15year old African American male presents with his mother to the ERwhere you are the physician assistant helping the ER attending in avery busy rural hospital. He is complaining of abdominal pain forone day and nausea with vomiting. His mother reports a fever andmalaise. He has no significant medical history but his mother isconcerned that he may have the \"kissing disease\" as he has a boyfriend who had mononucleosis six months ago and she does notapprove of him anyway. He describes the abdominal pain as sharp andpoints to his umbilical region. He ranks it 10/10 on a 1-10 scaleat its worse and he says it gets worse with sudden movements or ifhe sits up too quick or laughs. He is not on any medications andhis vital signs are normal except for a temperature of 101 degreesfahrenheit. On examination he looks sick and his skin is clammy tothe touch. Heart and lung examination is unremarkable. Abdominalexamination shows good bowel sounds and umbilical tenderness andtenderness in the right lower quadrant. When you press down firmlyon the RLQ while he takes in a deep breath, he stops breathing toyell out. He also shows tenderness when palpated at the RLQ deeplyat release to the area. He has pain with right leg raising and isin much pain when asked to stand and do a heel click where hestands on his toes then comes down hard on his feet. Also whenasked to do a jump he complains of extreme abdominal pain. Rectalexamination yields normal stool and no blood on guac card test. Hislabs ordered show a WBC of 18,000 with normal RBC and normalelectrolytes and kidney function. His ESR is 150 mm/hr and his CRPis 67 mg/L. Urinalysis is also normal for a basic urine dipstick.Abdominal and chest xray are normal and unremarkable. What are thenext steps here? What will your diagnosis be and what is thetreatment? This is a very common ER presentation and you shouldknow it
