On my last shift three roughly equivalent appearing patients arrived in a two hour period all worried about appendicitis. The one who was least comfortable on arrival ultimately went home. The one who felt she was getting better over the last 3 days, and only felt pain with deep pressure over the appendix, went to the OR. The last one just got better over an hour with no meds and went home.

The more appy ultrasounds and CTs we order the less I feel like I can predict the outcome from my exam. I really feel for surgeons pre-CT who had to make the hard calls on exam alone. History, however, remains critical.

Red Flags:

• No appetite
• Fever
• Vomiting
• Pain anywhere from the belly button to the right lower abdomen. (Some would say abdomen pain anywhere.)

Happy Words

• Wolfed down some Taco Bell, then developed vomiting and diarrhea a few hours later
• Feeling hungry for more Taco Bell now
• Walking and jumping around easily
• Urinating/defecating no problem
• History of frequent problems related to kidney stones, menstruation, ovarian cysts, UTIs, pregnancy

The textbook appy is someone who says they initially felt mid abdominal pain followed later by tenderness to the right lower belly. But patients don’t read textbooks. If the appendix perforates expect lots of pain, vomiting and difficulty moving. A “rigid” abdomen may develop as the surrounding muscles attempt to limit movement of the inflamed contents within. Some patients weather this period as the infection gets walled off to form an abscess. Kids in particular may arrive this way with vomiting and diarrhea as their bigger complaints. Pregnant women with appendicitis don’t read textbooks either.

My only other tip would be to consider an ultrasound first followed by CT to save a some radiation. But very often that leads to a longer stay and bigger bill. Appendectomy seems like a trivial snip on the surgical spectrum, but getting there can be a winding journey.

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