                        SYMPTOMS & SIGNS
                                
SYMPTOMS:
     Periumbilical or crampy epigastric pain
     Anorexia, Nausea & Vomiting 
     Pain localized to RLQ
     Possible Diarrhea or Constipation

SIGNS:
     Temperature < 38o C
     Tenderness over McBurney's Point
          = 2/3 of the way between Umbilicus & Rt. ASIS
     Guarding and Rebound over RLQ
     Tender Pt at T12 

ILIOPSOAS SIGN: Passive extension of Rt. Hip worsens Pain
OBTURATOR SIGN: Pain with internal rotation of a flexed hip

LABORATORY TESTS:
     Normal to elevated WBC with a left shift
     UA: Protein +; Trace WBC & RBC's

RADIOGRAPHIC SIGNS: (Non are pathognomonic)
     Fecalith in RLQ 
     Absent bowel gas in RLQ with normal gas pattern in the
          rest of the abdomen
     Free air in peritoneum or appendicular lumen = perforated
          appendix 
     Loss of Peritoneal Fat Line of the Rt. Flank                     Differential Diagnosis
                                
Gastroenteritis
Diverticulosis
Tubal Pregnancy
Rt Renal/Ureteral Calculus
Perforated Duodenal/Gastric Ulcer
Acute Cholecystitis
Pancreatitis
Intestinal Obstruction
Prostatitis
Colon Ca
Meckel's Diverticulum
Abdominal Aortic Aneurysm
Information base: 29 y/o White Female in ER

CC: Abdominal Pain that started about 8 hours ago

HxCC: Woke up this morning with generalized abdominal pain. 
Mostly around belly button.  Admits to Nausea & Vomiting x 3
since onset of pain.  Denies being hungry.  Pain is 9/10. 
Radiates to right lower part of abdomen.  Hurts worse when
moving.  Laying real still, with legs pulled up helps some. 
Denies any previous similar episode.  Tried taking Malox this
AM with no improvement

Past Medical and Surgical Hx:
Denies any chronic medical problems.  Pregnant 3 times; three
full term vaginal deliveries.  laparoscopic Tubal Ligation 6
months ago.

Medications: None

Allergies: None

ROS: Non contributory except as detailed in CC

PHYSICAL EXAM:
BP: 134/76   Pulse: 96   Temp 37.8oC      Resp 20
Heart: RRR without murmur
Lungs: CTA Bilaterally
Abdomen: + Guarding & Rebound in RLQ; Bowel Sounds x 4 
UG: Abdominal Mass palpated on bimanual pelvic examination
Rectal: No masses; guaiac negative
LABORATORY TESTS:
WBC: elevated at 13.2; PMN 86%, Lymphs 12%, Eosin 2%
Hb/HCT: 16.1/42.3
PT/PTT: 12.2/29
Chem20: All WNL

X-Rays:
Supine & Upright Plain radiographs of the abdomen show a
relative paucity of bowel gas on the left side of the abdomen. 
There is mild irregularity and thickening of the folds in a loop of
bowel in the RLQ.  No Appendicolith or free intraperitoneal air
is seen.  These findings are consistent with an inflammatory
process in the RLQ resulting in a localized small bowel ileus.

DIAGNOSIS:
Appendicitis

PLAN:
1.) IV Unasyn: 1 gm q6hrs x 3
2.) IV Lactated Ringers 110 mls/hr
3.) NPO
4.) Emergency laparoscopy with appendectomy