Missed Pediatric Appendicitis Cases and Common Misleading History and Findings – Closing the Clinical Knowledge Gap

Andrea Eberly, MD, MS, FAAEMEmergency Medicine, Family Medicine, Guideline Knowledge Check, Internal Medicine, Nurse Practitioner, Nursing RN/PN, Pediatric Emergency Medicine, Pediatric Medicine, Physician Assistant, Urgent Care

Missed Pediatric Appendicitis Cases - Closing the Clinical Knowledge Gap 0

Missed Pediatric Appendicitis Cases - Closing Clinical Knowledge Gaps

Beware these misleading history and physical findings that can lead to missed pediatric appendicitis cases.

In August 2021, a study was published that searched for – and found – a cluster of misleading history and physical findings that are shared among pediatric cases of missed appendicitis. We detail the common causes of these missed pediatric appendicitis cases.

Try this case and test your ability to avoid missing a case of pediatric appendicitis without over-utilizing resources.

A 7-year-old girl with a history of cystic fibrosis presents to the emergency department (ED) with her parents. During the last 4 days, the child has had several episodes of nausea, vomiting, and anorexia.

The patient tells you that she initially had "belly button" pain that became “below belly button pain” that did not localize to either side.

The patient and parents deny episodes of diarrhea or urinary symptoms.

Her vital signs are:

  • heart rate 105 beats/minute
  • blood pressure 100/80 mm Hg
  • respiratory rate 22 breaths/minute
  • temperature 100.5 °F (38.1 °C)
  • 96% pulse oximetry on room air

Examination reveals an alert, thin child who appears somewhat uncomfortable.

She has generalized mild lower abdominal pain to palpation that is maximal near midline towards her left lower quadrant. She has no guarding, or increased pain with walking.

Urinalysis reveals 5 WBCs without leukocyte esterase or nitrates.

Question:

What are reasonable management steps?

Answer Options:

Discharge the patient with treatment for urinary tract infection (UTI) and discharge instructions for signs and symptoms that should prompt a return visit.

Order a WBC count; discharge home if the WBC count < 10,000 cells/µL.

Order an abdominal ultrasound study; discharge home if the ultrasound is negative for appendicitis.

Order an abdominal ultrasound study, follow up with MRI if the ultrasound is negative.

See the Answer:


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