Case by Malek Mazzawi MD, CNMC PEM Fellow

Patient is a 16-year-old female presenting with 2 days of RLQ pain, nausea and tactile fevers. Abdominal pain is burning, constant, and gets worse with meals/deep breaths. She endorses nausea but no emesis. No urinary symptoms. No abnormal vaginal discharge. Denies any cough, congestion, vomiting, or diarrhea. LMP was 2 weeks ago.

ROS:
Constitutional: denies fatigue, +Tactile fevers
Skin symptoms: denies rash
ENMT symptoms: denies sore throat or nasal congestion
Respiratory symptoms: denies cough, denies wheezing
Cardiovascular symptoms: denies chest pain
Gastrointestinal symptoms: denies vomiting or diarrhea, +Abdominal pain, +Nausea
Genitourinary symptoms: no urinary symptoms, no vaginal discharge
Neurologic symptoms: no headaches

PMHx: History of Chlamydia one year ago that was treated. No meds or allergies.

FHx: None relevant to the chief complaint

SHx: She has had 1 male sexual partner in the last 6 months, reports using barrier protection but not on birth control. No substance use.

PHYSICAL EXAM:
VS: Temp 37.4, HR 92, RR 20 BP 110/76, SpO2 100% on RA

General: awake, alert, no acute distress
HEENT: EOMI, conjunctival clear, posterior oropharynx without erythema or exudate
CV: regular rate and rhythm, no murmurs
Resp: clear to auscultation b/l, no wheezes rales or rhonchi
GI: soft, tenderness of RLQ, +rebound tenderness, no guarding
MSK: full range of motion, normal strength, no edema
Neuro: no focal deficits
Skin: no rashes 

RLQ ultrasound was performed in triage:

Appendix was seen completely, enlarged in the mid/distal portion. The tip measures up to 9 mm in caliber. Appendicolith at the tip measuring 7mm. Periappendiceal inflammatory changes mostly around the tip.

IMPRESSION: Acute appendicitis

Urine pregnancy, U/A, GC/CT, Trich, HIV and RPR sent. Surgery was consulted. While awaiting their evaluation, urine came back positive for Chlamydia and Trich. Negative U/A and pregnancy. A bimanual exam was performed and showed no cervical motion tenderness.

The surgery team reviewed the ultrasound and was not convinced that this was appendicitis. They requested a confirmatory CT abdomen.

Decision was made to obtain abdominal CT.

CT results: Edematous appearance of the cervix and effacement of the deep pelvic planes, which may represent pelvic inflammatory disease. Prominent appendiceal tip is noted, which may reflect secondary inflammatory changes due to PID, and not a primary appendicitis. However, acute primary appendicitis remains in the differential.