16-Year-Old Girl: Severe Right-Sided Abdominal Pain - Emergency Approach

Immediate Stabilization (First 5 Minutes)

1. Vital signs - pulse, BP, temperature, RR, SpO2
2. IV access + draw labs simultaneously
3. NPO (nothing by mouth) immediately - surgery may be needed
4. IV fluids if hemodynamically unstable
5. Analgesia - do NOT withhold pain relief; it does not mask signs and is the humane standard of care

Key Differential Diagnoses

History (Ask Immediately)

• Onset and character of pain - sudden vs gradual, sharp vs crampy, constant vs intermittent
• Migration - did pain start periumbilically and move to RLQ? (classic appendicitis)
• Associated symptoms - nausea, vomiting, fever, anorexia, diarrhea
• Gynecologic history - LMP (last menstrual period), sexual activity, vaginal discharge, prior STIs
• Exertion-related onset (suggestive of ovarian torsion)
• Urinary symptoms (renal/bladder pathology)
• Medications and allergies

Physical Examination

• McBurney's point tenderness (2/3 of the way from umbilicus to ASIS) - appendicitis
• Rebound tenderness / guarding - peritoneal irritation
• Rovsing's sign (pressure in LLQ causing RLQ pain) - appendicitis
• Psoas sign (pain on right hip extension) - retrocecal appendicitis
• Obturator sign (pain on internal rotation of right hip) - pelvic appendicitis

• Cervical motion tenderness (CMT) - PID
• Adnexal tenderness or mass - ovarian torsion, tubo-ovarian abscess, ectopic

Investigations (Order All Simultaneously)

Labs

Imaging

• Non-ionizing, fast, detects appendicitis, ovarian torsion, free fluid, pelvic pathology
• Appendix >6 mm, non-compressible = appendicitis
• Ovary >4 cm, absent Doppler flow = torsion (but normal Doppler does NOT rule out torsion - up to 60% of torsion cases can be missed on arterial Doppler alone)

• MRI is the next preferred modality in pediatric/adolescent patients (avoids radiation)
• CT abdomen/pelvis with contrast if MRI unavailable and diagnosis unclear - highly sensitive for appendicitis and other pathology

Key point from Tintinalli's Emergency Medicine: "Plain radiography is not helpful." US is the preferred first study in children and young women. - Tintinalli's Emergency Medicine, Chapter 81

Scoring: Alvarado Score (Modified)

• Score 1-4: Low risk
• Score 5-9: Possible/probable appendicitis

Important caveat: "Different scoring systems often yield conflicting results and should not replace clinical judgment; the clinical impression of the experienced physician has the highest impact on patient outcome." - Tintinalli's Emergency Medicine

Ovarian Torsion - Special Note for Adolescents

• Nearly 70% of torsions occur on the right side (longer utero-ovarian ligament on the right)
• In adolescents, torsion is more likely to occur in a normal ovary (no underlying cyst needed), making it easy to miss
• Nausea and vomiting present in 70% of cases
• 50% of patients are initially misdiagnosed
• A negative US does NOT rule out torsion - if clinical suspicion is high, gynecology must be consulted regardless of imaging

Immediate Consultations

1. Surgery / Pediatric Surgery - for suspected appendicitis
2. Gynecology / Pediatric Gynecology - for suspected ovarian torsion, ectopic pregnancy, PID
3. Both if diagnosis is unclear

Management Summary by Likely Diagnosis

• Surgical consult immediately
• NPO, IV fluids, analgesia
• Laparoscopic appendectomy is standard; antibiotics alone can be considered in simple (non-perforated) appendicitis in some centers but operative management within 12-24 hours is preferred
• Perforation rates are higher in children with delayed presentation

• Emergent gynecology consult - this is a time-critical surgical emergency
• Laparoscopic detorsion should be done promptly to preserve ovarian function
• Do not wait for imaging if clinical suspicion is high

• Quantitative serum beta-hCG + pelvic US immediately
• Gynecology emergency consult
• Large-bore IV access, type and crossmatch
• Surgical or medical management depending on stability