CCS Interactive Case 21

Question 1

9 y/o M brought to the office with fever, N/V, anorexia, periumbilical abdominal pain. Fever (101.1F), HDS.

Ddx?

Answer 1

Acute appendicitis

Entercolitis 2/2 Campylobacter or Yersinia, Meckel’s diverticulum, intussusception, renal colic

Question 2

Exam?

Answer 2

Focused, abdominal, rectal

Question 3

Decreased bowel sounds, voluntary guarding and rebound upon palpation of the RLQ, Rovsing’s sign, Psoas sign

Next step?

Answer 3

BMP
CBC
FOBT
UA
Abdominal plain film
Transabdominal US

[CT abdomen if child is obese or US is equivocal]

Question 4

Leukocytosis w/left shift
Fecalith in RLQ on X-ray
Inflamed appendix on US

Next step?

Answer 4

General surgery consult
Standard pre-operative orders - PT/PTT/INR, NPO
Correct electrolyte abnormalities
IV hydration
Preoperative ABX (cefoxitin, Amp-sulbactam, cefazolin + metronidazole are all options) - post-operative reserved for gangrenous and perforated appendicitis
Pain management
Laparoscopic appendectomy
D/C 1-2 days after surgery

Question 5

Sequence?

Answer 5

Focused exam
Transfer to ER
Order: IV access, IV NSS 0.9%, CBC, BMP, LFT, FOBT, UA, abdominal US, abdominal x-ray, NPO, PT/INR, PTT (all stat)
Morphine IV, continuous
Phenergan IV, continuous
Advance clock to obtain resutls - leukocytosis, fecalith, inflamed appendix
Order cefoxitin IV x1
Consult general surgery stat
Advance clock to obtain recs
Laparoscopic appendectomy
Admit to ward
Advance to next available result
Appendectomy performed
Reevaluate in 4-8 hours
Case ends
Cancel NPO, IV access
Normal diet, counsel patient and parent
Dx: acute appendicitis