Surgery

24 year old woman presents with abdominal pain

Joshua Underhill on Jan 28, 2018 - University of Michigan

A 24 year old woman presents to the emergency room around 8pm with abdominal pain. She reports that the pain began this morning, first as a general ache in her entire abdomen. Now the pain is sharp and focuses in her right lower quadrant. She has not eaten anything today as she does not feel hungry at all, and she reports some nausea today but no vomiting.

  • Temp  38 C
  • HR  98
  • BP  115/80
  • RR  12
  • O2  99% on Room Air

Her physical exam is as follows:

General: young woman visibly in pain

Cardiac: regular rate and rhythm, +S1/S2, no murmurs/rubs/gallops

Respiratory: no increased work of breathing, lungs clear to auscultation bilaterally

Abdominal: diffusely tender with guarding of the abdomen, moreso in the right lower quadrant. Rebound tenderness in the right lower quadrant. Bowel sounds present.

Extremities: warm, well perfused. 2+ DP and PT pulses.

You are concerned for acute appendicitis in this patient. What physical exam signs would point towards appendicitis?

Select all that apply
Expand all answers
Obturator sign
Yes! The obturator sign can be seen in pelvic appendicitis. This is positive when the patient experience pain with internal rotation of the leg with the hip and knee flexed.


Courvoisier's sign
No. Courvoisier's sign is used to evaluate gallbladder pathology. If a patient has a painless palpably enlarged gallbladder with mild jaundice, then the cause is unlikely to be gallstones.


Murphy's sign
No. Murphy's sign is classic for cholecystitis. It is positive if the patient suddenly stops breathing in during ultrasound of the right upper quadrant due to pain.


Rovsing's sign
Yes! Rovsing's sign is classic for appendicitis. It refers pain in the right lower quadrant resulting from testing for rebound tenderness in the left lower quadrant.


Psoas sign
Yes! The psoas sign may be positive in retrocecal appendicitis. This sign is positive when there is pain while extending the hip with the knee in full extension or in hip flexion against resistance.


In this patient, Rovsing's sign is positive with all other special maneuvers negative. 

Which labs and studies are most important to obtain first?

Select all that apply
Expand all answers
CBC with differential
Yes! This will give us an idea of the inflammatory process going on at this time. Classically, we will see a leukocytosis with a left shift in acute appendicitis. Two other answers are correct.


Urinalysis
Yes! UA is important to rule out pyelonephritis and renal calculus. In acute appendicitis, UA will often be negative though mild hematuria and pyuria may be seen due to pelvic inflammation. Two other answers are correct.


B-HCG
Yes! It is very important that every woman who presents to the ED with abdominal pain receives a pregnancy test immediately. If she is pregnant, then this will change your diagnostics and management. For example, you should avoid obtaining a CT in a pregnant patient. Two other answers are also correct.


CT abdomen / pelvis without contrast
No. While helical CT is commonly used to diagnose acute appendicitis, the Surgical Infection Society and the Infectious Diseases Society of America recommend this be done with IV contrast, but no oral or rectal contrast.


CT abdomen / pelvis with IV contrast
Almost! Helical CT with IV contrast is recommended by the Surgical Infection Society and the Infectious Diseases Society of America for diagnosis of acute appendicitis. However, we must first rule out pregnancy before obtaining a CT, as the radiation is a risk to her pregnancy.


Abdominal and pelvic ultrasound
No. Ultrasound can be used to diagnose acute appendicitis, but it is generally better for diagnosis of pelvic pathology than abdominal pathology. Helical CT is considered the better radiologic test for diagnosing acute appendicitis. Ultrasound can be used instead if the patient is pregnant (which we are still not sure of yet).


  1. Blackbourne, L. H., (2012). Surgical Recall, Sixth Edition. Philadelphia, PA. Wolters Kluwer.
  2. Pestana, C. (2013) Dr. Pestana's Surgery Notes. New York, NY. Kaplan Publishing
  3. Joseph S. Solomkin, John E. Mazuski, John S. Bradley, Keith A. Rodvold, Ellie J.C. Goldstein, Ellen J. Baron, Patrick J. O'Neill, Anthony W. Chow, E. Patchen Dellinger, Soumitra R. Eachempati, Sherwood Gorbach, Mary Hilfiker, Addison K. May, Avery B. Nathens, Robert G. Sawyer, and John G. Bartlett. Surgical Infections. February 2010, 11(1): 79-109. https://doi-org.proxy.lib.umich.edu/10.1089/sur.2009.9930
  4. Toy, E. C., Liu, T. H., Campbell, A. R. (2012). Case Files Surgery, Fourth Edition. New York, NY. McGraw-Hill.

A 24 year old woman presents to the emergency room around 8pm with abdominal pain. She reports that the pain began this morning, first as a general ache in her entire abdomen. Now the pain is sharp and focuses in her right lower quadrant. She has not eaten anything today as she does not feel hungry at all, and she reports some nausea today but no vomiting.

  • Temp  38 C
  • HR  98
  • BP  115/80
  • RR  12
  • O2  99% on Room Air

Her physical exam is as follows:

General: young woman visibly in pain

Cardiac: regular rate and rhythm, +S1/S2, no murmurs/rubs/gallops

Respiratory: no increased work of breathing, lungs clear to auscultation bilaterally

Abdominal: diffusely tender with guarding of the abdomen, moreso in the right lower quadrant. Rebound tenderness in the right lower quadrant. Bowel sounds present.

Extremities: warm, well perfused. 2+ DP and PT pulses.

You are concerned for acute appendicitis in this patient. What physical exam signs would point towards appendicitis?

Select all that apply
Expand all answers
Obturator sign
Yes! The obturator sign can be seen in pelvic appendicitis. This is positive when the patient experience pain with internal rotation of the leg with the hip and knee flexed.


Courvoisier's sign
No. Courvoisier's sign is used to evaluate gallbladder pathology. If a patient has a painless palpably enlarged gallbladder with mild jaundice, then the cause is unlikely to be gallstones.


Murphy's sign
No. Murphy's sign is classic for cholecystitis. It is positive if the patient suddenly stops breathing in during ultrasound of the right upper quadrant due to pain.


Rovsing's sign
Yes! Rovsing's sign is classic for appendicitis. It refers pain in the right lower quadrant resulting from testing for rebound tenderness in the left lower quadrant.


Psoas sign
Yes! The psoas sign may be positive in retrocecal appendicitis. This sign is positive when there is pain while extending the hip with the knee in full extension or in hip flexion against resistance.


In this patient, Rovsing's sign is positive with all other special maneuvers negative. 

Which labs and studies are most important to obtain first?

Select all that apply
Expand all answers
CBC with differential
Yes! This will give us an idea of the inflammatory process going on at this time. Classically, we will see a leukocytosis with a left shift in acute appendicitis. Two other answers are correct.


Urinalysis
Yes! UA is important to rule out pyelonephritis and renal calculus. In acute appendicitis, UA will often be negative though mild hematuria and pyuria may be seen due to pelvic inflammation. Two other answers are correct.


B-HCG
Yes! It is very important that every woman who presents to the ED with abdominal pain receives a pregnancy test immediately. If she is pregnant, then this will change your diagnostics and management. For example, you should avoid obtaining a CT in a pregnant patient. Two other answers are also correct.


CT abdomen / pelvis without contrast
No. While helical CT is commonly used to diagnose acute appendicitis, the Surgical Infection Society and the Infectious Diseases Society of America recommend this be done with IV contrast, but no oral or rectal contrast.


CT abdomen / pelvis with IV contrast
Almost! Helical CT with IV contrast is recommended by the Surgical Infection Society and the Infectious Diseases Society of America for diagnosis of acute appendicitis. However, we must first rule out pregnancy before obtaining a CT, as the radiation is a risk to her pregnancy.


Abdominal and pelvic ultrasound
No. Ultrasound can be used to diagnose acute appendicitis, but it is generally better for diagnosis of pelvic pathology than abdominal pathology. Helical CT is considered the better radiologic test for diagnosing acute appendicitis. Ultrasound can be used instead if the patient is pregnant (which we are still not sure of yet).


  1. Blackbourne, L. H., (2012). Surgical Recall, Sixth Edition. Philadelphia, PA. Wolters Kluwer.
  2. Pestana, C. (2013) Dr. Pestana's Surgery Notes. New York, NY. Kaplan Publishing
  3. Joseph S. Solomkin, John E. Mazuski, John S. Bradley, Keith A. Rodvold, Ellie J.C. Goldstein, Ellen J. Baron, Patrick J. O'Neill, Anthony W. Chow, E. Patchen Dellinger, Soumitra R. Eachempati, Sherwood Gorbach, Mary Hilfiker, Addison K. May, Avery B. Nathens, Robert G. Sawyer, and John G. Bartlett. Surgical Infections. February 2010, 11(1): 79-109. https://doi-org.proxy.lib.umich.edu/10.1089/sur.2009.9930
  4. Toy, E. C., Liu, T. H., Campbell, A. R. (2012). Case Files Surgery, Fourth Edition. New York, NY. McGraw-Hill.

114  views

  0 likes

      0 comments