Case Presentation
Susie is a 16-year-old White female with no prior medical history who presents to the emergency room (ER) complaints of anorexia and abdominal pain. Her pain began three days ago and was initially vague periumbilical pain. Over the past 24 hours, the pain has migrated to the right lower quadrant (RLQ). Over the last two days, she experienced fever, chills, and nausea with vomiting. Her maximum temperature at home was 101° F. She denies having diarrhea or pain associated with defecation. She rates her current pain as 7 out of 10 located in the RLQ. The pain does not radiate anywhere else, and she has not attempted medications to alleviate the pain. The pain does, however, worsen with bending her knees toward her chest.
Past Medical/Surgical History
Susie denies prior medical or surgical history, and is not taking medications (prescription or over the counter).
Health Maintenance
Susie is up to date with all childhood immunizations and received meningitis, influenza, and COVID-19 vaccines this year. She is up to date on physical examinations, including vision exam.
Allergies
She denies any food allergies; however, she is allergic to penicillin (rash).
Development and Growth History
Susie reports a typical growth pattern during her life.
Family History
Susie's paternal grandmother is 75 years old, and has a history of hypertension and type 2 diabetes mellitus. Her paternal grandfather is deceased at age 52 years from a myocardial infarction. Susie's maternal grandmother is 71 years old with a history of coronary artery disease (CAD) and Alzheimer's disease. Susie's maternal grandfather is deceased at age 76 years from COVID-19 pneumonia.
Susie's mother is 52 years old and has a history of diabetes mellitus and CAD. Her father is 54 years old and has a history of hypertension. She has two older brothers (aged 22 and 20 years), and both are healthy without any known medical problems.
Social History
Susie lives in a large metropolitan area in a single-level home with her parents and two brothers. She is sexually active with one current sex partner. She is a high school senior and plays trumpet in the band. Susie denies any current or prior tobacco, alcohol, or illicit drug usage.
Review of Systems
Constitutional. Positive for fever and chills. Denies weakness, fatigue, or decreased activity.
Respiratory. Denies any dyspnea, cough, or wheezing.
Cardiovascular. Denies any chest pain, palpitations, syncope, or peripheral edema.
Gastrointestinal. Positive for nausea, vomiting, and abdominal pain in the RLQ. Denies any diarrhea or constipation.
Genitourinary (GU). Denies any dysuria, hematuria, or urethral discharge. Her last menstrual period was three days ago and described as normal. Denies ever being diagnosed or treated for a sexually transmitted infection (STI).
Musculoskeletal. Denies joint deformities and joint or muscle pain.
Neurological. Denies abnormal balance, numbness, tingling, or headache.
Vital Signs. Temperature: 100.7° F, Height: 65.50 ins., Weight: 154 lbs, HR: 115, RR: 20, BP: 106/78, O2 Saturation: 96 on room air. Her BMI is 25.23.
Physical Examination
General Appearance. Well-developed and well-nourished White female in mild distress. She is awake, alert, and oriented to person, place, and time. She is cooperative and responds to questions.
HEENT. Normal conjunctiva and PERRLA, normocephalic, neck is supple and non-tender. No carotid bruit or lymphadenopathy. Hair evenly distributed and thick, conjunctiva clear, sclera appears white bilaterally. Thyroid not palpable, trachea midline, and a full range of motion of the neck.
Integumentary. Skin warm and dry to touch without lesions or rash, normal skin turgor. No peripheral edema noted.
Respiratory. Respirations are even and non-labored. Breath sounds clear bilaterally upon auscultation. No wheezing, rhonchi, or rales were noted.
Cardiovascular. Tachycardic with HR of 101. Rhythm regular with S1 and S2 heart sounds present. No S3/S4 or murmur noted on auscultation. Capillary refill brisk less than 2 seconds.
Abdomen. Guarding of RLQ on examination, soft with RLQ tenderness on palpitation. Tenderness is located two-thirds the distance from the navel to the right anterior superior iliac spine. Bowel sounds present and normal in all quadrants, rounded abdomen, no abdominal bruit, and no ascites. Rovsing's, obturator, and psoas signs were all positive.
GU. Costovertebral angle tenderness (CVA), right side negative CVA tenderness on left.
Neurological/Psychiatric. Alert, orientated to person, place, and time. No focal deficits. CN II-XII intact. Normal reflexes DTRs 2+ in all four extremities. 5 out of 5 strength upper extremity and lower extremity bilaterally.
Musculoskeletal. Normal range of motion, normal strength. No tenderness, swelling, or deformity.
Labs/Diagnostics
Blood. WBC 16,000 cells/mm3, RBC 5.1 million cells/mm3, Hgb 13.5 g/dL, HCT 34%, platelet: 395,000/mm3, glucose 90 mg/dL, AST 30 units/L, ALT 20 units/L, total bilirubin 1.4, serum HCG negative.
Urinalysis. Leukocyte esterase urine negative, urine nitrate negative, ketones urine negative, pH urine 6.0, protein urine negative, WBC urine less than 4 cells, urine color yellow and clear, specific gravity 1.010.
CT Abdomen and Pelvis With IV Contrast. Appendiceal wall thickening, measuring at 2.5 mm. The appendix was dilated at 7.5 mm, with associated and fat stranding.
Pediatr Nurs. 2023;49(1):45-47. © 2023 Jannetti Publications, Inc.
