A 16-year-old girl presents to the emergency department with a chief complaint of abdominal discomfort. She states it started approximately 15 hours ago and was mainly localized to the mid-abdomen. It is associated with nausea and vomiting, and she has no desire to eat. The pain has become progressively worse and is now mainly localized to the right lower quadrant. On physical exam, the young woman appears ill but non-toxic. It hurts in her right lower quadrant upon palpation and hurts on the right when palpating the left lower quadrant. Her white blood cell count is 13,000.

The next step in the management of this patient should be:

A. Observe the patient in the emergency department until the abdomen becomes rigid.
B. Perform a colonoscopy.
C. Send the patient home with instructions to return in 24 hours if not feeling better.
D. Obtain a CT scan to confirm the clinical suspicion.
E. Admit the patient, order NPO status, start intravenous (IV) infusion. Postpone surgery until the WBC is greater than 16,000 or her abdomen becomes rigid.

E. Admit the patient, order NPO status, start intravenous (IV) infusion. Postpone surgery until the WBC is greater than 16,000 or her abdomen becomes rigid.

Explanation:

The clinical presentation of a 16-year-old girl with abdominal discomfort, localized right lower quadrant pain, nausea, vomiting, tenderness upon palpation, and an elevated white blood cell count (13,000) is highly suggestive of acute appendicitis. Appendicitis is a medical emergency that often requires surgical intervention, and the next step in the management of this patient should involve hospital admission and careful monitoring.

Option E is the most appropriate choice. It recommends admitting the patient, initiating NPO (nothing by mouth) status to prepare for possible surgery, and starting an intravenous (IV) infusion. Surgery is typically the primary treatment for acute appendicitis, but the decision to operate can be influenced by factors like the patient's clinical condition and white blood cell count. Generally, surgery is considered when the white blood cell count is greater than 10,000, which is the case here. Postponing surgery until the white blood cell count exceeds 16,000 or the abdomen becomes rigid would not be advisable, as the patient's condition may deteriorate further.

The other options are not appropriate. Option A suggests observing the patient until the abdomen becomes rigid, which may result in a delay in necessary treatment. Options B and C (performing a colonoscopy or sending the patient home with instructions to return in 24 hours) are not indicated in this context, as acute appendicitis is a surgical condition. Option D, obtaining a CT scan, may provide additional diagnostic information but should not delay hospital admission for this patient with a high clinical suspicion of appendicitis.

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