01
Nursing Note
Triage
26-year-old woman with worsening right lower abdominal pain since yesterday. Nausea. Vomited once. Walking hurts.
- HR
- 104
- BP
- 118/74
- RR
- 18
- Temp
- 38.1°C
- SpO₂
- 99% RA
01
Chief complaint?
Right Lower Quadrant Abdominal Pain
- Always start with the chief complaint.
- Be as specific as the available information allows, but do not make a diagnosis yet.
02
Differential
02
Differential by systems?
GI
- Appendicitis
- Terminal ileitis / Crohn disease
- Colitis
- Diverticular disease
- Bowel obstruction
GU
- Ureteral stone
- Pyelonephritis
GYN
- Ectopic pregnancy
- Ovarian torsion
- Ruptured ovarian cyst
- PID / tubo-ovarian abscess
Vascular
- Mesenteric ischemia
- AAA / iliac disease in the appropriate patient
Other / Referred
- Abdominal wall disease
- Psoas process
- Lower-lobe pneumonia
- Metabolic disease
03
Initial Assessment
You walk in and find her lying still with her knees slightly flexed. Moving on the stretcher hurts.
03
What immediate questions should you ask when first evaluating a patient with abdominal pain?
Immediate Assessment
- Determine whether the patient is critically ill or unstable and whether she has peritoneal signs.
- These findings determine whether she needs immediate resuscitation, urgent surgical assessment, or both.
- Her initial vital signs do not show hemodynamic instability. Pain with movement makes a focused examination for peritoneal irritation essential.
Critical Illness or Instability
- Prioritize ABCs, IV access, monitoring, and resuscitation.
- Use fluids, blood, antibiotics, vasopressors, bedside ultrasound, and other interventions according to the physiology.
Peritoneal Signs
- Involuntary guarding, rigidity, or rebound indicates peritoneal irritation and warrants urgent surgical assessment.
- Generalized findings are especially concerning.
04
Critical Diagnosis Gate
04
Before you settle into “RLQ pain,” what dangerous abdominal diagnoses do you need to clear?
Dangerous Diagnoses
- AAA
- Mesenteric ischemia
- Perforation
- Bowel obstruction
- Ectopic pregnancy
Current Patient
- She is stable, so continue through the algorithm while considering these dangerous diagnoses.
What if?
4a
72-year-old man + abdominal/back pain + hypotension?
Diagnosis to Consider
- AAA.
4b
75-year-old + AFib + severe pain out of proportion to exam?
Diagnosis to Consider
- Mesenteric ischemia.
4c
Sudden severe pain + rigid abdomen?
Diagnosis to Consider
- Perforation.
4d
Distention + vomiting + no stool or flatus?
Diagnosis to Consider
- Small bowel obstruction.
4e
Positive pregnancy test + hypotension?
Diagnosis to Consider
- Ruptured ectopic pregnancy.
05
History
She says:
“Yesterday it was this dull ache around my belly button. Overnight it moved down here.”
She points to the RLQ.
“Now it's sharp. Every bump in the car hurt.”
No appetite. Vomited once.
05
Why did her pain start dull and vague around the umbilicus, then become sharp and focal in the RLQ? What's the difference between visceral and parietal pain?
Pain Migration
- Her pain changed because early visceral irritation was followed by inflammation of the adjacent parietal peritoneum.
Visceral pain: early, vague, and midline
- Early appendicitis activates visceral afferent fibers from the appendix and visceral peritoneum.
- The visceral peritoneum covers the abdominal organs, and its sensory input travels largely with autonomic pathways.
- Stretch, distention, ischemia, and inflammation can produce visceral pain, but the brain has difficulty identifying exactly where the signal originated.
- Visceral pain is therefore typically dull, deep, vague, poorly localized, and near the midline.
- The appendix is a midgut structure, with afferent input classically referred around T10, so early appendiceal pain is felt around the umbilicus.
Parietal pain: later, sharp, and localized
- As inflammation progresses, it reaches the adjacent parietal peritoneum.
- The parietal peritoneum lines the abdominal wall and has somatic innervation, which allows the brain to localize the pain precisely.
- Parietal pain is therefore sharp, focal, and well localized, and it worsens with movement, coughing, or bumps in the road.
Why the pain migrates
- Early visceral irritation produces vague periumbilical pain.
- Later parietal irritation produces focal RLQ pain.
- This evolution is one of the core concepts in acute abdominal diagnosis. 3
06
Examination
Maximum tenderness is in the RLQ, about one-third of the distance from the right ASIS toward the umbilicus.
You press deeply in the left lower quadrant.
She immediately feels pain in the right lower quadrant.
06
Name both findings.
McBurney Point
- Focal tenderness at the classic RLQ landmark is McBurney point tenderness.
Rovsing Sign
- Pain in the right lower quadrant when the left lower quadrant is palpated is Rovsing sign.
Extending her right hip causes RLQ pain. Flexing her right hip and knee, then internally rotating the hip, also causes RLQ pain.
07
Name those two signs. What anatomy are you irritating?
Psoas Sign
- Pain with extension of the right hip is the psoas sign.
- An inflamed, often retrocecal appendix can irritate the psoas muscle.
Obturator Sign
- Pain with internal rotation of a flexed hip is the obturator sign.
- An inflamed pelvic appendix can irritate the obturator internus.
Diagnostic Limitations
- These signs can support the diagnosis, but the absence of an individual classic sign cannot rule out appendicitis. 8
08
She coughs and grabs the RLQ. What does that tell you? What finding would send you immediately back to the “peritoneal signs → surgery” branch?
Peritoneal Irritation
- Coughing moves the irritated parietal peritoneum.
Findings Requiring Urgent Surgical Assessment
- Diffuse involuntary guarding
- Rigidity
- Rebound
Clinical Concern
- These findings raise concern for generalized peritonitis, including perforation.
07
Labs
| Test | Result |
|---|---|
| WBC | 14.2 K/µL |
| Neutrophils | 84% |
| CRP | Elevated |
| Hemoglobin | 13.1 g/dL |
| Creatinine | 0.8 mg/dL |
| Lipase | Normal |
| UA | 3–5 WBC, 2–4 RBC |
| hCG | Negative |
09
WBC and CRP are elevated. UA has a little blood and a few WBCs. What traps are sitting here?
Inflammatory Markers
- Elevated WBC and CRP support inflammation but do not diagnose appendicitis.
Urinalysis Pitfalls
- A little blood or pyuria does not automatically establish a stone or UTI. An inflamed appendix can irritate adjacent urinary structures.
- An abnormal UA does not establish a GU diagnosis.
- Interpret laboratory results alongside the history and serial examination. 7
What if? An alternate branch
The nurse says:
“Pregnancy test is positive.”
10
What moves near the top of the differential? Stable patient—what test? Unstable patient—what changes?
Ectopic Pregnancy
- Ectopic pregnancy moves near the top of the differential.
Stable Patient
- Obtain transvaginal ultrasound and quantitative β-hCG.
Hypotensive Patient
- Treat this presentation as ruptured ectopic pregnancy until proven otherwise.
- Begin resuscitation, perform bedside ultrasound, and involve OB/GYN immediately.
08
Imaging
Our patient's hCG is negative.
11
Stable nonpregnant adult with suspected appendicitis: CT or ultrasound?
Typical Nonpregnant Adult
- Obtain CT abdomen/pelvis with IV contrast. 6
What if?
11a
What if she’s a child?
Child
- Use ultrasound first when imaging is indicated.
- A nondiagnostic ultrasound does not exclude appendicitis; the next step depends on clinical suspicion and local resources. 7
CT
Appendix: 11 mm
Wall thickening/enhancement
Periappendiceal fat stranding
No abscess
No free air
12
Diagnosis? Three CT findings? Complicated or uncomplicated?
Acute Appendicitis
- The CT findings support acute appendicitis.
Supporting CT Findings
- Dilated appendix
- Wall inflammation / enhancement
- Periappendiceal fat stranding
Complication Assessment
- No abscess or obvious perforation is present, so the findings indicate uncomplicated appendicitis at this point.
09
Treatment
13
She's CT-positive. What needs to happen before surgery gets downstairs? What organisms are you covering?
ED Treatment
- Keep the patient NPO.
- Provide analgesia and an antiemetic.
- Give IV fluids if needed and IV antibiotics.
- Consult surgery.
Antibiotic Coverage
- Cover enteric gram-negative organisms and anaerobes.
- A common regimen is ceftriaxone plus metronidazole.
- Choose antibiotics according to allergies, local resistance patterns, and disease severity. 7
10
Disposition
You're on speaker with the surgeon. They're scrubbed in the OR.
14
Twenty seconds. Go.
Twenty-Second Presentation
“Twenty-six-year-old woman with 18 hours of periumbilical pain now localized to the RLQ with anorexia, nausea and fever. Focal RLQ peritoneal findings, WBC 14, elevated CRP, hCG negative. CT shows an 11-mm inflamed appendix with surrounding stranding and no abscess or free air. She's NPO, medicated and receiving antibiotics. I need surgical evaluation for appendicitis.”
11
Four Hours Later
She is still in your ED because neither a bed nor an OR is available. She waves you over.
“Doctor, my pain is basically gone. Can I just go home?”
15
Good news? Can you just send her home? What are you worried happened?
Reassess the Patient
- Do not discharge her based on improvement in pain alone. Repeat the vital signs and abdominal examination.
- Sudden improvement can occur after the appendix perforates and decompresses.
- Localized pain can briefly improve before infected material spreads through the peritoneal cavity.
- Improvement alone does not prove either perforation or resolution of the disease.
Thirty minutes later
The monitor alarms.
- HR
- 138
- BP
- 82/46
- RR
- 30
- Temp
- 39.4°C
She is confused and gray, with a diffusely tender, rigid abdomen.
16
What happened? What are the four major shock types? Which one is she in?
Suspected Perforation and Septic Shock
- Suspected perforation → generalized peritonitis → sepsis → shock.
- This presentation is most concerning for primarily distributive septic shock.
The four major types of shock
- Hypovolemic shock: Blood or fluid loss reduces circulating volume, as with hemorrhage or severe dehydration.
- Cardiogenic shock: The heart cannot pump adequately, as after a large myocardial infarction.
- Distributive shock: Widespread vasodilation disrupts effective blood flow. Examples include sepsis, anaphylaxis, and neurogenic shock.
- Obstructive shock: A mechanical barrier impairs cardiac filling or outflow, as with tension pneumothorax, tamponade, or a massive pulmonary embolism.
Why this patient is in shock
- Her fever and newly rigid, diffusely tender abdomen suggest infection following perforation. The inflammatory response causes vasodilation and capillary leak, reducing effective circulating volume and impairing tissue perfusion.
- Her hypotension and confusion indicate circulatory failure with organ dysfunction. Fluid losses may contribute, so shock can have more than one mechanism.
- Shock means inadequate tissue perfusion; a low blood pressure is a warning sign, not the entire definition. Shock physiology (Merck Manual).
- This explains the need for resuscitation, antibiotics, vasopressors when needed, and urgent control of the abdominal infection. 9
12
Surgeon Calls Back
“Give me an update.”
17
What's going on now, and what are you doing right now?
Update the Surgeon
“She's deteriorated. Temp 39.4, HR 138, BP 82/46, confused with a rigid diffusely tender abdomen. I'm concerned she's perforated and is now in septic shock. She's crashing. I need you downstairs now.”
Immediate Resuscitation
- Give IV fluids and broad-spectrum IV antibiotics.
- Check a lactate and obtain blood cultures if they will not delay antibiotics.
- Start norepinephrine if hypotension persists after appropriate fluid resuscitation.
Source Control and Reassessment
- Arrange immediate surgical source control.
- Use repeated perfusion and fluid-response assessments; start norepinephrine promptly when hypotension persists.
- Resuscitation and urgent surgical source control proceed together. 9
13
Rapid fire
R1
Dull, vague, poorly localized pain?
Answer
- Visceral.
R2
Sharp, focal pain?
Answer
- Parietal.
R3
Appendix embryology?
Answer
- Midgut.
R4
Early referred dermatome?
Answer
- T10 → umbilicus.
R5
Periumbilical → RLQ?
Answer
- Classic appendicitis migration.
R6
Classic RLQ point?
Answer
- McBurney point.
R7
Press left, hurts right?
Answer
- Rovsing sign.
R8
Extend right hip, RLQ pain?
Answer
- Psoas sign.
R9
Internally rotate flexed hip, RLQ pain?
Answer
- Obturator sign.
R10
Rigid abdomen?
Answer
- Peritonitis.
R11
RLQ pain + positive pregnancy test?
Answer
- Ectopic until evaluated.
R12
Sudden unilateral pelvic pain + vomiting?
Answer
- Ovarian torsion.
R13
Child after viral illness + RLQ pain + enlarged mesenteric nodes?
Answer
- Mesenteric adenitis.
R14
Neutropenic chemotherapy patient + fever + RLQ pain?
Answer
- Typhlitis.
R15
Child + intermittent colicky pain + currant-jelly stool?
Answer
- Intussusception.
R16
Writhing around?
Answer
- Think ureteral stone.
R17
Lying still because movement hurts?
Answer
- Think peritoneal irritation.
R18
AFib + severe pain out of proportion?
Answer
- Mesenteric ischemia.
R19
Older patient + abdominal/back pain + hypotension?
Answer
- AAA.
R20
Appendicitis pain suddenly disappears?
Answer
- Reassess for perforation.
R21
Perforation + rigid abdomen + fever + hypotension?
Answer
- Peritonitis → sepsis → shock.
R22
Septic shock category?
Answer
- Distributive.
R23
No bed upstairs?
Answer
- Still your patient.