CASE 4

9 year old male with no significant pmh p/w 1 day of periumbilical pain. Patient has also had a few episodes of vomiting with decreased appetite.  Denies fever, diarrhea, dysuria, hematuria.

Physical:

Vitals: T: 97 P:107 BP: 112/67 RR: 20 O2Sat: 100%

Gen: well appearing. HEENT: Mucus membranes dry. Cardiac, lung exam WNL. GI/Abdomen: TTP in RLQ, Guarding RLQ. No rebound, no masses. Extremity, skin, neuro exam are unremarkable.

Laboratory Results

            WBC: 14.2 with L shift

            HG/HCT: 12.3/36

            Plt: 292

            BUN: 14

            Cr: 0.36

            Normal electrolytes and LFTs

No lipase/amylase ordered.

1. What is your differential diagnosis?

2. What should be ordered next?

3. What does the image below depict?

4.  What are the anatomical landmarks for obtaining this image? One of them is depicted below.

5.  What are the ultrasound criteria for this diagnosis?  Refer to image below.

Comments

[Moshe Weizberg]

Nice images!

[Abbas Husain]

1) ddx: appendicitis, hernia, gastro, torsion

2) ultrasound r/o appendicitis and gastrgraffin b/c surgery will require CT
3) image shows appendicitis
4) landmarks are iliacs and psoas
5) criteria- non compressible blind end pouch, lumen greater or equal to 7mm, appendolith or fecolith, thickened lumen greater than 3mm

-giovanni

[Jamecia Finnie]

Thank you GIovanni for responding. We appreciate your input. Excellent interpretation of the images.

As for the rest of you , who probably aren't even reading this, the answers are:
1) Good differentialGiovanni, we agree
2)Order: Ultrasound - r/o appy. If inadequate (no visualizatino of appendix) or negative - conitnue to CT scan. If u/s positive - definitive.
3)Image Dx: appendicitis
4) Landmarks: Iliacs (shown above), Psoas (difficult to visualize i n most cases)
5)Criteria:
1-blind ending tubular structure
2- non-compressible
3-fecalith (appendicolith)
4->6mm in diameter
+/- surrounding edema/fluid

Thank you for your participation,

Jamecia and Jenn