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Ms. Z. Cope
You are called to see a patient in the
Emergency Department, who is a 25 year-old
female with a 1 day history of right-lower
quadrant abdominal pain.
History
What other points of the history do you
want to know?
History, Patient ZC
Pain started in the middle of the
night and woke the patient from
sleep.
No significant MED.HX. or
SURG HX.
Negative Family HX
Differential Diagnosis
Based on History and Presentation
Influenza
Gastroenteritis
Hepatitis
Diaphragmatic pleurisy
Spinal disease
Typhoid
Tuberculosis
Acute porphyria
Diabetic ketoacidosis
Differential Diagnosis
(cont.)
Intra-abdominal conditions
Acute Appendicitis
Acute Cholecystitis
Diverticulitis (Meckels)
Inflammatory Bowel Disease (Crohns)
Duodenal Ulcer
Intestinal Obstruction
Carcinoma of the Cecum
Nonspecific adenitis Possible Yersinia infection
Differential Diagnosis
(cont.)
Intra-pelvic conditions
Salpingitis
Pelvic Inflammatory Disease
Ectopic Pregnancy
Ruptured Corpus Luteum Cyst
Ruptured Follicular Cyst (Mittelschmerz)
Ruptured Ovarian Cyst
Ovarian Torsion
Pyelonephritis
Ureteral/Renal stone
Physical Examination
What would you look for?
VAGINAL: nontender, no
Discharge
CV : nl S1S2, no murmurs
Neuromuscular: Minimal
hyperesthesia above umbilicus
inspiration
Acute appendicits
Diverticulitis (Meckels)
Inflammatory Bowel Disease (Crohns)
Ovarian pathology
Acute cholecystitis
Intestinal obstruction
Nonspecific adenitis Possible Yersinia infection
Laboratory
Labs ordered
CBC
Electrolytes
LFTs
Amylase /Lipase
B-HCG
Urinalysis
Studies
What further studies would
you want at this time?
Flat/Upright Abdomen
CT Scan: Abd/Pelvis
CT Scan: Other ?
US Abdomen/Pelvis
Abdominal Film
CT Scan Results
Acute Appendicitis
Thickened dilated appendix
Peri-appendiceal fat stranding
Scant free fluid
What next?
Additional Imaging?
Observation?
OR?
Other?
What next?
Management
Surgical Options
Pre-operative preparation
Discussion
Pathophysiology of the disease process, visceral vs.
parietal abdominal pain, laparoscopy vs. open,
antibiotic management, appropriate utilization of
resources, etc.
Discussion
Additional teaching points
QUESTIONS ??????
Summary
Alternative scenarios
Acute Appendicitis with perforation/ Abscess or
tumor
IBD
Acute Diverticulitis
Ovarian Cyst / Torsion/
Perforated Right colon tumor
CT Cecal Tumor
CT Sigmoid Diverticulitis
CT Acute Appendicitis
Acknowledgment
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