Right iliac fossa pain in a young woman

Patient details

Name: Mrs R.N.
Age / sex: 26-year-old woman
Occupation: Pharmacist
Marital status: Married, one child
Admitted: Emergency department, 11:40
Clerked: Surgical ward, 12:30
Source: Patient herself, reliable
Referred by: Self-referred

Presenting complaint

“Pain in the lower right side of my tummy since yesterday afternoon.”

History of presenting complaint

Mrs R.N. was well until about 20 hours before admission, when she noticed a dull, poorly localised ache around the umbilicus that came on gradually. About eight hours later the pain moved to the lower right side of the abdomen, where it has stayed, and it became sharp and constant, now 7 out of 10. It does not spread anywhere else. It is worse on walking, coughing and moving in bed, and the bumps in the road on the way to hospital were very painful; she is most comfortable lying still, and paracetamol has not helped. She lost her appetite from the start and has eaten nothing since last night. Nausea began a few hours after the pain, and she has vomited twice, bringing up food with no bile and no blood. She felt feverish this morning and measured 37.9 °C at home. She passed one loose stool this morning with no blood. She has never had a similar pain before. Her last menstrual period began three weeks ago, came on time and was of normal flow and length, and her cycles are regular every 28 days. She has had no vaginal bleeding since, no abnormal vaginal discharge and no pain during intercourse. She has not fainted or felt dizzy and has no pain at the tip of the shoulder. She uses no hormonal contraception and has no intrauterine device. She has never had an ovarian cyst, a pelvic infection or an ectopic pregnancy, and has had no fertility treatment. She has no burning on passing urine, no frequency, no blood in the urine and no pain running from the loin to the groin. She has no long-standing diarrhoea, mouth ulcers or weight loss.

One continuous storyA single passage in time order, with no sub-headings and no bullet points.

Migration is the key sentenceVague pain around the umbilicus that moves to the right iliac fossa and becomes sharp is the classic story of appendicitis. Record where it started, when it moved and how its character changed.

Order of symptomsIn appendicitis the pain comes first, then loss of appetite and vomiting, then fever. Vomiting before the pain suggests gastroenteritis. Vomiting from the first minute of a sudden pain suggests a twisted ovary.

The menstrual history is part of this storyIn a woman of reproductive age it belongs here, not in a separate section at the end. Last period, whether it was on time and normal, cycle length, bleeding, discharge, contraception.

End with the negativesEach one rules something out, in this order: ectopic pregnancy and internal bleeding · pelvic infection · ovarian cyst and torsion · urine infection and stone · Crohn's disease.

Common mistakeAccepting “I cannot be pregnant”. A normal period on time makes pregnancy unlikely. It does not exclude it. Only a pregnancy test does.

Past medical history

No chronic illness. No previous hospital admissions apart from childbirth.

Past surgical history

No previous operations. She still has her appendix.

Obstetric and gynaecological history

One pregnancy, one normal vaginal delivery two years ago. No miscarriages. Periods began at 13 and have always been regular.

Drugs and allergies

No regular medication. Paracetamol 1 g twice since the pain began.

No known drug allergies.

Family history

No family history of inflammatory bowel disease or bowel cancer.

Social history

Lives with her husband and two-year-old son. Does not smoke or drink alcohol.

Last ate at 20:00 yesterday; last drank water at 10:00 today.

Systems review

Cardiovascular, respiratory, neurological and musculoskeletal systems: no symptoms.

General examination

A young woman who looks unwell and flushed, lying still with her right hip slightly bent. Alert and orientated. Not pale. Not jaundiced. Tongue dry and coated. Weight 61 kg, height 164 cm, body mass index 23.

Temperature38.0 °C

Pulse102 /min, regular

Blood pressure112/70 mmHg

Respiratory rate18 /min

Oxygen saturation99% on air

Hands warm, capillary refill under two seconds. No enlarged lymph nodes in the neck.

Abdominal examination

Inspection

Abdomen flat, with no scars and no distension. Movement with respiration is reduced in the lower right. When asked to cough she winces and points with one finger to the right iliac fossa.

Palpation

Palpation was begun in the left iliac fossa, away from the pain. Tenderness is maximal at McBurney's point, with guarding and rebound tenderness. Rovsing's sign positive: pressure in the left iliac fossa produces pain in the right. No mass felt. The rest of the abdomen is soft, with no generalised rigidity. No suprapubic tenderness. Liver, spleen and kidneys not palpable. No renal angle tenderness. Psoas and obturator signs negative.

Percussion

Percussion tenderness in the right iliac fossa. No shifting dullness.

Auscultation

Bowel sounds present.

Groins

No lump and no cough impulse at the inguinal or femoral orifices on either side.

Pelvic and rectal examination

Not performed by me. Pelvic examination to be carried out by the gynaecology team if the pregnancy test or ultrasound suggests a pelvic cause.

Other systems

Chest: equal expansion, normal breath sounds, right base clear.

Heart: first and second heart sounds normal, no murmurs.

Legs: right hip moves fully without pain. Calves soft.

Summary

Say this to the examiner Mrs R.N. is a 26-year-old previously healthy woman who presents with 20 hours of abdominal pain that began around the umbilicus and moved to the right iliac fossa, with loss of appetite, vomiting and low fever. Her last period was three weeks ago and normal, and she has no vaginal bleeding, discharge or urinary symptoms. On examination she is not pale, has a temperature of 38.0 °C and a pulse of 102, and has tenderness, guarding and rebound at McBurney's point with a positive Rovsing's sign.

Provisional diagnosis

Acute appendicitis. Pregnancy and a pelvic cause to be excluded before treatment.

Initial plan

Urine pregnancy test first, before any imaging or drug.
Urine dipstick. Full blood count, C-reactive protein, urea and electrolytes.
Ultrasound of the abdomen and pelvis as the first imaging test.
Nil by mouth, intravenous fluids, analgesia and antiemetic.
Senior surgical review. Gynaecology opinion if the test or scan suggests a pelvic cause.
If appendicitis is confirmed or still likely: laparoscopy and appendicectomy, with antibiotics at induction.

Why the pregnancy test is firstIt changes everything that follows: the differential, the choice of imaging, the drugs and the urgency. It takes two minutes and is done in every woman of reproductive age with abdominal pain.

Why ultrasound, why laparoscopyUltrasound uses no radiation and shows the ovaries as well as the appendix. Laparoscopy lets the surgeon inspect the pelvis, so a normal appendix does not end the search.

Give analgesiaPain relief does not hide the signs of peritonitis. Withholding it is an old habit with no benefit.

The Alvarado scoreMigration 1, loss of appetite 1, nausea or vomiting 1, right iliac fossa tenderness 2, rebound 1, fever 1. She scores 7 on clinical features alone. A raised white cell count adds 2 and a left shift adds 1, to a maximum of 10.

Differential diagnosis of right iliac fossa pain in a woman of reproductive age

Give the differential in three groups: bowel, pelvic organs and urinary tract. For each, state the feature that supports or excludes it in your patient.

Diagnosis	Points to it in the history	Points to it on examination	In this patient
Bowel
Acute appendicitis	Central pain moving to the right iliac fossa over hours, loss of appetite, then vomiting, low fever	Low fever, tenderness and guarding at McBurney's point, rebound, Rovsing's sign	Most likely
Gastroenteritis	Vomiting and profuse diarrhoea before or with the pain; others at home affected	Diffuse mild tenderness, no guarding	One loose stool only; local peritonism
Crohn's disease of the terminal ileum	Weeks of diarrhoea, weight loss, mouth ulcers, earlier similar attacks	Thin patient, tender mass in the right iliac fossa, perianal disease	No previous symptoms
Mesenteric adenitis	Child or teenager, recent sore throat or cold, high fever	Tenderness that is not well localised and moves when the patient turns	Unlikely at 26
Meckel's diverticulitis	Same story as appendicitis	Same signs; found at operation	Cannot be told apart clinically
Tube, ovary and uterus
Ectopic pregnancy	Missed or late period, light vaginal bleeding, sudden pain, fainting, shoulder tip pain	Pallor, fast pulse, low blood pressure, lower abdominal tenderness	Period on time, not pale; pregnancy test to exclude
Ovarian torsion	Sudden severe one-sided pain with vomiting from the start; known cyst	Very distressed patient, tender lower abdomen, little fever at first	Gradual onset with migration
Ruptured or bleeding ovarian cyst	Sudden pain, often in the second half of the cycle or after intercourse or exercise	Lower abdominal tenderness, no fever	Possible by cycle day; ultrasound to exclude
Ovulation pain	Mid-cycle, one-sided, lasts hours, comes in other months	Mild tenderness, patient looks well	Day 21, and too unwell
Pelvic inflammatory disease	Pain on both sides, vaginal discharge, pain with intercourse, high fever	Temperature often above 38.5 °C, tenderness low on both sides	One-sided, no discharge
Endometriosis	Pain that returns with each period, painful periods, difficulty conceiving	Often normal	No cyclical pattern
Urinary tract
Urine infection or pyelonephritis	Burning urine, frequency, loin pain, rigors	Suprapubic or renal angle tenderness, high fever	No urinary symptoms; dipstick to confirm
Right ureteric colic	Sudden colicky pain from loin to groin, blood in urine, restless patient	Patient cannot lie still; soft abdomen	Constant pain, lies still
Others
Strangulated femoral or inguinal hernia	Groin lump that has become painful; vomiting	Tense, tender, irreducible lump in the groin	Groins normal
Appendicitis in pregnancy	Same story in a pregnant woman	Tenderness may be higher as the uterus grows	Remember that both can exist together

Model OSCE answer “My most likely diagnosis is acute appendicitis, because of pain migrating from the umbilicus to the right iliac fossa over 20 hours, with loss of appetite, vomiting and low fever, and tenderness, guarding and rebound at McBurney's point with a positive Rovsing's sign. Because she is a woman of reproductive age, I must first exclude an ectopic pregnancy with a pregnancy test, although her normal period and normal colour make it unlikely. My other differentials are ovarian torsion and a ruptured ovarian cyst, which ultrasound would show, pelvic inflammatory disease, which is less likely with one-sided pain and no discharge, and a urine infection, which I would check with a dipstick.”

Clinical signs related to this case

The signs you should look for in any patient with right iliac fossa pain. For each one, know how to elicit it and what a positive result means.

Sign	How to elicit it, or what you see	What it means
Signs of appendicitis
Pointing sign	Asked where the pain is, the patient points with one finger to the right iliac fossa	Well-localised pain: the peritoneum over the appendix is inflamed
Cough sign (Dunphy's)	Coughing causes sharp pain in the right iliac fossa	Local peritonitis
McBurney's point tenderness	Maximum tenderness one third of the way from the right anterior superior iliac spine to the umbilicus	Acute appendicitis
Rovsing's sign	Pressing in the left iliac fossa causes pain in the right iliac fossa	Acute appendicitis
Rebound tenderness	Pain is worse when the hand is released. Percussion tenderness shows the same thing more gently.	The peritoneum is inflamed
Psoas sign	Patient on the left side; passive extension of the right hip causes pain	Retrocaecal appendix lying on the psoas muscle
Obturator sign	Internal rotation of the flexed right hip causes pain	Pelvic appendix lying on the obturator muscle
Tender mass in the right iliac fossa	A fixed, tender swelling, usually after three or more days of symptoms	Appendix mass or abscess; in a thin patient with long history, Crohn's disease
Signs that point to the pelvis
Pallor with a fast pulse	Pale conjunctivae, pulse above 100, falling blood pressure	Internal bleeding: ruptured ectopic pregnancy
Shoulder tip pain	Pain felt at the shoulder, worse lying flat	Blood under the diaphragm
Tenderness low on both sides	Tenderness just above the pubis and in both iliac fossae	Pelvic inflammatory disease
Cervical motion tenderness	Elicited by the gynaecologist on pelvic examination: moving the cervix causes severe pain	Pelvic inflammation: pelvic infection or ectopic pregnancy. Can also occur with a pelvic appendix.
Adnexal mass	Tender swelling beside the uterus on pelvic examination	Ovarian cyst, torsion, ectopic pregnancy or tubo-ovarian abscess
Signs that point elsewhere
Shifting tenderness	The point of greatest tenderness moves towards the left when the patient lies on the left side	Mesenteric adenitis. In appendicitis the tenderness stays where it is.
Renal angle tenderness	Pain on firm pressure between the twelfth rib and the spine	Pyelonephritis
Groin lump without cough impulse	Small, tense, tender lump below and lateral to the pubic tubercle	Strangulated femoral hernia

Key: the position of the appendix changes the signsA retrocaecal appendix gives little tenderness in front and a positive psoas sign. A pelvic appendix gives diarrhoea, urinary frequency and a positive obturator sign. Know these, because the textbook picture is present in only about half of patients.

Key: one side or bothAppendicitis hurts on the right. Pelvic infection usually hurts on both sides. Always palpate the left iliac fossa and the suprapubic area and record what you found.

No sign excludes pregnancyThere is no finding on abdominal examination that rules out an ectopic pregnancy. The test does that.

Be kindElicit rebound once, gently. If the cough sign and percussion tenderness are clearly positive, you do not need rebound at all.

Key: in this patientPointing and cough signs positive, tenderness at McBurney's point, Rovsing's positive, psoas and obturator negative, left side and suprapubic area not tender, not pale. Together these fit an appendix in the usual position and argue against a pelvic cause.

Teaching case. The patient is fictional and written to illustrate format and reasoning. Local protocols decide investigation and treatment.