Welcome to this month’s What’s Your Diagnosis Challenge!
But before we begin, check to see if you got last month’s case on Pediatric Chest Pain: Using Evidence to Reduce Diagnostic Testing in the Emergency Department right.
Case Presentation: Current Practice and Pitfalls of Select Biomarkers in the Emergency Care of Children
A 10-year-old boy is brought in for stomach pain that started last night.
The boy’s mom says he has been complaining of “tummy pain” since before he went to bed last night, and he has been walking “hunched over.” The boy tells you that the pain started at his belly button and has now moved down into his lower abdomen. When you question him, he says that he is hungry, and he denies nausea.
On examination, the boy does not have a fever, and his vital signs are stable. The boy is lying comfortably on the bed. His heart and lung examinations are normal. His abdomen is mildly tender between the umbilicus and right lower quadrant but not specifically at McBurney’s point. There is no rebound or guarding. He has a positive obturator sign and negative psoas and Rovsing signs. The genitourinary examination is benign.
As you walk away, you think: Does this patient have acute appendicitis? What additional blood tests might change suspicion for acute appendicitis? If an ultrasound is inconclusive, is a CT of the abdomen warranted?
Case Conclusion
Recognizing that you had a moderate clinical suspicion for acute appendicitis, you ordered a CBC as well as a comprehensive metabolic panel and CRP. Your differential diagnosis also included mesenteric adenitis, psoas abscess, and genitourinary or musculoskeletal complaints. The boy’s pain was controlled, and you sent him out of the department to get a right lower quadrant ultrasound. The ultrasound later returned with an official reading of “cannot visualize the appendix, but findings suspicious for free fluid in the right lower quadrant.” Your patient’s bloodwork simultaneously returned with a WBC count of 16.2 × 109/L, with 84% neutrophils on the differential. Also, the CRP returned elevated, at 84 mg/L. Rather than subject the child to radiation with a CT scan of the abdomen and pelvis, you decided to consult your pediatric surgeon. The pediatric surgeon also suspected acute appendicitis as well and came down to evaluate the patient in the ED. You initiated antibiotics in the ED, and the patient underwent an appendectomy 2 hours later. With the aid of a biomarker, you appropriately diagnosed acute appendicitis without subjecting this young boy to unnecessary radiation. A day later, the pathology report confirmed your diagnosis of a perforated appendicitis.
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Last Updated on January 26, 2023
The CT or any further investigation is not indicated at this time. The likelihood of appendicitis or another organic process is quite unlikely with given info. However further history specifically for possible constipation, stress related pain, or other constitutional symptoms is paramount at this stage. Period of observation and indirect or distracted examination might also be rewarding. If appendicitis is still a concern, WBC, CRP, UA in additional to the US would be my initial work up before the CT.