Всём привет!!
Позволю себе привести песню из Большого Суржинета - текст Моше Шайнеа ...
Значит так, приняли по скорой в приёмное деда 78 лет... Диабетик
Переводить пока буду только основные моменты:
Осмотрен дежурным врачом приёмного в 10:50 вечера ...
В 1 час после полуночи осмотрен хирургом в приёмном...
В 3 ночи осмотрен специлистом интренистом ..
В 2:00 часа дня - КТ - назначиоли анибиотики и записали на операцию...
В 4:00 часа дня - лапаротомия выявили перфорированный аппендикс... гной разлитой
После операции септический шок , ARDS , умер в течение 36 часов.
Вот, блин...
Никогда не видал аппендицита у стариков такого возраста
Вот результат запроса в Гуугле:
Аппендицит в старческом возрасте:
Аппендицит в старческом возрасте встречается значительно реже, чем в детском,
но вместе с тем у стариков он почти в 95% случаев оказывается деструктивным.
В старческом возрасте как местные, так и общие симптомы аппендицита могут быть стертыми.
О шкале при ОА впервые слышу...
Поехали...
Members,
I have never used scoring systems to diagnose of treat AA...such as the AIR score or the Alverado. I a hire such scores.
However, I know that people use them...
Now let me tell you about a case I was asked to advice about.
78 years old male patient presenting to ER with a day of lower abdominal pain, nausea, one episode of vomiting. He was diabetic and hypertensive.
10:50 pm. Examined by ER doc: HR 74, temp 37.3, BP 170/71. Soft abdomen, a little distended, some lower abdominal tenderness, no peritoneal signs.
WBC 12,000 85% neutrophils. CRP 9.6 (normal up to 5). BUN mildly up at 28.
AXR --non specific.
1:00 am seen by surgeon in ER who notes abdo distention and diffuse tenderness without peritoneal signs but diagnoses Constipations and advices on colonoscopy as an outpatient, even that patient had normal scope a year ago...
However the internist decides to admit patient to medicine to evaluate the Constipations....
Arriving to medicine at 3:00 am BP 190/98, HR 108, tempo 36.8.
In the morning because the pain continued and so vomiting seen again by surgeon who suspected SBO and transferred the pat to surgical floor...
10:30 am: abdomen distended with peritoneal signs. Temp 36.9
2:00 pm...CT of the abdomen....air bubbles in r colonic wall, some fluids. Suspected colon ischemia (I did not see the images as yet...)
AB started....booked for OR.
4:00 pm...midline laparotomy-- perf appendix, diffuse pus.
Postop, septic shock ARDS died within 36 hrs.
Cannot find in chart that anyone measured or noted urine output before operation...or attempts at organized optimization.
Now measuring in retrospective this patient's AIR score, advocated by Roland, it would place him within the intermediate group, indicating admission and observation....
In my humble hospital on the other hand this patient would have a CT an hour after showing up in ER and be in the OR by midnight....
If we decide to support a lawsuit against that hospital the defense will cite Roland's and other scoring aficionados papers: hey it was alright to admit and observe and wait with AB.
So according to them the patient was treated adequately.
The problem with scores is that they ignore the individual patient. You can have an OK score and die despite of it. The second problem with scores is that they are measured by humans....
