What is the best course of action for a patient suspected of appendicitis with right lower quadrant pain, normal white blood cell (WBC) count, and no signs of fever, anorexia, or rebound tenderness?

Management of Low-Risk Suspected Appendicitis

For this patient with right lower quadrant pain, normal WBC (9), and absence of fever, anorexia, and rebound tenderness, the best course of action is discharge with clear return precautions and mandatory 24-hour follow-up (Option C). 1

Clinical Risk Stratification

This patient presents with a low-risk clinical picture that does not warrant immediate imaging or admission:

• Absence of classic appendicitis features: The patient lacks fever (present in only ~50% of appendicitis cases), anorexia, and rebound tenderness 2, 1
• Normal WBC count: While a normal WBC does not exclude appendicitis (negative likelihood ratio only 0.25), it significantly reduces probability when combined with the benign clinical presentation 2, 3
• Laboratory limitations: WBC alone has limited diagnostic power (positive likelihood ratio 2.47), and clinical findings should drive risk stratification rather than lab values 3

Why Discharge is Appropriate (Option C)

Low-risk patients can be safely discharged with appropriate safety netting, avoiding unnecessary imaging and radiation exposure. 1

• The World Journal of Emergency Surgery specifically recommends against admission for low-risk patients who can be safely discharged with return precautions 1
• Admission with 24-hour observation (Option A) is resource-intensive and exposes the patient to unnecessary hospitalization costs and risks without changing management in truly low-risk presentations 1
• Immediate CT (Option B) exposes patients to unnecessary radiation without changing management when clinical suspicion is low 1

Critical Components of Safe Discharge

Mandatory 24-hour follow-up is essential due to measurable false-negative rates in low-risk presentations: 1

• Provide clear emergency return precautions: worsening pain, development of fever, persistent vomiting, inability to tolerate oral intake 1, 4
• Schedule definitive follow-up within 24 hours to reassess for symptom progression 1, 4
• If symptoms persist or worsen at follow-up, proceed to imaging (CT with IV contrast in adults) 1, 4

When to Reconsider and Image

Do not reflexively order CT for all suspected appendicitis—reserve imaging for intermediate or high-risk patients: 1

• If symptoms worsen during observation or at 24-hour follow-up 1
• If peritoneal signs develop (guarding, rigidity, rebound tenderness) 2
• If fever or leukocytosis emerge on repeat assessment 1

Key Pitfalls to Avoid

• Do not rule out appendicitis based solely on normal WBC: Early appendicitis may not demonstrate laboratory abnormalities, and 8.4% of appendicitis patients have low clinical scores 3, 4
• Do not discharge without establishing clear follow-up: This is the most critical error—patients must have a safety net 1
• Do not rely on absence of fever to exclude appendicitis: Fever is absent in approximately 50% of cases 1
• Recognize that NSAIDs can mask evolving symptoms and delay diagnosis if pain control is too aggressive 1

Evidence Strength

The recommendation for discharge with follow-up in low-risk patients comes from 2025 World Journal of Emergency Surgery guidelines synthesized in Praxis Medical Insights, representing the most current evidence-based approach to appendicitis risk stratification. 1 This approach balances diagnostic accuracy with resource utilization and patient safety, specifically addressing the scenario of atypical presentations with low clinical suspicion.