appendicitis

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Hello everyone,

I am looking for some feedback.

I had a 3rd grader come into my office mid morning the other day. She said that she felt like she may throw up. She did not have a fever, had eaten breakfast earlier in the morning, and she said she had a normal BM that morning. She had no specific area of tenderness or guarding of her abdomen. A couple other kids have had the stomach virus, so I thought she probably had the stomach virus or maybe it was from eating too much candy (this was after Halloween). I told her if she vomited or felt worse to return to the office. I told her to try to eat lunch and see what happens (lunch was about an hour later). I left to go to another school at lunch time, and I actually left a couple hours early from the other school that day for my own medical appointment so I did not follow up with anyone that day about her. The next morning I found out she had returned to the office later in the afternoon (still no vomiting or fever). They let her rest in the office for a little bit, but did not send her home. Apparently, her parents took her to the ER later that night for appendicitis, and her appendix was remove the next afternoon.

She is fine, but I hate that I didn't catch it. Is there anything you would have done differently? Anything else you think I should have done that would have helped me recognize appendicitis? Of course, anytime a child complains of a stomach ache/nausea I consider appendicitis, but in this case I just did not have much reason to believe it was appendicitis, at least not at that point of time. I just want to do better in the future and appreciate any feedback you may have!

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Specializes in ICU/community health/school nursing.

True story: Mr. Ruby Jane (also a nurse) and I both missed RJ junior's hot appi. Because she presented exactly like what you saw. And progressed exactly as you describe. I had a nauseous tween in the morning and at 2 AM she had surgery.

Sometimes appendixes (appendicies?) don't present with rebound tenderness or immediate fever until they're septic enough to produce those signs.

She was afebrile with no particular stomach tenderness. Another random diagnostic I have is to ask the student to bounce up and down on his/her toes. If there's a lot of pain, that may be an early indicator. BUT - she did what you asked. And the fact they didn't send her home is reflective of that they saw the same things as you - nausea without emesis, no fever. Would you call every parent for that? I sure wouldn't.

You didn't miss anything. It was progressing. Glad the parents took her when they needed to, though!

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In my 8 years as a elementary school nurse I can remember having 3 kiddos that ended up with appendicitis. All of them presented the same as yours, one even went all weekend with the stomach ache and parents finally took her in late sunday night after she started to vomit nonstop (mom was also a nurse). I wouldn't worry about it - your assessment was fine.

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That's a hard one but you did right in not zooming on that particular diagnosis, which we don't do but call the parent if the problem persists or is getting worse. There is a fine line without additional testing capabilities in the school setting but I would probably look at maybe firmness of the abdomen and sounds. Abdominal distension, no gas sounds. It is much subtler in kids, imo.

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Specializes in School Nursing.

My own child had classic appendicitis symptoms. Her pain was in the appropriate area, radiating. Nausea and fever. I was convinced she needed her appendix out and quick. Off we go to the ER. After 2 days of testing and the surgery team coming in and out, they decided it was not her appendix. They started throwing out all kinds of possible dx such as CANCER! 2 weeks later (still in hospital) we find out she has salmonella. UGGHH!!!

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If it makes you feel better, my BFF's son had a ruptured appy this Summer that her husband who is an ER attending missed. He felt a bit lousy in the morning and decreased appetite, but otherwise nothing. 12 hours later he was on the OR table.

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Specializes in school nursing, ortho, trauma.

I had a student several years ago who presented at dismissal with a stomach ache. I gave her a quick once over - nothing striking, typical stomach ache - and sent her to meet up with her parent. The parent was in the next day screaming at me that they had to take her to the ER at 1am and she had her appendix out. When I discussed the visit made at dismissal and her status then, she still wasn't satisfied. I guess I should have brought my crystal ball too. I literally just had a kid who is presenting like he could be appendicitis. Sent out, told mom to get him checked.

How strange that we are just discussing that... I think we should start discussing how cool it would be to win the lotto!

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Specializes in school nursing/ maternal/child hospital based.

I think you are being too hard on yourself. Your assessment findings were like most of our benign stomach issues. An Appi is always in the back of my head, but this one would not have triggered any unusual concern for me. You did everything that you needed to do. Thankfully the parents were on it and took the kiddo when they needed to.

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Specializes in IMC, school nursing.

The fact that they waited for surgery proves you didn't "miss" anything. It was a progression and, given the info you provided, nothing really pointed to anything abnormal. I have seen surgeons look at CT results and say no to surgery only to be called in 3 hours later with a septic perfed bowel. Don't beat yourself up, you didn't have the diagnostics and you are not to diagnose. I had a student a few years ago present with nausea only, no vomiting. Noted he was pretty listless. This student was upper school and I normally don't cut slack, but something was just not feeling right. Dad picked him up and he had surgery eight hours later. That was all the parents kudos, I just sent him home.

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Specializes in School Nurse, past Med Surge.

Almost the same thing happened to me last year. It was the morning after Halloween, kid thought he just ate too much candy. There was nothing in the way he was presenting that made me think it was anything other than a run of the mill stomachache. He ruptured over the weekend...his own parents didn't even do anything about his continued complaints until later Sunday. They felt like total crap. I think what you did was reasonable.

A few years ago we took my son to the ER because we thought it might be his appendix. The doc had him lay on the bed and sit up without using his hands to push...just by engaging his core, and hop on one foot. He did both of those without any problems so the doc said it was highly unlikely his appendix. I've done that a couple of times with kiddos in my clinic since.

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I really appreciate all your feeback! Like you all said, I think it was just too early when I saw her so she only had mild symptoms. I just wanted to make sure there was nothing else I could have done. I actually did have her hop up and down a few times, and she did that without any trouble. Anytime anything like this happens, I tend to overthink and doubt myself. Thank you all so much for the reassurance.

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Several years ago I had a 6th grade student come to see me on the first day of school. At first, I thought nervous tummy. A few hours later he came back. No temp, no guarding, no fever, etc. He just looked off though. I called mom who was hesitant to pick up but finally did. She e-mailed me the next day to thank me as he was in surgery.

Sometimes you miss it, sometimes you go with a gut feeling and get it right.

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