Tommy Jackson 18 years old presented to ED with pain in his right lower abdomen
Q- Tommy Jackson 18 years old presented to ED with pain in his right lower abdomen started 5 hours ago while playing Tennis. His pain worsens when standing straight and gets better when bending forward. Denise has any other symptoms of fever, chills, burning urination, nausea, or vomiting.
GI: On inspection of abdomen, scaphoid without distension, visible peristalsis, visible pulsations, no bulging of the umbilicus, or any signs of inflammation or herniation. On auscultation, normal bowel sounds without bruits or hums. On light palpation, tenderness on light palpation and severe pain on deep palpation with questionable rebound tenderness and a patient grimace on percussion indicating tenderness. There is tenderness on deep palpation at the tip of the 12th rib and a positive Chapman’s reflex at that point denotes appendix origin. I could not elicit any McBurney’s point tenderness, Rovsing’s sign, psoas sign, obturator sign cannot be performed in this simulation.
Genitourinary: There are small non-tender, mobile inguinal nodes that denote infection/ inflammation of the surrounding structures including appendicitis. No inguinal hernia or varicocele identified.
Diagnostic tools selected:
1. I would select to do a CBC to see any leukocytosis with an elevated neutrophil count which is diagnostic in these patients’ presenting with acute right-sided lower quadrant pain for possible acute appendicitis. CBC- Leukocytosis with WBC OF 17,900 with a neutrophil count-66%. The sensitivity and specificity of leukocytosis were found to be 76% and 12.5 respectively and overall diagnostic accuracy is 56%, and leukocytosis is a helpful investigation to support the diagnosis of acute appendicitis (Vaidya, Lamture, Ramteke, Mundada, Gajbhiye, & Yeola, 2020). Right blower quadrant tenderness left shift of neutrophils, and leukocytosis were the most common symptoms on presentation of acute appendicitis (Shchatsko, Brown, Reid, Adams, Alger, & Charles, 2017).
2. BMP to rule out any uncontrolled diabetes with ketoacidosis/KKNK present with acute abdomen, any underlying electrolyte, fluid imbalances, and kidney problems. BMP: unremarkable. in this patient
3. Urine analysis: To rule out any urinary infection which shows unremarkable.
4. X-ray KUB: To rule out any obstruction with dilated intestine, rupture of bowels with free fluid or air, large masses, or any fractures of the bony structures. In this patient it was unremarkable.
5. CT abdomen/pelvis: – to rule out any acute infection and inflammation, masses, obstruction in the abdomen and its organs and viscera and pelvic organs. In this patient CT showed sigmoid colon, bladder and ureters are in normal appearance. The cecum is enlarged and there is a small fluid collection. Cecal swelling denotes appendicitis and the fluid collection possibly an abscess formation. According to Yardimci, et al, (2017), appendiceal diverticulitis patients may have peri-appendiceal extraluminal loculated fluid, peri-appendiceal stranding, and a larger diameter of the appendix.
Yardimci, A. H., Bektas, C. T., Pasaoglu, E., Kinaci, E., Ozer, C., Sevinc, M. M., … & Kilickesmez, O. (2017). Retrospective study of 24 cases of acute appendiceal diverticulitis: CT findings and pathological correlations. Japanese journal of radiology, 35(5), 225-232. Retrieved from https://link.springer.com/article/10.1007/s11604-017-0625-z
Vaidya, V. P., Lamture, Y. R., Ramteke, H., Mundada, A., Gajbhiye, V., & Yeola, M. (2020). Reliability of Leukocytosis in Diagnosing Acute Appendicitis. Journal of Evolution of Medical and Dental Sciences, 9(32), 2274-2279. Retrieved from https://go.gale.com/ps/i.do?id=GALE%7CA633840130&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=22784748&p=AONE&sw=w&userGroupName=anon%7Ea8e8521d
Shchatsko, A., Brown, R., Reid, T., Adams, S., Alger, A., & Charles, A. (2017). The utility of the Alvarado score in the diagnosis of acute appendicitis in the elderly. The American Surgeon, 83(7), 793-798. Retrieved from https://journals.sagepub.com/doi/abs/10.1177/000313481708300740