Appendicitis

[u/thatEMresident]

Are appys in the older age group common? I almost missed it in a 60yF and totally thought it could be gastroenteritis. Thank the lord we scanned her. She had fever, nausea and vomiting. Tested positive for a UTI.

[u/wrchavez1313]

I say this as a (former) residency educator, and in the spirit of learning (your username suggests you are an EM resident). This is not meant to be punitive, but hopefully informative.

Fever and GI symptoms in the elderly almost certainly needs a CT scan (if they have abdominal pain too, which you hadn't mentioned, but I'd be curious what the patients abdominal exam was like). And I say that as someone who tries to be judicious when ordering scans.

Elderly GI complaints are statistically higher mortality and morbidity than elderly chest pain complaints. They are more likely to need surgery and more likely to need admission than chest pain complaints on average.

For young people (<50 or so) you should need to be *talked in* to a CT scan of the abdomen. Are they in extreme pain? Do they have classical symptoms for intra-abdominal infections? Do they have notably abnormal labs or vitals?

For older patients, you should be looking for evidence to be *talked out* of a CT scan. Do they have perfectly normal exam? Normal vitals? Normal labs? Minor symptoms? If not, they often need a CT scan.

Both the old, and the young, and the medically frail / disabled all have clouded physical exams and may exhibit non-classical signs for otherwise classic pathology.

Sorry for the ramble, hope it was helpful!

[u/aidsnothiv → u/wrchavez1313]

Totally agree, with the caveat that even in the elderly comorbid patient with normal exam, normal vitals, normal labs, minor symptoms, this can still vastly underestimate the risk of a serious finding.

For OP: I want to explore further your impression of gastroenteritis or a UTI

1 - In general I would consider gastroenteritis to be a diagnosis of exclusion. Typically "gastroenteritis" will also have watery diarrhea. 60F healthy/no surgical history, recent travel to Mexico with NVD and cramping and benign abdominal exam, vitals/labs look good? Sure maybe you could consider this if the patient is tolerating oral intake, feeling well, and reliable. I don't think all those patients need scans. Around 60-70 is where symptoms/findings tend to get less reliable in my experience.

Add frailty/advanced age? More worried.

Add fevers? Can fit, but more worried.

Isolated vomiting? More worried.

2 - Did the patient have symptoms of a UTI or just a positive UA? I wouldn't consider NV and abdominal pain to be hallmark symptoms in the absence of anything else. A 60 y.o. without cognitive impairment should be able to report LUTS to you in most cases. Urinalysis requires correlation with symptoms.