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Updated 01 June 2015

Answer: What's your diagnosis? – Case 12

Last week we met Mr E (45) who presented to his GP with severe abdominal pain and vomiting. Mr E presented with a classic case of appendicitis.

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Read the full case study here.

Appendicitis can present in many ways, but the most common way is severe abdominal pain that usually starts around the navel and then moves to the right lower abdomen. Vomiting is common and patients generally refuse to eat.

On history taking, the sudden onset of pain, the distribution of the pain and the dull, aching nature of the pain are important clues. The fact that Mr E vomits adds to the appendicitis diagnosis. The absence of diarrhoea suggests that it is unlikely due to food poisoning, but it should still form part of the working diagnosis until completely ruled out. Appendicitis patients often report constipation rather than diarrhoea.

The physical examination important clues that supports the diagnosis of appendicitis:

1.  Mr E is experiencing significant pain – he is restless and sweating. His raised heart rate
     (tachycardia) of 112 supports this.  The case study does not mention his temperature, but
     if high, may also be the cause of an increased heart rate.

2.  His very tender abdomen is a give-away sign. The fact that he is guarding (tensing abdominal muscles on examination) suggests peritoneal
     irritation. Considering the site of his pain, appendicitis is still the most likely diagnosis.

In all cases of significant abdominal pain, one should do a urine test. This is especially important in women of childbearing age to exclude gynaecological causes like ectopic pregnancies or miscarriages.

A clinical diagnosis of appendicitis should be confirmed with imaging studies (like sonar) and blood tests (full blood count to check for raised white cells). It is important to know that doctors will not blindly cut into the abdomen unless they’ve excluded all other possibilities like obstructed bowels and are fairly sure that the cause of the pain is surgical in nature.

NOTE: Health24's on-site GP Dr Owen Wiese reveals new cases on Thursdays. The answer is posted with the story on Mondays, or you can get it in our Daily Tip – sign up here.

Previously on What's Your Diagnosis?

What's your diagnosis? – Case 1: vomiting and weight loss

What's your diagnosis? – Case 2: eye pain

What's your diagnosis -  Case 3: strange behaviour and a bullet in the back

What's your diagnosis - Case 4: seeing odd things

What's your diagnosis - Case 5: mysterious lungs

What's your diagnosis - Case 6: runner with seizures

What's your diagnosis - Case 7: swollen knee

What's your diagnosis - Case 8: bloody semen

What's your diagnosis - Case 9: confusing neurological signs

What's your diagnosis - Case 10:diabetic teenager with unusual signs and symptoms

What's your diagnosis - Case 11:bruising with no apparent cause

 
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