17 y/o female presents with RLQ pain...

Sunday evening, my 17 y/o daughter complained to me that she had a sharp pain in her belly. She pointed to the right lower quadrant (appendix area). She had no fever, no nausea, no vomiting, no rebound tenderness, mild tenderness to palpation. She said that it ALSO hurt up under her ribs on the right side - and in fact this area was far more tender to palpation than the RLQ was. She could pinpoint the onset of the pain - 4:30pm, while she was driving. She had not done any unusual activities at the gym recently. Her physical exam was pretty benign (yes, of course I examined her, what do you think??!!) - mild tenderness to palpation but not very impressive. She had pain when bending in ways that compressed the area where she felt most tender.
It looked sufficiently musculoskeletal, despite the sudden onset, that I told her to take some Motrin and hope it went away. The next day, she paged me to say that while she no longer had RLQ pain, she now had pain in her right shoulder.
My differential: ruptured ovarian cyst and other GYN problems that I won’t embarrass her by detailing; appendicitis; musculoskeletal source; something weird and inflammatory involving her ribs although don’t ask me WHAT.
At the doctor’s on Monday afternoon, he was impressed by the extreme tenderness over the bottom ribs on the right side. Abdomen was benign. He asked about gall bladder - while acknowledging that aside from the fact that the gall bladder is under the bottom rib, it sure didn’t look much like GB. It ended up with him concluding that the pain picture was just too scattered to make a good decision about which tests to do just yet. He wanted her to wait a day and see if the picture became more clear. Imagine a teenager being told to suffer a while so we can figure out what is wrong! laugh.gif She was miffed.
So today she woke up feeling pretty good - just mild discomfort. She ate her usual bagel for breakfast and nothing for lunch. She came home from school, had a piece of pizza, and twenty minutes later had sharp pain from her ribs all the way down her right side to her iliac crest. Since she learned a little bit about gall bladders yesterday, she also commented that, come to think of it, she’d had chicken tenders and fries a few hours before the onset of pain on Sunday.
Gaaaaaaaaaaak. It looks like my young, healthy, athletic, trim 17 y/o is experiencing biliary colic!!! Hopefully tomorrow we’ll get to start the diagnostic workup. It is REALLY frustrating to be in a setting where I can’t place calls and have them returned - I am delegating the initial work to my husband (I’ve written out a detailed script for him!). Meanwhile I’ve put her on a lowfat diet and she must be feeling crappy because she has agreed to it.
Now to see if the surgeon I’d want is on my insurance plan…

hi mary
…as my daughter just leaves for school with the feature menu item for the day being '''chicken tenders'''. however, being 13 she starts her day with generalized complaints that either progress or dissipate as the day progresses. sometimes she even forgets about them. that's why when she had a hairline fx. of her metacarpal it took near a week b/f an xray.
my son is having some kidney problems and today he visits the pedi nephrology guy. it's strange to turn someone you love most over to a stranger. to date i have not even opened a book to investigate or diagnos. i have a wonderful pediatrician that i have faith knows her job better that i.
good luck with your daughter mary. hopefully it will be a benign finding.

I also have a 17 y/o daughter and I think would have done the same as what you did. He really said that the pain picture was too scattered to run tests and said to wait? I’d be pretty miffed. too. Did he not take an accurate history and see if the pain was related to food intake? What if she had an unusually located appendix and had appendicitis, waited a day, and then ruptured?
Isn’t it a weird and frustrating feeling when we know enough to question the doc’s methods and think we might do a bit more or different, yet are not in the position to do so? blink.gif
Good luck with her,

mary as i reread your post and the PP'er you also wonder why he/she didn't just run a quick U/A…you know how sometimes a simple UTI , ask her about her bowel habits etc. instead of just waiting…i'm curious to hear how she made out (keeping in mind the HIPA rules and all).

I wasn’t at all miffed at the suggestion to wait and see if the picture became more clear. And he took a good thorough history, it’s just that it was a damn confusing picture. This kid never had a lick of fever, nausea, vomiting or anything that would make me even remotely concerned that her appendix was going to rupture any time soon. I was confident that if it was something more serious, it would get more serious in its presentation. I actually felt considerably reassured by the peds and didn’t question his reasoning at all - he explained it quite well. My daughter was the one who was miffed, she wanted him to wave a magic wand and not only diagnose it but fix it!
Anyway, the latest is that her abdominal ultrasound did NOT show any abnormalities of the GB or anything else. Today she had a follow-up office visit and did get the u/a which was negative. All the pain symptoms have pretty well disappeared except for lingering soreness in her rib cage.
so at this point we are back to “musculoskeletal pain” which was my original diagnosis - I wasn’t very happy with it then, because of the sudden onset, and I can tell the peds docs aren’t very happy with it either but since she looks perfectly FINE it will have to do.
Except for the fact that it is MY kid and I’d like to get this settled, I actually loooove the uncertainties and vagaries of medicine. It ain’t cookbook! Patients don’t EVER read the books.

Anything new happen with this? How is she?

it would seem that perhaps she has confirmed the dx of musculoskeletal pain, as she has been pain-free for a few days now. She did remember, days after the fact, that she and a friend were horsing around and she got “shoved into a wall” (ahem, I probably don’t want to know more about this) the night before she started hurting, and she DID whack her ribs on a corner. SO maybe it was MSK after all. In any case, I’m not worrying about her at the moment! She is safely at a friend’s house tonight - watching movies by candlelight, the power’s out but friend’s family has a generator!!
the wind is really kicking up now… but everyone’s tucked in here on the peds floor and I’m still hoping for a quiet night…