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Challenge: Can you get this right on your first read?
Clinical Vignette
A 29-year-old woman comes to the ED with right lower quadrant abdominal pain for 12 hours. She has nausea, loss of appetite, and a low-grade fever. Last menstrual period was 3 weeks ago.
On exam: temperature 38.2°C (100.8°F), pulse 104/min, BP 114/70 mmHg. Abdominal exam reveals rebound tenderness at McBurney's point. Labs show WBC 13,000/µL. Transvaginal ultrasound shows no adnexal masses.
On exam: temperature 38.2°C (100.8°F), pulse 104/min, BP 114/70 mmHg. Abdominal exam reveals rebound tenderness at McBurney's point. Labs show WBC 13,000/µL. Transvaginal ultrasound shows no adnexal masses.
Which of the following is the most appropriate next step in management?
- A CT abdomen with contrast
- B Diagnostic laparoscopy
- C IV antibiotics only
- D Immediate appendectomy
- E Pelvic MRI
Full explanation with high-yield teaching points
Explanation
This patient has classic acute appendicitis — localized RLQ pain, fever, leukocytosis, and peritoneal signs (rebound tenderness at McBurney's point). When the clinical presentation is this convincing, appendectomy is appropriate without further imaging delay.
CT abdomen with contrast is helpful when the diagnosis is unclear, but not needed here. Diagnostic laparoscopy is sometimes used but isn't the standard first-line approach. IV antibiotics alone may be considered in select, uncomplicated cases but is not standard management. Pelvic MRI is unnecessary given the ultrasound already ruled out gynecologic pathology.
CT abdomen with contrast is helpful when the diagnosis is unclear, but not needed here. Diagnostic laparoscopy is sometimes used but isn't the standard first-line approach. IV antibiotics alone may be considered in select, uncomplicated cases but is not standard management. Pelvic MRI is unnecessary given the ultrasound already ruled out gynecologic pathology.
💡 Further Insight
- Delay in diagnosis increases the risk of perforation, which significantly raises morbidity.
- Ultrasound is particularly helpful in reproductive-age women to rule out gynecologic causes of RLQ pain before proceeding with surgery.
From MedBoardEducation
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