Robin Gray-Reed, RN, IBCLC, SNM NURS 561 Winter 2013

Julie is a 35 year old woman, using a Paragard IUD for birth control for the last two years since the birth of her 3rd child. She presents to your office concerned about RLQ pain she started having yesterday. She reports that it is getting worse today. She usually has a regular menses with mild cramping the first day and her last period was almost 4 weeks ago.

OB history Menstrual history Sexual history (new sex partner(s)? STIs?) Contraceptive history (any problems with IUD?) Medical history (especially GI and GU) Surgical history (abdominal surgery? appendectomy?) Medications

 OB history: G4P3, TAB 1997; NSVDs in 2007, 2009, & 2011 Lactation history: still breastfeeding 26-month-old Menstrual history: 29-31 day cycles, regular, moderate flow, mild cramping Sexual history: monogamous with partner (husband); denies history of STIs Contraceptive history: condoms until she got the Paragard (2011); no problems with IUD Medical history: mild intermittent asthma (exerciseinduced), uses rescue inhaler less than once per week Surgical history: tonsillectomy in 1999 Medications: prenatal vitamins, albuterol; NKDA

Onset: yesterday, as crampy periumbilical pain Location: RLQ Duration: constant Characteristics: sharp Aggravating: coughing and movement Associated symptoms: nausea, vomiting, anorexia Radiation: from umbilicus to RLQ Temporal: worse today than yesterday Severity: 6-7 out of 10

Heart rate: 78 Blood pressure: 110/62 Respiratory rate: 14 Temperature: 100.7 Pain: 6-7/10

 Abdominal guarding Rebound tenderness (positive McBurneys sign) Positive psoas sign (RLQ pain on practitioner extending patients hip) Positive Rosvings sign (RLQ pain upon palpation of LLQ) No CVA tenderness No cervical motion tenderness No uterine or adnexal pain or palpable masses No rectal masses or occult blood in stool

What are our differential diagnoses?

Ectopic pregnancy Ovarian cyst/torsion Fibroids Pelvic inflammatory disease IUD perforation/migration Pyelonephritis Urinary calculi

Acute appendicitis Perforated duodenal ulcer Diverticulitis Inflammatory bowel disease Gastroenteritis Intestinal obstruction Acute mesenteric adenitis

Pregnancy test CBC with differential Urinalysis C-Reactive Protein

Pregnancy test: negative CBC with differential: leukocytes 16,000/mm3 Urinalysis: negative C-Reactive Protein: elevated

Abdominal CT with IV contrast

Abdominal CT with IV contrast shows: Distended appendix (>6 mm in diameter) Peri-appendiceal inflammation with fat streaking Thickened appendiceal wall (>2 mm thick) IUD visualized within uterus

Acute appendicitis without perforation Diagnosis is primarily made from history and clinical findings (diagnostic accuracy is 75-90% according to UpToDate); imaging and labs are supportive but secondary.

Migratory right iliac fossa pain (1 point) Anorexia (1 point) Nausea/vomiting (1 point) Tenderness in the right iliac fossa (2 points) Rebound tenderness in the right iliac fossa (1 point) Fever >37.5C (1 point) Leukocytosis (2 points)

A low Alvarado score (<5) has more diagnostic utility to rule out appendicitis than a high score (7) does to rule in the diagnosis. UpToDate, 2012

 Referral for surgical management 1 g IV cefoxitin within 60 minutes of surgery Laparoscopic appendectomy Laparoscopy is preferred in female patients to permit visualization of potential pelvic causes of pain

 2-3 days recovering in hospital No antibiotics needed after uncomplicated appendectomy (infection is very rare) Follow-up with surgeon in one week Pt education: inform Julie that recurrence is impossible. Teach her warning signs for postsurgical infection (rare if appendectomy was uncomplicated).

 S: 35-y/o female complaining of sharp RLQ pain (rated 67/10) aggravated by coughing and movement. Onset 24 hours ago as crampy periumbilical pain. Also experiencing N/V and anorexia. O: HR 78, BP 110/62, RR 14, T 100.7. Abdominal guarding, rebound tenderness, positive psoas and Rosvings signs. No CVAT, CMT, or uterine/adnexal/rectal pain or palpable masses; no occult blood in stool. Labs: negative pregnancy test, leukocytes 16,000/mm3. Elevated CRP. CT with contrast shows distended appendix, peri-appendiceal inflammation with fat streaking, thickened appendiceal wall. A: Acute appendicitis without perforation P: Referral for surgical management (laparoscopic appendectomy)

 American Association of Family Physicians (2013). Evaluation of abdominal pain in adult populations. Accessed January 31, 2013 from http://www.aafp.org/afp/2008/0401/p971.html Family Practice Notebook (2013). Appendicitis. Accessed January 29, 2012, from http://www.fpnotebook.com/Surgery/GI/Apndcts.htm Hackley, B., Krebs, J., & Rousseau, M.E. (2007). Primary care of women: A guide for midwives and womens health providers. Sudbury, MA: Jones and Bartlett. McCaffrey, R., & Youngkin, E.Q. (2010). NP notes: Nurse practitioners clinical pocket guide. Philadelphia: F.A. Davis Company. UpToDate (2012). Acute appendicitis in adults: Management. Accessed January 29, 2013 from http://www.uptodate.com.proxy.seattleu.edu/contents/acuteappendicitis-in-adults-management UpToDate (2012). Acute appendicitis in adults: Clinical manifestations and diagnosis. Accessed January 29, 2013 from http://www.uptodate.com.proxy.seattleu.edu/contents/acuteappendicitis-in-adults-clinical-manifestations-and-diagnosis

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