Chief Complaint: David is a 20 year-old male presenting with severe abdominal pain

Onset – 3 hours ago

Location – right lower quadrant

Duration – pain is constant

Character – started intermittent periumbilical, now a constant sharp pain in the RLQ

Aggravated by – walking, coughing

Relieved by – nothing relieves the pain

Treatments (and response) – no medications were taken

Severity – patient states the pain is a 10/10

PMH:

Denies any past medical history

Medications:

Patient is not currently taking any medications

Family History:

Father; alive, HTN

Mother; alive and well, no known medical history

Brother; alive and well, no known medical history

Social History:

• Denies tobacco use, drinks socially on weekends, 8 drinks/week, denies illicit drug use
• Lives in an apartment with 1 roommate 
• Current full time college student
• Denies recent travel
• States they maintain a “healthy diet.”  Has pizza or take out food on most weekends.
• States sleeping well an average of 7 hours / night
• Denies regular exercise regimen but rides bike most days of week as transportation

ROS:

General: Endorses mild fever and generalized malaise.  Denies recent weight loss/gain, loss of appetite

HEENT:  Denies headache, trauma, visual changes, hearing changes, photophobia, nasal discharge, sore throat, neck stiffness, or swelling

Cardiovascular: Denies chest pain, palpitations, edema, syncope, known murmurs

Pulmonary: Denies SOB, DOE, wheezing, hemoptysis, or cyanosis

Gastrointestinal: 10/10 sharp pain in RLQ with nausea and 1 episode of vomiting 20 minutes prior to presentation.  Denies diarrhea, constipation, melena, BRBPR, changes in bowel habits

Genitourinary:  Denies testicular pain, dysuria, polyuria, oliguria, frequency, incontinence, flank pain, hesitancy, or dribbling

Musculoskeletal:  Denies any muscle/joint pain

Hematologic: Denies anemia, easy bruising or bleeding

Physical Exam:

Vitals – HR: 102, BP: 127/80, RR: 20 , Temp: 99.8°F

Gen – In NAD, alert, appears stated age

Heart – Distinct S1/S2, no murmurs noted

Lungs – Clear bilaterally, no adventitious sounds

Abdomen – 10/10 TTP at RLQ. Abdomen soft, bowel sounds normoactive

• McBurney’s point tenderness
• Rovsing’s sign
• Psoas sign
• Carnett’s test

Differential Diagnosis:

• Acute appendicitis
• Testicular torsion
• Cecal diverticulitis (Right sided diverticulitis)
• Meckel’s diverticulitis

Tests:

LABS

• CBC (leukocytosis / left shift)
• CMP 
• CRP (elevated)
• UA (neg)

IMAGING

• CT + IV contrast (positive)

ADDITIONAL

• Alvarado score

• Scrotal Ultrasound if testicular torsion suspected (negative)

LAB RESULTS

CBC

WBC – 12.0 x10^3/mcL (H)

RBC – 4.85 x10^6/mcL

Hct – 41.4% 

Hb – 13.7 g/dL

PLT – 221 x10^3/mcL

MPV – 9.8 fL

RDW – 13.2 %

Neutrophil % – 70.8

Lymph % – 22.0

Mono % – 7.0

CRP – 48 mg/L

CMP

Glucose serum – 92 mg/dL

BUN – 20 mg/dL

Creatinine serum – 0.90 mg/dL

BUN/Cr Ratio – 20

Sodium – 137 mmol/L

Potassium – 4.1 mmol/L

Chloride – 101 mmol/L

Carbon Dioxide – 28 mmol/L

Calcium – 9.5 mg/dL

Protein, total – 6.8 g/dL

Albumin – 4.3 g/dL

Bilirubin, total – 0.3 mg/dL

Alkaline Phosphatase – 63 IU/L

AST (SGOT) – 20 IU/L

ALT (SGPT) – 24 IU/L

UA – results unremarkable

Treatment/Management:

Non-perforated appendicitis

If fit for surgery + approves surgery = Immediate appendectomy

If unfit for surgery +/- refuses surgery = admit for IV antibiotics and observation

→ Clinical improvement = discharge with PO antibiotics x 10 days

→ No clinical improvement = immediate appendectomy

Pt. counseling:

• Acute appendicitis is a common surgical emergency, with lifetime risk around 8.5% for males worldwide.  
• If left untreated, acute appendicitis can be quite dangerous as you run the risk of a ruptured, or ‘perforated’ appendix. 
• It’s possible for an appendix to rupture as soon as 58-72 hours after first symptoms
• The treatment is an urgent surgical removal of the appendix, an “appendectomy”
• An appendectomy is performed laparoscopically, and typically leaves only 3 small incisions on the abdomen
• Mortality is very low for appendicitis with treatment, less than half of one percent
• Complication rate range from 8 to ~31%, with the most common complications being a surgical site infection or intra-abdominal abscess.  These are rare in non-perforated appendicitis cases
• The appendix is considered a ‘vestigial’ structure, meaning it is no longer needed for us to function and be healthy.  Removal of the appendix does not impact your body functions