This comprehensive clinical case study follows the diagnostic journey of a 45-year-old patient presenting with acute abdominal pain to the emergency department. Through this real-world example, we explore the systematic approach emergency physicians use for differential diagnosis, diagnostic testing, and treatment decision-making.
Case Presentation
Patient Profile:
- • Age: 45-year-old female
- • Chief Complaint: Severe abdominal pain for 6 hours
- • Pain Location: Right lower quadrant, migrating from periumbilical area
- • Associated Symptoms: Nausea, vomiting, low-grade fever
- • Pain Scale: 8/10 intensity
History of Present Illness
The patient reports that pain began suddenly while at work, initially around the umbilicus as a dull, cramping sensation. Over the next 2-3 hours, the pain migrated to the right lower quadrant and became sharp and constant. She experienced two episodes of non-bilious vomiting and developed a low-grade fever of 100.2°F (37.9°C).
Pain Characteristics (OPQRST Assessment):
- • Onset: Sudden, 6 hours ago
- • Provocation: Movement, coughing worsen pain
- • Quality: Sharp, constant
- • Radiation: No radiation to back or pelvis
- • Severity: 8/10
- • Timing: Constant, worsening
Physical Examination
Vital Signs and General Appearance
Vital Signs:
- • Temperature: 100.2°F (37.9°C)
- • Heart Rate: 95 bpm
- • Blood Pressure: 128/82 mmHg
- • Respiratory Rate: 18/min
- • Oxygen Saturation: 98% on room air
General Appearance:
- • Appears uncomfortable, guarding abdomen
- • Positioned lying still, knees flexed
- • Alert and oriented x3
- • Mild diaphoresis
- • No acute distress at rest
Focused Abdominal Examination
The systematic abdominal examination revealed key findings that would guide the diagnostic workup:
Positive Examination Findings:
- • McBurney Point Tenderness: Localized tenderness at McBurney point (1/3 distance from anterior superior iliac spine to umbilicus)
- • Rovsing Sign: Positive - pain in RLQ with palpation of LLQ
- • Guarding: Voluntary guarding over right lower quadrant
- • Rebound Tenderness: Mild positive Blumberg sign
- • Psoas Sign: Pain with right hip flexion against resistance
Differential Diagnosis
Based on the clinical presentation, several conditions must be considered in the differential diagnosis:
Primary Considerations:
- • Acute Appendicitis (most likely)
- • Ovarian torsion/cyst rupture
- • Ectopic pregnancy
- • Cholecystitis
Other Possibilities:
- • Ureterolithiasis
- • Pyelonephritis
- • Inflammatory bowel disease
- • Mesenteric lymphadenitis
Clinical Decision-Making Process
The emergency physician used the Alvarado Score (MANTRELS) to assess the probability of appendicitis:
Alvarado Score Components (Total: 7/10):
- • Migration of pain: +1 point ✓
- • Anorexia: +1 point ✓
- • Nausea/Vomiting: +1 point ✓
- • Tenderness in RLQ: +2 points ✓
- • Rebound tenderness: +1 point ✓
- • Elevated temperature: +1 point ✓
- • Leukocytosis: Pending labs
- • Left shift: Pending labs
Diagnostic Testing
Laboratory Results
Complete Blood Count (CBC):
- • White Blood Cells: 13,500/μL (elevated, normal: 4,000-11,000)
- • Neutrophils: 78% (elevated, normal: 50-70%)
- • Hemoglobin: 12.8 g/dL (normal)
- • Platelets: 285,000/μL (normal)
Comprehensive Metabolic Panel:
- • All electrolytes within normal limits
- • Creatinine: 0.9 mg/dL (normal kidney function)
- • Glucose: 95 mg/dL (normal)
Additional Tests:
- • β-hCG: Negative (rules out pregnancy)
- • Urinalysis: Normal (rules out UTI/stones)
- • Lipase: Normal (rules out pancreatitis)
Imaging Studies
Given the clinical presentation and Alvarado score of 7/10, CT imaging was ordered to confirm the diagnosis:
CT Abdomen and Pelvis with IV Contrast Findings:
- • Dilated appendix measuring 8mm in diameter (normal less than 6mm)
- • Appendiceal wall thickening and enhancement
- • Periappendiceal fat stranding
- • Small amount of free fluid in pelvis
- • No evidence of perforation or abscess formation
- • Normal ovaries and adnexa bilaterally
Final Diagnosis and Treatment
Diagnosis: Acute Appendicitis
Based on the combination of clinical presentation, physical examination findings, laboratory results, and imaging studies, the diagnosis of acute appendicitis was confirmed.
Treatment Plan:
- 1. Immediate Management:
- • IV access and fluid resuscitation
- • Pain management with morphine 4mg IV
- • Antiemetics (ondansetron 4mg IV)
- • NPO (nothing by mouth) status
- 2. Antibiotic Prophylaxis:
- • Cefoxitin 2g IV preoperatively
- • Alternative: Cefazolin + Metronidazole
- 3. Surgical Intervention:
- • Urgent surgical consultation
- • Laparoscopic appendectomy planned
- • Surgery scheduled within 6 hours
Key Learning Points
Clinical Pearls:
- • Classic appendicitis pain migrates from periumbilical to RLQ
- • Physical examination findings (McBurney point, Rovsing sign) are highly suggestive
- • Alvarado score helps risk-stratify patients for appendicitis
- • CT imaging is gold standard for diagnosis in equivocal cases
- • Early surgical intervention prevents complications
- • Laparoscopic approach offers faster recovery and less scarring
This case demonstrates the importance of systematic clinical evaluation, appropriate use of diagnostic testing, and timely surgical intervention in acute appendicitis. The combination of careful history-taking, focused physical examination, and judicious use of imaging led to accurate diagnosis and excellent patient outcome.