1. Dx of appendicitis a. Acute appendicitis is the most common condition requiring emergency surgery in the pediatric population.

There are about 60,000-80,000 cases a year in the United States. It occurs most often in older children and is rare in children under 2 years of age. The prevalence of appendicitis in children with acute abdominal pain ranges from 1% to 4%. We have reviewed the history and physical exam findings that typify appendicitis, but remember that up to 1/3 of pediatric patients have atypical presentations. This fact leads to both over-diagnosis of appendicitis (false-negative appendectomy rates of 5%-25%) and to a high incidence of perforation (23%-73%) in the pediatric population. Making the diagnosis of appendicitis in children is difficult and requires taking an accurate history and performing a thorough physical examination. Many clinicians use adjunctive laboratory and radiographic studies to increase the accuracy of the diagnostic process. Commonly ordered tests such as CBC with differential or CRP (C reactive protein) have variable sensitivities and specificities (CBC: sensitivity 19-88%, specificity 53-100%; CRP: sensitivity 48-75%, specificity 57-82%). Ordering of labs in this case a. In Mandy's case, CBC and ESR will help gauge the severity of inflammation that might be associated with disease states listed in your diagnostic network, but they are not very specific. An ALT/AST/Lipase and bilirubin are indicated because of her trip to Mexico (because that trip might increase her risk of infectious hepatitis) as well as her history of ethanol use. She hasn't been vomiting much and her physical examination doesn't support dehydration, so electrolytes won't help her management. A urinalysis will help rule out a UTI. Key elements for any pain history: A useful mnemonic to help remember questions to ask about pain is PQRSTAAA: P=Position (be exact) Q=Quality (dull, sharp, burning) R=Radiation (be exact) S=Severity (scale from 1 to 10, if patient can do this) T=Timing (when it happens) A=Alleviating factors A=Aggravating factors A=Associated symptoms

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