Case

An 18-year-old college student complains of abdominal pain that began 12 hours ago around their umbilicus and then shifted to the right lower quadrant (RLQ) and flank. They indicate they have been nauseous over the past several hours. Their temperature is 38°C. On physical examination, there is abdominal tenderness, particularly in the RLQ. Laboratory analysis of urine is normal.  

Question 1/2 - What is the most likely diagnosis?

Click on your selected option(s) below  (correct = 1, over-thinking = 2+)

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Incorrect. This would typically be upper abdominal or back pain from the irritation of the esophagus. Onset of this condition is generally slow with mild bouts followed by more significant over time, rather than the rapid onset in this patient.

Incorrect. While the condition is acute over hours, the most vulnerable region to ischemic colitis is the splenic flexure of the large bowel resiting in the upper left quadrant (ULQ) not the right lower right (RLQ).

Incorrect. Peritonitis is a generalized inflammatory response throughout the abdominal cavity. Pain would be more widely localized and not result in heightened tenderness to a specific location such as the RLQ.  

Correct!  Classic appendicitis begins periumbilically and then the pain migrates to McBurney's point in the right lower quadrant (McBurney's point is 1/3 of the distance from the right anterior superior iliac spine to the umbilicus, but a patient will rarely have that level of perceptual specificity in their description of the pain). Generally associated with a low grade fever initially (37-38°C), higher fever may indicate rupture.

The pain shifting location is most likely due to initial symptoms presenting as irritation of the appendix visceral peritoneum referred to the periumbilical region. Then as inflammation worsens, parietal peritoneum of the abdominal wall in the vicinity of the appendix becomes irritated and the pain perception shifts to the right lower quadrant.

McBurney's point itself may represent the brains attempt to reconcile pain intensity and perception between the two locations, settling upon an intermediate McBurney point.

Age of the patient is also in the most common range for appendicitis (10-30 years of age), though it can occur at any age so this is a weak discriminator of condition.

Incorrect. Heart ischemic pain may refer to the epigastrium (T6 dermatome) or to upper shoulders, it does not refer pain distally to the lower abodmen.

Incorrect. This would typically result in upper abdominal or back pain from the irritation of the peritoneum around the stomach (depending on where the ulcer is located on the stomach).