Week 3 DQ 1

Tommy Jackson is an 18-year-old male who presents with acute abdominal pain that began while playing tennis about five hours ago. He describes it as a burning pain in his lower right abdomen without radiation. He has associated anorexia and nausea without vomiting. He also denies any recent injury, but had nasoseptal repair surgery yesterday. He denies chronic medication use, but was started on prophylactic Keflex and PRN Tylenol-codeine by his ENT surgeon.   

Upon exam, his right abdomen is tender to palpation and palpation of the left lower quadrant produces pain in the right lower quadrant (positive Rovsing’s sign) (Krzyzak & Mulrooney, 2020).  He reports pain relief with learning forward and worsening with lying flat. On auscultation he has active bowel sounds without bruits. My differentials were: acute appendicitis, cholecystitis (low suspicion), diverticulitis, bowel perforation, kidney stones, and bowel obstruction. I began the work up with a CBC that demonstrated leukocytosis with a left shift. This is consistent with many infectious abdominal pathologies. I elected to do an abdominal ultrasound to evaluate for acute appendicitis and cholecystitis, which was unremarkable. I then decided to order an abdominal CT; that demonstrated an enlarged cecum with fluid collection which is consistent with acute appendicitis. A diagnosis of appendicitis can be made with right lower quadrant pain and a visualized appendix >6mm in diameter (Krzyzak & Mulrooney, 2020). After research, I discovered an abdominal ultrasound is often nondiagnostic in acute appendicitis and abdominal CT is preferred (Cappell, 2017, p. 3074). The positive predictive value of a CT in appendicitis is 95-97% with an accuracy of 90-98%  (Cappell, 2017, p. 3074). However, some literature does suggest beginning with an abdominal ultrasound as it is less risky and more cost-effective to the patient and escalating to a CT if the US is nondiagnostic. Although, an ultrasound is more sensitive and specific in children with appendicitis (Cappell, 2017, p. 3074).  

References

Cappell, M. S. (2017). Large bowel disorders. In Principles and practice of hospital medicine (2nd ed., pp. 3051–3090). McGraw Hill.

Krzyzak, M., & Mulrooney, S. M. (2020). Acute appendicitis review: Background, epidemiology, diagnosis, and treatment. Cureus, 12(6).  https://doi.org/10.7759/cureus.8562