Case 28

30 yo M PMHx of HTN sent in by PMD for RLQ pain and elevated WBC. Pt reports pain is moderate, non-radiating, present x 2 days. Pain has been worsening. Associated with urinary frequency, nausea, watery non-bilious, non-bloody diarrhea. No dysuria, penile discharge. No hx of abdominal surgery.

ROS
Eyes: No visual changes, eye pain or discharge.
ENMT: No hearing changes, pain, discharge or infections.
Cardio: No chest pain, SOB or edema.
Respiratory: No cough or respiratory distress.
GI: + abd pain as per HPI.
GU: + increased frequency
MS: No myalgia, muscle weakness, joint pain or back pain.
Neuro: No headache or weakness. No LOC.
Skin: No skin rash.
Endocrine: No history of thyroid disease or diabetes.

PHYSICAL EXAM
VITAL SIGNS: T 100.7  HR 123  RR 18   BP135/76   S100 ra

CONSTITUTIONAL: Well-developed; well-nourished; in no acute distress, appears to be uncomfortable but nn toxic.
SKIN: No acute rashes and normal skin exam
HEAD: Normocephalic; atraumatic.
EYES: PERRL, EOM intact; conjunctiva and sclera clear.
ENT: No nasal discharge; airway clear.
CARD: S1, S2 normal; no murmurs, gallops, or rubs. Regular rate and rhythm.
RESP: No wheezes, rales or rhonchi. CTAB
ABD: Normal bowel sounds; soft; non-distended; +ttp in the rlq , w/o guarding, + rebound, no CVAT b/l
EXT: Normal ROM.
NEURO: Alert, oriented, grossly unremarkable
PSYCH: Cooperative, appropriate.

PERTINENT LABS
WBC: 18.19
GRAN%: 87.6
LACTIC ACID: 2.0

 

QUESTIONS:

  1. In this patient with chief complaint of RLQ pain what is in your differential?
  2. What are your landmarks for the RLQ US?
  3. What are the primary and secondary signs of appendicitis?
  4. What do you see in the images below?
  5. If this were a female patient, what other ultrasound imaging would you perform?

ANSWERS:

  1. Appendicitis, diverticulitis, cholecystitis and biliary colic, pancreatitis, ureterolithiasis and renal colic, Crohn disease, colonic carcinoma, rectus sheath hematoma, omental torsion, UTI, gastroenteritis, enterocolitis, perforated ulcer
  2. Psoas muscle, external iliac artery and vein. The terminal ileum can be recognized as crossing over the psoas muscle to the cecum; just caudal to this area is the cecal tip. To locate a tip of the appendix, a careful inspection with graded-compression technique should be done at the point of maximal abdominal tenderness.  The linear probe should be used for the exam.
  3. Primary: Non-compressible, blind-ended tubular structure without peristalsis that is > 6mm in diameter and appears to be a "target" sign in transverse view.   
    Secondary: appendicolith, hyperemia, extraluminal fluid collection
  4. In the top figure (image 1), a appendicolith can be seen with shadowing posterior to hyperechoic structure.  
    In the bottom image (image 2), you can identify a blind-ended, tubular structure >6 mm.
  5. Pelvic ultrasound to evaluate for cysts, torsion, abscess

Image 1

Image 1

Image 2

Image 2