Mat # 18115114
On May 10, 2025, 5yo child was seen at standalone peds urgent care for 1–2 days of vomiting, diarrhea, abdominal pain, and decreased appetite. The urgent care record documents no fever, a pulse of 154, and an exam described as clinically well hydrated with a flat, soft, non-tender abdomen. No labs, imaging, or other diagnostic testing were ordered or reviewed. The provider diagnosed acute gastroenteritis, listed differential diagnoses including benign viral illness, COVID, adenovirus, enterovirus, allergies, and norovirus, prescribed Zofran and an antacid, and discharged the child home with instructions for fluids, supportive care, PCP follow-up as needed, and return if symptoms worsened.
SEE ATTACHED REDACTED MED REC FOR REFERENCE
On May 14, 2025, the child presented to a different hospital based ER with a 6-day history of abdominal pain, vomiting, and diarrhea, with worsening abdominal pain over the prior 2 days and refusal to walk, requiring the mother to carry him. Triage documented the complaint as fever/vomiting/diarrhea since Thursday, now with umbilical pain and refusal to walk; vitals included temperature 99.3°F, pulse 113, respirations 24, blood pressure 104/78, and weight 15.1 kg. On ED evaluation, the mother reported the child had previously been seen at after-hours urgent care and given Zofran, with vomiting improved but persistent diarrhea and increasing abdominal pain. Exam showed mild diffuse abdominal tenderness and unsteady gait with bowing of the legs during ambulation.
The ER performed a full workup. Abdominal x-ray showed dilated small bowel loops with air-fluid levels suggesting obstruction or ileitis. Laboratory studies were notable for WBC 21.1, platelets 464, sodium 132, chloride 97, and CRP 12.28; CK was low/negative, and infectious testing including strep and respiratory viral panel was negative. Because of the duration of symptoms, abnormal exam, leukocytosis, elevated inflammatory markers, and imaging concerns, a CT abdomen/pelvis with contrast was obtained. The CT showed ruptured acute appendicitis with an appendicolith at the base of the appendix and adjacent abscesses, the largest measuring up to 4.4 cm.
After the CT results, the ER team documented ruptured appendicitis, abdominal abscess, leukocytosis, and elevated CRP, started IV fluids, gave Toradol, and then administered Flagyl and Rocephin. The case was discussed with pediatric surgery, which recommended ER-to-ER transfer to a Children’s Hospital so the child could go directly for surgical management. The child was transferred in guarded condition later that afternoon. The receiving surgical history and physical states he had been sick for 6 days with nausea, vomiting, and abdominal pain, had been diagnosed with ruptured appendicitis, and CT review confirmed a right lower quadrant abscess and fecalith.
Our question revolves around the initial urgent care visit and if standard of care was met with the resulting complications.
Files:
Q: Were there any communications after the initial visit?
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Q: I am trying respond and it won't let me.
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Q: How long after urgent care visit did patient take to go to the ED?
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Do you believe there might have been medical error?
On the initial visit, the child was described as having a benign abdominal exam, and was well hydrated. Instructions were to return or seek further medical attention if symptoms persisted or worsened. 4 days elapsed before presenting to medical attention with the ruptured appendix. Without further details, it does not appear that an error occurred, as early presentation of appendicitis can be similar to gastroenteritis, for example, and follow up should have happened sooner.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
In retrospect, the child likely had symptoms of early appendicitis. This progressed to ruptured appendicitis 4 days later. However, since the exam at the initial visit was inconsistent with appendicitis, it is not clear a medical error occurred.
What makes you a good expert for this case?
I have almost 3 decades clinical experience in pediatrics and in pediatric critical care medicine. I have reviewed other medical cases and have experience with medico-legal reviews.
How often do you encounter cases similar to this one in your practice?
I have seen many patients with complications of ruptured appendicitis or similar conditions and over 25 years of PICU experinece.
Do you believe there might have been medical error?
Appendicitis is a very non specific diagnosis. In A child with vomiting and diarrhea with a soft abdomen, appendicitis is unlikely. I feel that a gastroenteritis is still likely the most common diagnosis. With a benign abdominal exam, a CT scan is unlikely to be necessary. Often, this is unnecessary radiation as well.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Appendicitis is non specific and the initial presentation showed a benign abdominal examination. It’s unfortunate that the child went to another hospital but the symptoms were more classical at that time of appendicitis.
What makes you a good expert for this case?
I’m a board certified pediatrician with extensive experience
How often do you encounter cases similar to this one in your practice?
Very often. Abdominal pain is one of the most common reasons a child visits the ED or urgent care
Do you believe there might have been medical error?
Initial management in urgent care seems appropriate as illness just began 2 days prior and no abdominal tenderness. Fact that for 4 days patient was not seen by PCP but ultimately as condition worsened, seen in ED suggest that child's condition deteriorated with worsening symptoms of abdominal pain and low grade fever. Now 4 days later we have more information from labs and radiology the diagnosis of ruptured appendicitis.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Initial management in urgent care seems appropriate as illness just began 2 days prior and no abdominal tenderness. Fact that for 4 days patient was not seen by PCP but ultimately as condition worsened, seen in ED suggest that child's condition deteriorated with worsening symptoms of abdominal pain and low grade fever. Now 4 days later we have more information from labs and radiology the diagnosis of ruptured appendicitis. I do not see in medical error.
What makes you a good expert for this case?
I worked in Pediatric ICU and had opportunity to care for multiple (>500) similar cases in my career so far. I also worked as pediatric hospitalist for 30 years along with PICU.
How often do you encounter cases similar to this one in your practice?
This is one of the common condition starts as gastroenteritis and small number of children develops further deterioration from different abdominal pathology.
Do you believe there might have been medical error?
The initial presentation is commonly seen with viral syndrome. Of greater interest is what occurred over the next e days.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Same reason as above. Not all cases that present as initially require the workspace that occurred subsequently.
What makes you a good expert for this case?
I'm a board certified pediatrician and a board certified neonatologist.
How often do you encounter cases similar to this one in your practice?
Now retired as an Emeritus neonatologist.
Do you believe there might have been medical error?
I am a Peds ER doctor. I choose 6, more likely than not, as a bit of middle ground...there is nothing glaringly obvious as a miss from the urgent care OTHER THAN the heart rate. I would have liked to see another set of vital signs with a better heart rate. If, in fact, the HR was elevated during the entire course of the urgent care stay (and wasn't just the isolated, triaged, mad/upset 3yo with a high HR), then his would be more problematic. I would have investigated further if the HR was knowingly elevated ruing his entire urgent care visit. Assuming 3 different routes: 1) HR was elevated only at triage then normalized during the stay...No issues with the care provided. 2). HR checked multiple times and consistently elevated...definitely a missed opportunity. 3) No HR was never re-checked despite it being elevated at check-in...not great care or attention to details. But with a documented normal belly exam, I would be hesitant to say this was a major miss...Unless the HR was known to be persistently elevated.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above. Would be willing to say causation of harm if the HR was KNOWN to have been elevated during the entire urgent care visit but was ignored.
What makes you a good expert for this case?
Peds ER trained, worked in busy level 1 trauma center with man outside hospital transfers for exactly this same condition.
How often do you encounter cases similar to this one in your practice?
Evaluation for abdominal pain is very routine in the pediatric ER as are transfers to peds ER for appendicitis.
Do you believe there might have been medical error?
I am an infectious diseases specialist, so I would not comment on the standard of care of other specialties.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This opinion is contingent upon what the standard of care would have dictated had it been followed. I would need to know the SOC expert's opinion to opine on whether an alternative course of treatment would have altered the outcome.
What makes you a good expert for this case?
I am a board certified pediatric infectious diseases specialist.
How often do you encounter cases similar to this one in your practice?
Infectious diseases physicians are not typically consulted for appendicitis.
Do you believe there might have been medical error?
The family took him in appropriately as soon as symptoms began but unfortunately the picture was only starting to build up. The child had no fever, no signs of dehydration on exam and a negative abdominal exam. Also, why had they not followed up with the pcp in a couple of days as instructed. The assumption would be that symptoms would be intensifying progressively.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The presenting initial symptoms were not consisting with an acute abdomen. The family to the child in for follow up 5 days later instead of the prescribed 1-2 days. The symptoms and fever and abdominal pain would have been escalating exponentially over the course of time. The rupture is a natural sequela of the delay in management. The family should have taken him again potentially to the same provider for continuity or to the pcp once more symptoms had developed and not waited till the child was unable to walk due to pain and intra abdominal abscess
What makes you a good expert for this case?
Being a pediatric intensivist I see many cases of progression of disease where the initial diagnosis is a reserved common one but the ultimate and final diagnosis is not reached for sometime until the patient is in extremis and lands in my unit
How often do you encounter cases similar to this one in your practice?
Many times a year or delayed or incorrect diagnosis. The “they diagnosed this patient with asthma but it turned out to be a mediastinal mass” example of horrific uncommon diagnosis is far too commonly soon. In general the medical field has been taught to this in terms of statitics and numbers and common is common. As a pediatric intensivist yes I believe in the mantra of common is common but the reality in my patient population is that it’s more important to think worst case scenario first and rule it out then think of common and self limiting.
Do you believe there might have been medical error?
Although the abdomen was documented as soft, flat, and nontender during the first visit, that did not resolve the clinical concern. The child had an elevated pulse without fever, raising concern for pain, dehydration, or both. That presentation warranted further observation and reassessment rather than reliance on a single benign abdominal exam. Simply palpating the abdomen might not elicit pain, and the pain response is often misinterpreted in this age population. For a patient like this one, it is common for the physician to watch the child walk and jump, and assess for pain with these movements. Eliciting psoas and obturator signs are also important. These are all common techniques to rule in/rule out abdominal pain associated with appendicitis in the pediatric population, but none were done or documented. The plan did not include an oral hydration challenge despite acute gastroenteritis being the working diagnosis. Had the child failed that challenge because of continued vomiting, that would have supported escalation of care, including intravenous hydration and/or inpatient admission, at which point the appendicitis would have worsened and become even more apparent, and surgery would have been done before its rupture. Only one set of vital signs was obtained, and it was incomplete: no blood pressure was obtained. A blood pressure could have provided useful information about pain, dehydration, and overall clinical status. And the physician was responsible for ensuring that a complete set of vital signs was obtained. In a child with vomiting and an elevated pulse, that omission removed data that might have supported longer observation, further testing, or transfer to the ED. Overall, the incomplete vital signs, tachycardia without fever, limited child-specific abdominal assessment, and failure to perform an oral hydration challenge reflect a likely breach in the standard of care.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The lack of observation, pediatric-specific abdominal exam, reassessment, and escalation of care likely led to a delayed diagnosis and worsening of the appendicitis, which eventually led to its rupture.
What makes you a good expert for this case?
The ER at my hospital does not have pediatric emergency medicine physicians, so pediatric patients are seen by adult emergency medicine physicians, who would consult me (a double board-certified pediatric hospitalist and general pediatrician) very often for pediatric management and disposition.
How often do you encounter cases similar to this one in your practice?
I encounter pediatric patients with vomiting, diarrhea, and abdominal pain in the ER weekly. I have also diagnosed children with appendicitis many times in the ER.
Do you believe there might have been medical error?
Vomiting and diarrhea in an otherwise healthy child is almost always due to infectious gastroenteritis. The fact that the patient had apparently not had fever is noteworthy and probably would help reassure the clinician. In this particular case, the exam would be very important, so I would want to review the medical record in detail.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Since I am not sure whether there was a medical error, I cannot say with confidence whether an error resulted in an injury. The patient probably had unruptured appendicitis when initially seen, so the fact that it ruptured apparently led to a prolonged course of antibiotics and a longer hospitalization.
What makes you a good expert for this case?
I am an experienced pediatric hospitalist (20 years) at two nationally known children's hospitals. I am Division Chief for Pediatric Hospital Medicine at a large children's hospital and full Professor of Pediatrics at a leading US medical school. I have served as an expert witness for over 20 cases, both for the prosecution and defense.
How often do you encounter cases similar to this one in your practice?
We see patients with similar complaints just about every day, though a misdiagnosis such as this one is thankfully much less common.
Do you believe there might have been medical error?
Because abdominal exam was normal, soft nontender
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Abdomen was soft and nontender
What makes you a good expert for this case?
I’m a board certified pediatrician
How often do you encounter cases similar to this one in your practice?
Not too often but I do see this
Do you believe there might have been medical error?
Yes, standard of care appears to have been met. Traditional criteria for acute appendicitis include fever and abdominal pain that starts in the periumbilical area and migrates to the right lower quadrant. This is usually accompanied by tenderness to palpation, often due to peritonitis. The chart, as documented, describes a child with vague "belly pain" that is not tender to palpation, is afebrile, and has vomiting with diarrhea. His tachycardia could be explained by a combination of discomfort and tachycardia, with increased metabolic demands due to an acute infection. While diarrhea can be seen in appendicitis, it is not typically a presenting sign. The note documents that the family was advised to return to care if symptoms worsened, which is the appropriate guidance, as the child's worsening GI related symptoms, along with their new difficulty walking, is much more suggestive of a pathologic intraabdominal process, like an abscess or ruptured appendicitis. In children of this age, the classic presentation of acute appendicitis is not as typical, particularly because they are not as reliable at reporting the location and progression of their pain. It requires more signs and a higher index of suspicion to think about this diagnosis, and it appears that that is indeed what transpired, based on the case presentation and documentation provided.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This child's initial presentation was most consistent with an acute viral gastroenteritis with mild dehydration (the first sign of dehydration typically being tachycardia in children). As the child was prescribed supportive care, and proper anticipatory guidance appears to have been given, there is no medical error, and therefore there cannot be causation.
What makes you a good expert for this case?
I am board certified in pediatrics (since 2014) and pediatric critical care. I have been a pediatric intensivist for over 8 years and have taken care of many young pediatric patients with both ruptured and unruptured acute appendicitis who have developed sepsis, peritonitis, and septic shock. I have worked closely alongside pediatric surgeons, hospitalists and emergency physicians and discussed the various presentation that are typical and unusual in children of various ages.
How often do you encounter cases similar to this one in your practice?
I admit a patient with this type of presentation 2-3 times per year to the pediatric ICU.
Do you believe there might have been medical error?
If a child comes with complaints of abdominal pain for 2 days and the mother brings the child to an urgent care center, then the symptoms of pain must have been significant. The child had a high heart rate at that visit and this should have alerted the physician that something was not right. Furthermore, I would question the mother as to exactly what sort of physicial exam was done and did the doctor press down on different quadrants of the abdomen and specifically at the McBurney's point, a diagnostic point for tenderness with acute appendicitis.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The delay in the diagnosis led to rupture of the appendix, which is much more severe than a simple acute appendicitis. If the proper physical exam had been done, the child would have received antibiotics and been observed in the hospital to see if it resolved or required a simple appendectomy. Also, the physician should have called back in a day to see how that child was doing.
What makes you a good expert for this case?
I am a pediatrician who was in charge of a Children's hospital and had to be sure that all the pediatricians working there were followings established standards of care.
How often do you encounter cases similar to this one in your practice?
Not often, as my clinical practice has been mainly in neonatology. However, as the Physician-in-Chief of our Children's Hospital, I had to review the care of every child in the hospital.
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