For Emergency Medicine rotation, I had the opportunity to present some interesting cases to Professor Mohammed. Of the two cases I presented, I found the 11-year-old pediatric patient with a PMH of exploratory laparotomy for Meckel’s diverticulum and volvulus with a small bowel resection in September 2022 who presented with abdominal pain and 7 episodes of non-bloody/non-bilious vomiting the most interesting. The patient had stated the pain started at 3am in the morning and began in the periumbilical region with radiation to bilateral lower quadrants, but worse on her right side. She had not taken anything for the pain and rated it an 8/10.  Her last bowel movement was 1 night ago and denied any bloody stool. Patient denied any fever, cough, sore throat, ear pain, or diarrhea. 

On exam, the patient was guarding and had normoactive bowel sounds in all four quadrants. She was also tender to palpation in the periumbilical region and bilateral lower quadrants. She had (-) obturators sign, (+) psoas sign, and (+) rebound tenderness. Otherwise, the rest of the physical exam was unremarkable. 

Based on these physical exam findings, my leading differentials were appendicitis, small bowel obstruction, ovarian torsion, and gastroenteritis. However, after ordering the appropriate imaging and labs which included abdominal US, abdominal CT, BMP, CBC, UA, lactate, CRP, hepatic panel, lipase and amylase, and RPP, my differentials changed. My leading diagnosis after the workup was small bowel obstruction. While the clinical presentation led us to believe it may be appendicitis, the CT showed us that there was indeed an obstruction. Based on her surgical history, I should have been more inclined to think this was an SBO rather than appendicitis, but I did have it listed in my differential. I found this case the most interesting because she had the classic appendicitis presentation and that she was a pediatric patient; I wasn’t sure if the management and treatment were different from that of an adult. 

After receiving feedback from site evaluator, he mentioned that my HPI was good but that I could also include when the patient last passed gas. Another point he made was that I could consider a supine/upright abdominal x-ray for possible quicker rule in with faster surgical consult.