Clinical case involving abdominal right lower quadrant or RLQ pain

Before we look at a clinical case involving right lower quadrant (RLQ) pain, let’s review two key components of a medical evaluation.

First, remember the OLD CARTS (onset, location, duration, character, alleviating factors, radiation, temporal patterns, and symptoms) acronym, which can help you develop your history of present illness questions. Also, recall how to take SOAP (subjective, objective, assessment, and plan) notes. The subjective portion involves allowing the patient to tell you their symptoms. The objective portion includes your physical exam findings. As well, the assessment portion involves your differential diagnoses. Finally, the plan portion is how you plan to treat the patient.

This clinical case involves a 19-year-old, healthy, thin male with a three-day history of RLQ pain.

First, think of your history of present illness questions using the OLD CARTS acronym, and ask the patient what brings them in today. The patient reports that the pain started suddenly three nights ago around his belly button and was intermittent.

He also reports that yesterday evening the pain moved to his right lower side. It is stabbing and constant. Nothing makes it better, and movement makes it worse. He also admits to nausea, vomiting, and diarrhea, but denies constipation. He has no appetite and has not eaten anything for the last two days.

The patient has provided a lot of detail about the pain. You can organize his description using the OLD CARTS acronym, which will guide your questions and help create the differential diagnosis

The onset (O) of the pain was three days ago, it’s located (L) in the RLQ, and the duration (D) has been three days. He characterizes (C) the pain as stabbing, constant pain. Lying still alleviates (A) the pain. Associated symptoms (S) include nausea, vomiting, diarrhea, and anorexia.

The patient has not told you anything about the radiation of pain (R) or temporal patterns (T), so you directly ask him about those details. He reports that the pain radiates into his right lower back and suprapubic region. The pain has no specific pattern and has been constant for the past day.

In addition to the details of his history of present illness, you remember to get other pertinent history details:

• He denies any past medical history.
• He has a history of tonsillectomy and adenoidectomy.
• He is not on any medications.
• He has no allergies to medications.

Except for a 101.7°F (e.g., 38.7°C) fever, the patient’s vitals are normal and stable. The patient is a thin male and appears to be in distress with his knees flexed up toward his abdomen. When asked to straighten out his legs, it causes pain.

No surgical scars are noted, and he has normal-appearing male genitalia with no visible inguinal bulges. He has bowel sounds, but are diminished in the left lower quadrant (LLQ) and RLQ. No abdominal aortic bruits are present.

There is appropriate dullness over his liver and mild tympany over the small bowel near his umbilicus. He has referred pain with palpation of his LLQ (e.g., Rovsing’s sign), a positive psoas sign, and tenderness at McBurney’s point (e.g., McBurney’s sign). No inguinal hernia is found on palpation.

Here’s a quick refresher for the signs present in the patient’s exam:

1. Psoas sign:

1. Pain occurs with passive extension of the hip with the patient in the left lateral decubitus position.
2. This indicates irritation to the iliopsoas muscle (a retroperitoneal hip flexor).
3. An inflamed appendix that is retrocecal will irritate this muscle.

2. Rovsing’s sign:

1. Pain occurs in the RLQ during palpation of the LLQ.
2. This indicates irritation of the entire peritoneum due to increased pain from the RLQ.

3. McBurney’s sign:

1. Pain occurs with palpation at McBurney’s point (one-third of the distance from the anterior superior iliac spine to the umbilicus), which is the most common location of the appendix base.
2. When the appendix is inflamed, pressure on this point will generate pain.

Based on the patient’s presentation, appendicitis is high on the differential diagnosis. Ischemic colitis is also in the differential, but the physical exam findings are suggestive of appendicitis.

Testicular torsion must be considered in all young male patients with abdominal pain. But, there was no testicular pain and the testicles appeared normal on the exam.

The Alvarado score for appendicitis

The Alvarado score is a scale created to further aid in the diagnosis of appendicitis. It is a clinical scoring system that predicts the likelihood of appendicitis. This patient displays all three symptoms, as well as at least two of the listed signs (Fig. 5).

The scale is based on six clinical findings and two laboratory measures. A score of five to six indicates that appendicitis is possible, seven to eight means that appendicitis is probable, and greater than nine means that appendicitis is highly probable.

Now that you have a differential diagnosis based on the patient’s history and physical exam, you’re well on your way to diagnosing and treating the cause of the pain. The diagnosis may require further assessment with imaging modalities and laboratory findings.

The plan could involve surgery with or without the addition of antibiotics. This final component completes the SOAP for your patient with RLQ pain.

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