How can you prevent misdiagnosis of appendicitis in a patient with right lower quadrant pain, mild tenderness, leukocytosis (elevated white blood cell count), and no fever?

Management of Right Lower Quadrant Pain with Mild Tenderness, Leukocytosis, and No Fever

The correct answer is C: admit, observe, and repeat testing every 6-12 hours. This patient presents with an equivocal clinical picture that requires active surveillance rather than premature discharge or delayed imaging. 1

Clinical Context and Diagnostic Challenge

This patient has an atypical presentation for appendicitis:

• Classic appendicitis features are present in only ~50% of cases, making clinical assessment alone unreliable 2, 3
• The absence of fever does not exclude appendicitis and is common in early disease 3
• Leukocytosis with mild RLQ tenderness represents an intermediate-risk presentation requiring further evaluation 1
• Clinical determination of appendicitis is notoriously poor, with negative appendectomy rates as high as 25% when relying on clinical assessment alone 3

Why Each Option is Appropriate or Inappropriate

Option A (NSAID and discharge): Inappropriate

• Discharging based solely on absence of fever and mild symptoms risks missing early appendicitis or other serious pathology 3
• NSAIDs can mask evolving symptoms and delay diagnosis 1
• This approach provides no mechanism for detecting disease progression 2

Option B (Outpatient colonoscopy): Inappropriate

• Colonoscopy has no role in acute appendicitis diagnosis 2
• Delays definitive imaging and treatment 2
• Does not address the acute presentation requiring urgent evaluation 1

Option C (Admit, observe, repeat testing): CORRECT

• Active surveillance with serial clinical examinations and laboratory testing every 6-12 hours is the standard approach for equivocal presentations 1
• Allows detection of evolving appendicitis before perforation occurs 2, 3
• Provides opportunity for definitive imaging (CT) if symptoms progress 2, 1
• The combination of imaging with clinical observation provides the highest diagnostic yield while minimizing unnecessary surgery 3

Option D (Discharge with return precautions): Inappropriate for this patient

• While discharge with 24-hour follow-up is appropriate for low-risk patients, this patient has leukocytosis indicating intermediate risk 1
• The presence of leukocytosis elevates concern beyond simple discharge criteria 2
• This patient requires more intensive monitoring than outpatient follow-up provides 1

Recommended Diagnostic Algorithm

Immediate steps during observation period:

• Serial abdominal examinations every 6-12 hours to assess for progression of peritoneal signs 2, 1
• Repeat complete blood count to monitor leukocytosis trend 2
• Monitor for development of fever, worsening pain, or peritoneal signs 2

Imaging threshold:

• Proceed to CT abdomen/pelvis with IV contrast if symptoms persist or worsen during observation 2, 1
• CT provides sensitivity of 85.7-100% and specificity of 94.8-100% for appendicitis diagnosis 2
• CT also identifies alternative diagnoses in 23-45% of cases with RLQ pain 2

Disposition after observation:

• If symptoms resolve and repeat labs normalize: discharge with mandatory 24-hour follow-up 1
• If symptoms progress or imaging confirms appendicitis: proceed to surgical consultation 1
• If CT is negative but symptoms persist: continue observation or consider alternative diagnoses 2, 1

Critical Pitfalls to Avoid

• Do not rely on absence of fever to exclude appendicitis - fever is absent in approximately 50% of cases 2, 3
• Do not discharge without establishing a clear follow-up plan - false-negative rates exist even in low-risk presentations 1
• Do not delay imaging if symptoms worsen during observation - early CT prevents progression to perforation 2, 3
• Avoid premature surgical intervention without imaging in equivocal cases - this leads to unnecessary negative appendectomies 3, 4