Question

15 year old African American male presents with his mother to the ER where you are the physician assistant helping the ER attending in a very busy rural hospital. He is complaining of abdominal pain for one day and nausea with vomiting. His mother reports a fever and malaise. He has no significant medical history but his mother is concerned that he may have the "kissing disease" as he has a boy friend who had mononucleosis six months ago and she does not approve of him anyway. He describes the abdominal pain as sharp and points to his umbilical region. He ranks it 10/10 on a 1-10 scale at its worse and he says it gets worse with sudden movements or if he sits up too quick or laughs. He is not on any medications and his vital signs are normal except for a temperature of 101 degrees fahrenheit. On examination he looks sick and his skin is clammy to the touch. Heart and lung examination is unremarkable. Abdominal examination shows good bowel sounds and umbilical tenderness and tenderness in the right lower quadrant. When you press down firmly on the RLQ while he takes in a deep breath, he stops breathing to yell out. He also shows tenderness when palpated at the RLQ deeply at release to the area. He has pain with right leg raising and is in much pain when asked to stand and do a heel click where he stands on his toes then comes down hard on his feet. Also when asked to do a jump he complains of extreme abdominal pain. Rectal examination yields normal stool and no blood on guac card test. His labs ordered show a WBC of 18,000 with normal RBC and normal electrolytes and kidney function. His ESR is 150 mm/hr and his CRP is 67 mg/L. Urinalysis is also normal for a basic urine dipstick. Abdominal and chest xray are normal and unremarkable. What are the next steps here? What will your diagnosis be and what is the treatment? This is a very common ER presentation and you should know it

Answer 1

Ans -- Diagnosis is acute appendicites

Appendicitis is most common in older children, with peak incidence between the ages of 12 and 18 yr. Perforation in appendicitis is more common in children compared to adults

Clinical feature -

fever and malaise

Nausea and vomiting

Severe abdominal pain is sharp and points to his umbilical region, which gets worse with sudden movements

Sick looking child

Physical examination

.Abdominal Palpation shows umbilical tenderness and tenderness in the right lower quadrant.

Rebound tenderness -- shows tenderness when palpated at the RLQ deeply at release to the area.

Diagnosis -

Lab investigation shows elevated WBC count, and Marker of inflammation like CRP.

Ultrasound abdonem is investigation of choice.

USG  criteria for appendicitis include wall thickness ≥6 mm, luminal distention, lack of compressibility, a complex mass in the RLQ, or an appendicolith. normal appendix must be visualized to exclude appendicitis by ultrasound.

Treatment - Emergency treatment include stabilsation of patient by giving analgesics and IV fluids and correction of any electrolyte abnormality and administration of IV antibiotics in uncomplicatred case.

To be considered uncomplicated, patients had pain ≤48 hours, ultrasonographic or CT documentation of a nonruptured appendix, as well as an appendiceal diameter ≤1.1 cm without phlegmon, abscess, or fecalith.  

Surgical removal of appendix (Laproscopic appendicectomy) is done in Peforated appendix, or recurrent appendicites or pain not resoponding to medical mangement