HISTORY. Most patients with appendicitis report a history of midabdominal pain that initially comes in waves. In addition, early in the disease process, many patients report a discomfort that creates an urge to defecate to obtain relief. As the disease process progresses, patients usually complain of a constant epigastric or periumbilical pain that eventually localizes in the right lower quadrant of the abdomen. Some patients may report a more diffuse lower abdominal pain or referred pain. Should perforation of the appendix occur, pain may subside to generalized abdominal discomfort. In addition to pain, patients often complain of anorexia, nausea, vomiting, abdominal distension, and temporary constipation. Temperature elevations may also be reported (usually 100°F to 101°F).

PHYSICAL EXAMINATION. Observe the patient for typical signs of pain, including facial grimacing, clenched fists, diaphoresis, tachycardia, and shallow but rapid respirations. In addition, patients with appendicitis commonly guard the abdominal area by lying still with the right leg flexed at the knee. This posture diminishes tension on the abdominal muscles and increases comfort. Slight abdominal distension may also be observed.

Early palpation of the abdomen reveals slight muscular rigidity and diffuse tenderness around the umbilicus and midepigastrium. Later, as the pain shifts to the right lower quadrant, palpation generally elicits tenderness at McBurney's point (a point midway between the umbilicus and the right anterior iliac crest). Right lower quadrant rebound tenderness (production of pain when palpation pressure is relieved) is typical. Also, a positive Rovsing's sign may be elicited by palpating the left lower quadrant, which results in pain in the right lower quadrant.

PSYCHOSOCIAL. The patient with appendicitis faces an unexpected hospitalization and surgical procedure. Assess the patient's coping ability, typical coping mechanisms, stress level, and support system. Also, assess the patient's anxiety level regarding impending surgery and the recovery process.

100 Appendicitis

Diagnostic Highlights

General Comments: Note that the diagnosis of appendicitis is made by clinical evaluation with the diagnostic tests of secondary importance. Prior to radiography, complete a pregnancy test on women who might be pregnant.

Abnormality with

Test Normal Result Condition Explanation

Complete blood Adult males and Infection and Leukocytosis may range from 10,000 to count females inflammation may 16,000/pL. Neutrophil count is frequently

4500-11,000/pL elevate the WBC elevated above 75%. In 10% of cases, count leukocyte and differential cell counts are normal.

Other Tests: Flat-plate abdominal x-ray to confirm the diagnosis; urinalysis in 25%-40% of people with appendicitis indicates pyria, albumininuria, and hematuria; serum electrolytes, blood urea nitrogen, and serum creatinine identify dehydration; abdominal ultrasound (particularly useful in women to rule out gynecological causes); abdominal computed tomography (CT) scan; barium enema; diagnostic laparoscopy.

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