You must get a UCG. There are many reasons why a sexually active girl may not wish to divulge this information, so do the test. It’s easy, and it can change management decisions. Will you do a pelvic exam? This could go either way, but your reasons should be clear. Will you get an ultrasound or a CT scan? There should probably be an imaging study done unless it is a clinically clear picture of appendicitis, and even then, the surgeons will likely insist upon it. What about a CBC? Will a low, high, or neutral number of white blood cells change management? If not, don’t order the test.

You can do all of the right things, but if you don’t document it properly, it may as well never have happened.

The Handoff

The patient has been in the ED now for a couple of hours. Her pain is down to a 6/10 after 2 mg of morphine, and her nausea was relieved with antiemetics. You ordered an abdominal ultrasound to avoid radiation exposure, but unfortunately the appendix could not be visualized (no significant findings other than right-sided ovarian cysts, good blood flow to the ovary, and a small amount of free fluid in the pelvis), so you order a CT study to evaluate for appendicitis. You relate the patient’s history and pertinent findings and tell the oncoming physician to look for the CT results.

As the oncoming physician, you have an obligation to do a quick check of the history, do a focused physical exam, and write your own note. This can be done quickly, but it must be done. This is a high-risk complaint at a high-risk time. There is almost always some information lost in the shuffle, yet you are still responsible for knowing all of it, so quickly glance at the chart. Make sure that all chief complaints are addressed. For example, was there a syncopal episode? Vaginal discharge or bleeding? Keep an open mind about the differential diagnosis and do a quick reevaluation. You do not want to make your risk of liability that of the lowest common denominator, and you do not want to make a mistake due to framing effect.

The Disposition

The CT study comes back negative for appendicitis and confirms the findings on ultrasound. The patient’s pain is now 2/10, and she feels hungry and wants to go home. There is not really a convincing explanation for the sudden 10/10 pain and the small amount of free fluid in the pelvis, but you have done a thorough work-up given the findings and the history, the patient looks well, and you want to discharge her. This point in the encounter is the time of highest risk, and you must do several things. First, reexamine the patient. A patient with abdominal pain should have serial exams, including an exam prior to discharge. Second, give strict precautions that include returning to the ED within a certain amount of time (say, 8 hours) if the pain is not gone or gets worse, if fever develops, or if the patient has nausea and vomiting. Third, ensure adequate and close follow-up. In this case, it may be an appointment with an ob.gyn. within the next few days or a week. Fourth, explain that you do not have a good answer for the abdominal pain, and emphasize that that is why precautions must be taken and follow-up appointments must be made and kept.