Classic Patient

The classic patient with appendicitis complains of peri-umbilical pain 1 or 2 days prior to presentation that has subsequently migrated to the right lower quadrant. The patient has a low grade fever. The patient may have one or two episodes of vomiting, which are self-limiting, and is usually anorexic. Diarrhea, persistent vomiting, or a patient requesting food or drink would be unusual. A clinical course exceeding 2 or 3 days would also be unusual. A protracted course beyond 72 hours may indicate that the appendix has perforated, with the patient initially feeling better, and then worsening systemically as a phlegmon or abscess was being formed.

On physical examination, there is usually focal tenderness and localized peritoneal irritation in the right lower quadrant of the abdomen, over the appendix. Although the appendix is classically located at McBurney's point (two-thirds the distance from the umbilicus to the right anterior superior iliac spine), anatomic variations are common and include retrocecal, intrapelvic, left lower quadrant, or right upper quadrant positions.

A number of clinical signs can be used to discern localized peritonitis. Tenderness to percussion over the appendix is more sensitive, more specific, and certainly more kind to the patient being examined than rebound tenderness. The unsolicited complaint of pain in the right lower quadrant with maneuvers such as palpation of the left lower quadrant (Rovsing sign), cough (Dunphy sign), internal rotation of the flexed right thigh (obturator sign), or extension of the right hip (iliopsoas sign) all indicate an inflammatory process in the right lower quadrant.

Laboratory values can be notoriously misleading, but the classic patient has a mild leukocytosis with a left shift of neutrophils to immature forms. Urinalysis should be negative, although pyuria without bacteria can occur in the setting of appendicitis from periureteral inflammation.

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