ABOMINAL PAIN IN THE EMERGENCY ROOM....
An eighty-two year-old female presents to the emergency room with right lower pain. The emergency room physician is suspicious of appendicitis and calls the surgeon on-call to come evaluate her for possible surgery.
The surgeon promptly arrives and examines her. On her exam he notices that she has multiple abdominal incisions. She informs the surgeon that she has had "numerous operations" including bowel resections and a hysterectomy among others but can not remember any other operations other than this.
Her exam is indeed concerning for appendicitis. All other diagnostic tests such as labwork and CT scans are inconclusive - meaning that they cannot confirm the presence or absence of appendicitis.
All the surgeon wants to know is simply whether or not her appendix was removed during any of her previous operations. It is late at night and of course, her records from years ago at other institutions are unavailable.
This example represents a common problem facing physicians daily throughout our nation. This patient also has a history of heart and lung disease and represents a significant risk for both intra-operative and post-operative complications.
The surgeon has two options. If he feels strongly that this patient has appendicitis, then the safest course of action is to proceed to surgery and perform an appendectomy knowing that there is a chance she might not have appendicitis. He knows that if she does not have appendicitis then this is an operation that she does not need, but this can only be determined in retrospect after her surgery is completed. He also knows that there is a chance of finding that her appendix has already been removed during one of her previous operations.
The second option is to admit this patient and observe her to see if she gets better. The risk of this option is that if she does indeed have appendicitis and does not have surgery in a timely fashion then her appendix could rupture and she could then become gravely ill.
The surgeon decides to take her to the operating theater to perform an appendectomy. He finds that she has numerous adhesions (scar tissue) from her previous operations which makes her surgery significantly more difficult and dangerous because of the possibility of injuring the small bowel, colon, or right ureter. After two hours of carefully dissecting through all of these adhesions, the surgeon finds that she does not have an appendix and concludes that it was removed during one of her prior operations.
Her post-op recovery was uneventful and after several days in the hospital she was later released.
This is an excellent example of why it would be nice to have an archive of this patient's previous medical records in order to determine whether or not she has had a previous appendectomy. If this surgeon had a copy of her previous operative note describing an appendectomy it would have spared her from an unnecessary, additional operation.
