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Megan O’Flaherty is a 23-year-old graduate student with a 36-hour history of periumbilical pain that has migrated to her RLQ. She states that she has felt febrile and is nauseated but denies vomiting or diarrhea. She is sexually active with a single partner and her last menstrual period was 2 weeks ago.

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She denies prior hospitalizations and her only medications are birth control pills.

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On physical examination, her vital signs are:

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  • Temperature: 38.5°C
  • Blood pressure: 130/80
  • Heart rate: 80 (regular)
  • Respirations: 18
  • Finger oximetry: 98.5% (room air)

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Abdominal examination reveals RLQ tenderness without rebound and hypoactive bowel sounds. Pelvic examination reveals right adnexal tenderness without cervical discharge or motion tenderness. Rectal examination confirms RLQ tenderness and brown, soft, guaiac-negative stool.

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Your working diagnosis is: acute abdomen, rule out appendicitis.

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1. What findings support the diagnosis of appendicitis?

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2. What confirmatory laboratory tests are indicated?

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RLQ Pain

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Answers
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  1. Ms. O’Flaherty has clearly read the textbook chapter on appendicitis. Her pain developed over 36 hours and began with visceral (appendiceal) irritation that she perceived as midline discomfort. As her appendiceal inflammation became transmural, she stimulated somatic peritoneal nerves sufficient to cause RLQ pain but not sufficient to cause rebound. “Rebound” can be elicited by pressing very gently on the RLQ and then releasing the pressure. When the inflamed visceral and parietal peritoneum rub against each other, this causes discomfort. If the patient winces during this procedure, he or she has an inflamed peritoneal surface.

    As with all patients, the history and physical examination can help you narrow the differential. For example, if this patient had recently eaten at an unfamiliar ethnic restaurant and now had raging diarrhea, you would think more of gastroenteritis. If she had a cervical discharge and exquisite tenderness with cervical motion (chandelier sign), you would think of pelvic inflammatory disease (PID).

  2. (A) Obtain a CBC with differential. The Surviving Sepsis Campaign defines a “septic state” as WBC less than 4000 or greater than 12,000. We obtain a hemoglobin, hematocrit, and platelets probably because it is part of the “CBC package” (and, because “we have always done it that way”).

    (B) A normal menstrual period 2 weeks ago does not preclude pregnancy. A serum HCG is an exquisitely sensitive test and should be obtained.

  3. Calculating an Alvarado score (which does not, unfortunately, include C-reactive protein) can help you decide whether you need additional confirmatory data or if you can take the patient directly to the OR (Table 5-1).

    A French group (Pouget-Baudry et al) took patients with an Alvarado score of ≥6 directly to the OR and found 3 of 174 “negative” appendices. This group safely “watched” patients with <4 points. A Dutch group (Ünlü et al) evaluated routine diagnostic imaging in patients with appendicitis and reported diagnostic accuracy of ultrasound 71% and CT scan 95%.

  4. Take the patient to the operating room with the preoperative diagnosis of “acute abdomen,” ...

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