equivocal diagnosis of appendicitis. 
W J Surg 2000; 24 479-485. 

L Graff
Probability of appendicitis before and after observation. 
Ann Emerg Med 1991;20:503-507.



Ciro Paolillo




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