Mr. Jackson presented with abdominal pain and other symptoms. Differential diagnoses included appendicitis, urinary calculus, and bowel perforation. Laboratory tests showed elevated white blood cells. A CT scan showed an enlarged cecum with a small fluid collection, consistent with acute appendicitis. This led to a diagnosis of appendicitis, ruling out the other differentials.

1. Samantha Chanel De Vera Posted Date Mar 24, 2022, 12:00
Samantha Chanel De VeraPosted DateMar 24, 2022, 12:00 AMUnreadReplies to Megan
MarrMr. 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.ReferencesCappell, 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-
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