What is the best course of action for a patient with right lower quadrant pain, no nausea or fever, and a normal white blood cell (WBC) count, in the context of possible appendicitis?

Management of Right Lower Quadrant Pain with Atypical Presentation

This patient should NOT be discharged home without further evaluation, and admission for serial observation with repeat labs in 6 hours is the appropriate initial management strategy. 1

Clinical Context and Risk Assessment

This patient presents with an atypical picture for appendicitis that requires careful evaluation:

• Absence of fever occurs in approximately 50% of appendicitis cases, making it an unreliable exclusion criterion 1, 2
• Normal WBC count (9) does not exclude appendicitis, as 11% of patients with pathologically confirmed appendicitis have normal WBC counts, including 22% with perforated appendicitis and diffuse peritonitis 3
• The absence of nausea further reduces likelihood but does not eliminate the diagnosis 1
• Clinical determination alone has an unacceptably high negative appendectomy rate of 25%, highlighting the danger of discharge based solely on atypical presentation 4, 1

Why Discharge is Inappropriate

Discharging this patient based solely on absence of fever and normal WBC risks missing early appendicitis or other serious pathology 1:

• Pain as the only consistent sign occurs in 15.6% of confirmed appendicitis cases, with 96.1% ultimately confirmed by imaging 5
• NSAIDs for pain control at home can mask evolving symptoms and delay diagnosis 1
• Without structured follow-up and serial examination, progression to perforation may occur undetected 1

Recommended Management Algorithm

Initial Observation Period

Admit for serial clinical assessment with the following protocol 1:

• Serial abdominal examinations every 6-12 hours to assess for development of peritoneal signs (guarding, rigidity, rebound tenderness) 1
• Repeat complete blood count in 6 hours to monitor for evolving leukocytosis 1
• Monitor for development of fever, nausea/vomiting, or worsening pain 1

Imaging Decision Points

Proceed to CT abdomen/pelvis with IV contrast if 4, 1:

• Symptoms persist or worsen during observation period 1
• Peritoneal signs develop on serial examination 1
• WBC count rises on repeat testing 1

CT provides definitive diagnostic accuracy 4, 2:

• Sensitivity: 85.7-100% and specificity: 94.8-100% for appendicitis 4, 2
• Identifies alternative diagnoses in 23-45% of cases with RLQ pain 1
• Reduces negative appendectomy rate from 25% (clinical alone) to 1.7-7.7% 4, 2

Disposition Based on Findings

If imaging confirms appendicitis: Surgical consultation and antimicrobial therapy 1

If imaging is negative or shows alternative diagnosis: Appropriate management with mandatory 24-hour outpatient follow-up 1

If patient remains stable with improving symptoms and negative repeat labs: Discharge with clear return precautions and mandatory 24-hour follow-up 1

Critical Pitfalls to Avoid

• Never rely on absence of fever to exclude appendicitis - present in only 50% of cases 1, 2
• Never discharge without establishing clear follow-up plan with specific return precautions 1
• Never delay imaging if symptoms worsen during observation - early CT prevents perforation-related morbidity 1
• Do not use clinical scoring systems alone (Alvarado score) as they have mixed results and don't improve diagnostic accuracy sufficiently 4

Alternative Consideration

If institutional resources permit and clinical suspicion remains low after initial assessment, ultrasound with graded compression technique may be considered as first-line imaging 4, 2, with CT reserved for inconclusive ultrasound results. However, given the atypical presentation, the threshold for proceeding directly to CT should be low 4, 2.