Case Study 124 Appendicitis
Scenario
R.O. is a 12-year-old girl who lives with her family on a farm in a rural community. R.O. has four
siblings who have recently been ill with stomach pains, vomiting, diarrhea, and fever. They were
seen by their primary care provider (PCP) and diagnosed with viral gastroenteritis. A week later,
R.O. woke up at 0200 crying and telling her mother that her stomach “hurts really bad!” She had
an elevated temperature of 37.9 ° C (100.2 ° F). R.O. began to vomit over the next few hours, so
her parents took her to the local emergency department (ED). R.O.'s vital signs, complete blood
count, and complete metabolic panel were normal, so she was hydrated with IV fluids and
discharged to home with instructions for her parents to call their PCP or to return to the ED if her
condition did not improve or if it worsened. Over the next 2 days, R.O.'s abdominal pain localized
to the right lower quadrant, she refused to eat, and she had slight diarrhea. On the third day, she
began to have more severe abdominal pain, increased vomiting, and fever that did not respond to
acetaminophen. R.O. has returned to the ED. Her VS are 128/78, 130, 28, 39.5 ° C (103.1 ° F).
R.O. is guarding her lower abdomen, prefers to lie on her side with her legs flexed, and is crying.
IV access is established, and morphine sulfate 2 mg IV is administered for pain. An abdominal CT
scan confirms a diagnosis of appendicitis. R.O.'s white blood count is 12,000 mm3.
1. Which of the following are common clinical manifestations of appendicitis? Select all that
apply.
a) Diarrhea
b) Vomiting
c) Left lower quadrant abdominal pain
d) Constipation
e) Arthralgia
f) Diffuse rash
g) Fever
Answer:
Diarrhea, Vomiting, Constipation, and
Fever a, b,d, g
2. Discuss why R.O.'s presenting clinical manifestations make diagnosis more difficult.
Identify two other possible diagnoses.
Answer:
R.O’s symptoms presented first were very vague and the PCP could not distinguish the exact
diagnosis. When looking at her symptoms of stomach pain, vomiting, diarrhea, and fever she
was diagnosed with viral gastroenteritis. R.O’s diagnosis most likely looked like a flare up,
and proceeded to get worse after medical intervention.
1. Inflammatory bowel disease (IBS)
2. Crohn’s disease
Page 1 of 9
, 2b. What are the early and late signs/symptoms of appendicitis and special clinical signs?
Answer:
Early signs of appendicitis include dull pain near the naval or upper abdomen becoming
sharp as it moves to the lower right abdomen, loss of appetite, nausea, vomiting, abdominal
swelling, fever, and inability to pass gas. Late signs or signs rarely seen include dull or sharp
pain in the upper or lower abdomen, back, or rectum, painful urination or difficulty passing
urine, severe cramps, and constipation or diarrhea with gas.
Page 2 of 9
Scenario
R.O. is a 12-year-old girl who lives with her family on a farm in a rural community. R.O. has four
siblings who have recently been ill with stomach pains, vomiting, diarrhea, and fever. They were
seen by their primary care provider (PCP) and diagnosed with viral gastroenteritis. A week later,
R.O. woke up at 0200 crying and telling her mother that her stomach “hurts really bad!” She had
an elevated temperature of 37.9 ° C (100.2 ° F). R.O. began to vomit over the next few hours, so
her parents took her to the local emergency department (ED). R.O.'s vital signs, complete blood
count, and complete metabolic panel were normal, so she was hydrated with IV fluids and
discharged to home with instructions for her parents to call their PCP or to return to the ED if her
condition did not improve or if it worsened. Over the next 2 days, R.O.'s abdominal pain localized
to the right lower quadrant, she refused to eat, and she had slight diarrhea. On the third day, she
began to have more severe abdominal pain, increased vomiting, and fever that did not respond to
acetaminophen. R.O. has returned to the ED. Her VS are 128/78, 130, 28, 39.5 ° C (103.1 ° F).
R.O. is guarding her lower abdomen, prefers to lie on her side with her legs flexed, and is crying.
IV access is established, and morphine sulfate 2 mg IV is administered for pain. An abdominal CT
scan confirms a diagnosis of appendicitis. R.O.'s white blood count is 12,000 mm3.
1. Which of the following are common clinical manifestations of appendicitis? Select all that
apply.
a) Diarrhea
b) Vomiting
c) Left lower quadrant abdominal pain
d) Constipation
e) Arthralgia
f) Diffuse rash
g) Fever
Answer:
Diarrhea, Vomiting, Constipation, and
Fever a, b,d, g
2. Discuss why R.O.'s presenting clinical manifestations make diagnosis more difficult.
Identify two other possible diagnoses.
Answer:
R.O’s symptoms presented first were very vague and the PCP could not distinguish the exact
diagnosis. When looking at her symptoms of stomach pain, vomiting, diarrhea, and fever she
was diagnosed with viral gastroenteritis. R.O’s diagnosis most likely looked like a flare up,
and proceeded to get worse after medical intervention.
1. Inflammatory bowel disease (IBS)
2. Crohn’s disease
Page 1 of 9
, 2b. What are the early and late signs/symptoms of appendicitis and special clinical signs?
Answer:
Early signs of appendicitis include dull pain near the naval or upper abdomen becoming
sharp as it moves to the lower right abdomen, loss of appetite, nausea, vomiting, abdominal
swelling, fever, and inability to pass gas. Late signs or signs rarely seen include dull or sharp
pain in the upper or lower abdomen, back, or rectum, painful urination or difficulty passing
urine, severe cramps, and constipation or diarrhea with gas.
Page 2 of 9
