Emergency Medicine · Year 3 · from Emergency Medicine

Case 1: Acute Appendicitis - The Classic Presentation

Patient Demographics

  • Age: 24 years
  • Sex: Female
  • Occupation: Graduate student

Chief Complaint

"I have terrible pain in my right side."

History of Present Illness

A 24-year-old female presents with 18 hours of abdominal pain. Pain began periumbilically last night, described as dull and crampy. Over the past 6 hours, pain has migrated to the right lower quadrant and become sharper and more constant. She reports nausea with two episodes of vomiting and complete anorexia. She denies diarrhea but had one loose stool this morning.

Initial Assessment

ESI Level: 3 - Urgent evaluation required

First Impression:

  • Appearance: Uncomfortable, lying still, knees drawn up
  • Work of breathing: Normal
  • Circulation: Normal color

Vital Signs:

  • Heart rate: 98 bpm
  • Blood pressure: 118/72 mmHg
  • Respiratory rate: 18 breaths/min
  • SpO2: 99% on room air
  • Temperature: 38.1C (100.6F)

Primary Survey

Airway: Patent Breathing: Normal effort, clear lungs Circulation: Mild tachycardia, good perfusion Disability: Alert, oriented, GCS 15 Exposure: No rashes, guarding RLQ on movement

Secondary Survey

SAMPLE History:

  • Symptoms: RLQ pain, nausea, vomiting, anorexia, low-grade fever
  • Allergies: None
  • Medications: Oral contraceptives
  • PMH: Healthy
  • LMP: 2 weeks ago, regular cycles
  • Last Meal: Dinner last night, nothing today
  • Events: Gradual onset, classic migration pattern

Physical Examination:

Abdominal Exam:

  • Inspection: No distension, no visible masses
  • Auscultation: Hypoactive bowel sounds
  • Percussion: Tender RLQ
  • Palpation:
  • Maximal tenderness at McBurney's point
  • Voluntary guarding RLQ
  • Rovsing's sign: Positive (RLQ pain with LLQ palpation)
  • Psoas sign: Positive (pain with right hip extension)
  • Obturator sign: Negative
  • No rebound (early presentation)

Pelvic Exam:

  • Cervical motion tenderness: Absent
  • Adnexal tenderness: Mild right-sided (referred)
  • No masses palpated
  • No discharge

Risk Stratification

Alvarado Score:

  • Migration of pain: +1
  • Anorexia: +1
  • Nausea/vomiting: +1
  • RLQ tenderness: +2
  • Rebound: 0
  • Fever: +1
  • Leukocytosis: +2
  • Left shift: +1
  • Total: 9/10 (High probability)

Diagnostic Testing

Labs:

  • WBC: 14,200 with 82% neutrophils, 8% bands
  • Hgb: 13.2
  • Platelets: 245,000
  • BMP: Normal
  • Lipase: Normal
  • Urinalysis: 5-10 WBC (likely contamination from adjacent inflammation)
  • Urine pregnancy test: Negative

Imaging:

CT Abdomen/Pelvis with IV contrast:

  • Dilated appendix (11mm diameter)
  • Appendiceal wall thickening and enhancement
  • Periappendiceal fat stranding
  • No abscess or free fluid
  • No free air

Diagnosis: Acute uncomplicated appendicitis

Management

Preoperative:

  1. NPO status
  2. IV fluid resuscitation
  3. Pain management: Morphine 4mg IV
  4. Antiemetic: Ondansetron 4mg IV
  5. Antibiotics: Cefoxitin 2g IV (or ceftriaxone + metronidazole)
  6. Surgical consultation

Surgical Plan:

  • Laparoscopic appendectomy
  • Patient consented and taken to OR within 4 hours

Operative Findings:

  • Acutely inflamed appendix without perforation
  • Successful laparoscopic appendectomy

Disposition

  • Post-operative recovery unit
  • Discharged home POD 1
  • Follow-up in 2 weeks
  • Return precautions given

Teaching Points

  1. Classic migration pattern: Periumbilical pain migrating to RLQ occurs in ~50% of cases; absence doesn't rule out appendicitis
  2. Scoring systems: Alvarado and AIR scores help risk-stratify but don't replace clinical judgment
  3. Imaging in women of childbearing age: Consider transvaginal ultrasound first; CT if US inconclusive
  4. Pregnancy test: Always obtain before CT in women of childbearing age
  5. Early antibiotics: Reduce surgical site infection rates
  6. Atypical locations: Retrocecal appendix may present with flank pain; pelvic appendix with urinary symptoms

Clinical Image

Image Description: Axial CT scan of the abdomen/pelvis with IV contrast demonstrating a dilated, fluid-filled appendix (arrow) measuring greater than 6mm in diameter with surrounding fat stranding, consistent with acute appendicitis.

Attribution: Image from Radiopaedia.org, Case courtesy of Dr. Henry Knipe. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/acute-appendicitis-ct

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