Suspected Appendicitis – Emergency Department – History and Physical

Suspected Appendicitis Clinical Pathway – Emergency Department

History and Physical

  • Older children and teenagers in which appendicitis is more prevalent are more likely to have the classic signs of appendicitis. Symptoms progress from anorexia to peri-umbilical pain followed by migration to the RLQ.
  • In younger children, migration of pain may not occur but focal abdominal tenderness (usually right sided) is often present.
  • Appendicitis is uncommon in children < 5 yr; these children present with diffuse abdominal tenderness.
  • Ovarian pathology must be considered in females, especially if post-pubertal.
  • Common diagnoses that may mimic appendicitis include gastroenteritis, mesenteric lymphadenitis, UTI, renal stone, PID, TOA, ovarian torsion and ovarian cyst.

History

Onset/Progression of Symptoms
Pain
  • Duration, location, migration
  • Severity, use pain scale score
  • Worse on walking, squatting, riding in the car
    • Evidence of peritoneal irritation
Anorexia/Nausea
  • Last good meal
  • Oral intake since symptom onset
  • Fluid intake, urine output
Vomiting
  • Time of onset
    • Before or after abdominal pain
    • Number of episodes, last episode
  • Bilious/bloody
Stool
  • Time of last stool
  • Diarrhea, blood/mucous
Fever
  • Duration
  • Medications given
Past Medical History
  • Prior abdominal pain episodes
  • Constipation
  • Previous UTI
GU
  • Menarche, last menses
  • Hx/concern for UTI, pregnancy
  • Hx of ovarian cyst

Physical

General Appearance, VS
Abdomen
  • Focal tenderness, guarding/rebound
    • Psoas
    • Obdurator
  • Rovsing signs
  • CVA tenderness
Genital
  • Tanner stage
  • Inguinal canal abnormality/hernia
  • Scrotum/testicles abnormalities
  • Bimanual exam, as indicated
  • Rectal exam, as indicated