Samantha Chanel De Vera
Mar 24, 2022, 12:00 AM
UnreadReplies to Megan Marr
Mr. Jackson is an 18-year-old that presented with complaints of recent onset of abdominal pain that started 5 hours prior to admission. He described the pain as burning that is worsened with straightening up and is better if he bends forward. The patient also complained of anorexia, nausea, bowel irregularity but denied any fever, chills, or vomiting. My differential diagnoses were appendicitis, urinary calculus, and a bowel perforation. On examination, the patient vital signs were unremarkable; however, he was positive for Rovsing sign, but his abdomen was soft. His CBC showed a WBC of 17,900, indicating an infectious or inflammatory process. In an otherwise healthy adult, laboratory tests should generally only be ordered to rule in a clinically suspected diagnosis or to assess a patient with an acute abdomen of unclear etiology(Kendall & Moreira, 2020); this is why I only ordered CBC initially. Rigid abdomens are most often due to perforation or obstruction, but this patient’s abdomen was soft with some tenderness(Kendall & Moreira, 2020); therefore, bowel perforation is at the bottom of my list with my differentials. I also ordered urinalysis, which only shows some hematuria. Urinalysis can sometimes be misleading. The presence of pyuria, proteinuria, and hematuria suggests UTI diagnosis, but these findings may also be present with acute appendicitis or any inflammatory process occurring adjacent to either ureter(Kendall & Moreira, 2020). I did not order KUB because random use of plain radiographs to assess general abdominal pain is an extremely low-yield practice, and only a small percentage is abnormal. CT is the study of choice in the evaluation of undifferentiated abdominal pain. Approximately two-thirds of patients presenting to the ED with acute abdominal pain have a disease that CT can diagnose(Kendall & Moreira, 2020). Thus, I ordered an abdominal CT. His abdominal CT also shows that the cecum is enlarged and has a small fluid collection. CT scan usually shows inflamed, a distended appendix that fails to fill with contrast or air, appendicolith, mural thickening, pericecal fluid collection, and periappendiceal fat stranding for acute appendicitis coinciding with the result of his CT scan(Cappell, 2017). Thus, I ruled out bowel perforation, urinary calculi, and diagnosed this patient with appendicitis.
Cappell, M. S. (2017). Large bowel disorders. In S. C. McKean, J. J. Ross, D. D. Dressler, & D. B. Scheurer (Eds.), Principles and practice of hospital medicine (2nd ed., pp. 3051–3090). McGraw-Hill.
Kendall, J. L., & Moreira, M. E. (2020, December 29). Evaluation of the adult with abdominal pain in the emergency department. UpToDate. https://www.uptodate.com/contents/evaluation-of-the-adult-with-abdominal-pain-in-the-emergency-department?source=history_widget#H16′