Case study: An 18-year-old white female presents to your clinic today with a 2-week history of intermittent abdominal pain. She also is positive for periodic cramping and diarrhea as well as low grade fever. She also notes reduced appetite. She notes that She admits smoking ½ PPD for the last 2 years. Denies any illegal drug or alcohol use. Does note a positive history of Crohn\’s Disease. Based on the information provided answer the following questions:
What are the top 3 differentials you would consider with the presumptive final diagnosis listed first?
What focused physical exam findings would be beneficial to know?
What diagnostic testing needs completed if any to confirm diagnosis?
Using evidence based treatment guidelines note a treatment plan.
SOLUTION TO THE CASE STUDY
The following are the differential diagnoses for this patient: acute appendicitis, pelvic inflammatory disease, and endometriosis.
Focused physical exam findings
Physical examination reveals low-grade fever with tachycardia. There is localized pain to the right iliac fossa on an abdominal exam at McBurney’s point (Jones, Lopez & Deppen, 2021). There is also rebound tenderness in that area. Movement and abdominal pressure aggravate the pain. For instance, when asked to cough, the pain is localized to the right iliac fossa. There is tenderness and guarding on percussion of the abdomen. A confirmatory physical exam is the Rovsig’s sign by palpating the left iliac fossa to elicit pain in the right iliac fossa (Baird et al., 2017). A positive Rovsig’s signs indicate acute appendicitis.
According to Jones et al. (2021), a complete blood count reveals a high white blood cell count of more than 10,500 cells/µL and neutrophilia of more than 75%. A pregnancy test is performed to rule out pregnancy. A final confirmatory investigation using computed tomography scanning reveals an abnormal appendix or calcified appendicolith and periappendiceal inflammation of a diameter of more than 6 mmw8 (Di Saverio et al., 2020).
Appendectomy is the most curative treatment for acute appendicitis. Broad-spectrum antibiotics play a significant role in the treatment process. Cefotetan and cefoxitin are the antibiotics of choice in treating acute appendicitis (Jones et al., 2021). However, factors such as the stage of appendicitis during diagnosis determine the administration duration. Several studies agree that prophylactic antibiotics should be administered preoperatively and post-operatively (Jones et al., 2021). Antibiotic treatment should be stopped once the patient becomes afebrile and white blood cells count normalizes.
Baird, D. L., Simillis, C., Kontovounisios, C., Rasheed, S., & Tekkis, P. P. (2017). Acute appendicitis. Bmj, 357.
Di Saverio, S., Podda, M., De Simone, B., Ceresoli, M., Augustin, G., Gori, A., … & Catena, F. (2020). Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World journal of emergency surgery, 15(1), 1-42.
Jones, M. W., Lopez, R. A., & Deppen, J. G. (2021). Appendicitis. In StatPearls [Internet]. StatPearls Publishing.
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