What is the best course of action for an 18-year-old male, one day post-operative from a nasoseptal (nasal septal) repair, presenting with sudden-onset severe right lower quadrant abdominal pain, nausea, and a pain severity of 10 out of 10?

Immediate Surgical Evaluation Required for Suspected Appendicitis

This 18-year-old male requires urgent surgical consultation and imaging with CT abdomen/pelvis with IV contrast to rule out appendicitis, which is the most likely diagnosis given his presentation of severe right lower quadrant pain with nausea. The recent nasal surgery is a red herring and unrelated to his acute abdominal pathology.

Clinical Reasoning

Why Appendicitis is Most Likely

• Right lower quadrant pain with sudden onset during physical activity (tennis) is the classic presentation of appendicitis in this age group 1
• The 10/10 pain severity, constant nature, and 5-hour duration represent typical acute appendicitis progression 1
• Nausea without vomiting is common in early appendicitis and does not rule out the diagnosis 1
• The pain being exacerbated by movement (standing/walking) and relieved by leaning forward suggests peritoneal irritation, consistent with appendicitis 2, 3

Critical Pitfall: Normal Vital Signs and Labs Don't Exclude Appendicitis

• The absence of fever and potentially normal white blood cell count are present in approximately 50% of patients with appendicitis and do not rule out the diagnosis 1
• Classic symptoms (fever and leukocytosis) are unreliable, particularly in early appendicitis 1
• Clinical determination of appendicitis is notoriously poor, with negative appendectomy rates as high as 25% when relying on clinical assessment alone 1

Immediate Management Algorithm

Step 1: Obtain Imaging Without Delay

• CT abdomen/pelvis with IV contrast is the primary imaging modality for right lower quadrant pain in adults, with sensitivity of 90-94% and specificity of 94% for appendicitis 1, 2
• Do not delay imaging for laboratory results or prolonged observation 4, 5
• Ultrasound is inferior in this age group and clinical scenario; CT is the definitive study 1, 5

Step 2: Laboratory Testing (Concurrent with Imaging)

• Complete blood count to assess for leukocytosis 1
• C-reactive protein if available, as elevated CRP is predictive of surgical complications 6
• Basic metabolic panel to evaluate electrolyte abnormalities 1
• Urinalysis to rule out urinary tract infection or nephrolithiasis as alternative diagnoses 1

Step 3: Symptomatic Management

• Administer IV ondansetron 4 mg over 2-5 minutes for nausea control 7
• Provide analgesia (opioids are safe and do not impair diagnostic accuracy when used judiciously) 8
• NPO status pending surgical evaluation 3
• IV fluid resuscitation 3

Step 4: Surgical Consultation

• Immediate surgical consultation should occur concurrently with imaging, not after 1, 3
• Discharging this patient home based on absence of fever or normal labs would risk missing early appendicitis with potential for perforation and increased morbidity 1

Why the Nasal Surgery is Irrelevant

• Nasoseptal repair performed one day ago does not cause right lower quadrant abdominal pain 2
• The temporal relationship is coincidental; the acute onset during physical activity points to an intra-abdominal process 1, 3
• Post-operative complications from nasal surgery (bleeding, infection) would manifest with nasal/facial symptoms, not isolated RLQ pain 2

Alternative Diagnoses to Consider (Lower Probability)

• Testicular torsion (though pain is described as abdominal, not testicular) 2
• Mesenteric adenitis (less likely given severity and lack of recent viral illness) 1
• Inguinal hernia with incarceration (though no history of hernia or groin mass mentioned) 2

The combination of imaging with immediate surgical consultation provides the highest diagnostic yield while minimizing unnecessary delay that could lead to perforation and increased morbidity and mortality 1, 5.