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Question: Abd Pain

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You are seeing a 10 year old boy with abdominal pain. He was seen last night with a few hours of periumbilical abdominal pain. Work-up at that time showed a CBC with WBC 10.2, 55% neutrophils, UA negative, RLQ ultrasound appendix not visualized. He was discharged home with return precautions and instructions to follow-up with his pediatrician. He returns 15 hours later with continued constant right mid-abdomen pain, anorexia, nausea, a few episodes of non-bilious vomiting, and temperature of 37.8.

What is the best next diagnostic test to obtain?

pemsou5_wp • November 5, 2019

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  1. Kelly November 5, 2019 - 9:06 pm Reply

    B) Repeat RLQ ultrasound to assess for appendicitis
    The patient’s age, disease progression with migration of pain from periumbilical to right-sided (even if not exactly McBurney’s point in the RLQ), nausea, vomiting, and anorexia, are all consistent with appendicitis. Low-grade fever can occur. While WBC may be elevated with left shift, these findings are not sensitive nor specific for appendicitis. The clinical scenario presented is still more consistent with appendicitis than biliary disease (pain not RUQ, not with food) or nephrolithiasis (pain not colicky). Ultrasound is the first-line imaging study in children suspected of uncomplicated appendicitis, to avoid CT radiation. Even though the ultrasound was non-diagnostic the night before, with progression of disease, it may be diagnostic now.

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