The Chief Complaint
Triage
24-year-old woman with worsening right lower abdominal pain since yesterday. Nauseated, no vomiting.
- HR
- 104
- BP
- 118/72
- RR
- 18
- Temp
- 38.0°C
- SpO₂
- 99% RA
What is the chief complaint?
Right Lower Quadrant Abdominal Pain
- Start with the complaint, not the diagnosis.
- RLQ pain should immediately bring appendicitis, GU, and GYN causes into the differential.
Differential Diagnosis
Give me a focused systems-based differential for RLQ pain.
GI
- Appendicitis
- Gastroenteritis / colitis
- IBD
GU
- Ureteral stone
- Pyelonephritis / UTI
GYN
- Ectopic pregnancy
- Ovarian torsion
- Ruptured ovarian cyst
- PID / tubo-ovarian abscess
Other
- Incarcerated hernia
Priority
- Appendicitis is the major GI diagnosis to exclude in a patient with RLQ pain or tenderness.
Doorway Evaluation
You enter the room.
She is uncomfortable but awake, conversant, and not pale or diaphoretic. Her blood pressure is normal. Her abdomen is not rigid.
Sick or not sick? What would change the pace immediately?
Currently Stable
Immediate Concern If
- Shock / hypotension
- Generalized peritonitis
- Severe sepsis / toxic appearance
- Major bleeding
If Unstable
- ABCs + IV access + resuscitation
- Early surgery / GYN involvement depending on the suspected cause
Focused History And Exam
She tells you:
“It started around my belly button yesterday. A few hours later it moved down to the right side and stayed there. I don’t feel like eating.”
She has nausea but no diarrhea, dysuria, flank pain, vaginal bleeding, or vaginal discharge.
Exam
- Focal RLQ tenderness
- Mild guarding
- Maximum tenderness near McBurney point
- No CVA tenderness
What findings move appendicitis up your differential?
Appendicitis Becomes Much More Likely With The Combination Of
- Migration: periumbilical → RLQ
- Focal RLQ tenderness / peritoneal irritation
- Anorexia / nausea
- Fever / inflammatory response
- No single finding diagnoses appendicitis; the pattern matters. The current lower-abdominal-pain chapter emphasizes migration, peritoneal findings, and inflammatory response as the main findings that push probability upward.
Purposeful Workup
What basic tests do you need, and what question is each answering?
Purposeful Tests
- CBC: inflammatory response / anemia
- CMP: renal function / electrolytes before imaging or treatment
- UA: UTI / stone mimic
- Pregnancy test: ectopic pregnancy + determines imaging pathway
- Do not skip the pregnancy test in a reproductive-age patient with lower abdominal pain.
Results
- WBC 14.2 K/µL with neutrophilia
- Creatinine normal
- UA without infection
- Pregnancy test negative
Imaging
She is a nonpregnant adult with persistent RLQ pain and a concerning exam. What imaging do you want?
CT Abdomen/Pelvis
- In a nonpregnant adult, CT is the primary imaging study for suspected appendicitis.
- Imaging confirms the diagnosis and evaluates for complications.
The Current Chapter Uses
- Adult → CT
- Child → US first
- Pregnant → US ± MRI
CT shows:
Dilated inflamed appendix with periappendiceal fat stranding. No abscess or free perforation.
Diagnosis
What is the diagnosis? Uncomplicated or complicated?
Acute Uncomplicated Appendicitis
Complicated Appendicitis Would Include Findings Such As
- Perforation
- Abscess / phlegmon
- Diffuse peritonitis
- Sepsis
Essential ED Management
What do you do in the ED now?
Essential ED Management
- NPO
- Analgesia
- IV fluids if needed
- Antibiotics
- Surgery consultation
Definitive Treatment
- Laparoscopic appendectomy remains the standard definitive treatment.
Disposition
The surgeon calls back. Give the 20-second presentation.
“Twenty-four-year-old woman with one day of abdominal pain that began periumbilically and migrated to the RLQ, with anorexia, nausea, fever, focal RLQ tenderness and guarding. Pregnancy test is negative, WBC is 14, and CT shows uncomplicated acute appendicitis without abscess or perforation. She’s NPO, has analgesia and antibiotics started, and I need surgical evaluation for appendectomy.”