Appendicitis Clinical Pathway — Emergency Department

History and Physical Examination

Older children and teenagers in which appendicitis is more prevalent are more likely to have the classic signs of appendicitis. Symptoms progress from anorexia to peri-umbilical pain followed by migration to the RLQ. In younger children, migration of pain may not occur but focal abdominal tenderness (usually right sided) is often present. Appendicitis is uncommon in children < 5 yr; these children present with diffuse abdominal tenderness. Ovarian pathology must be considered in females, especially if post-pubertal.

Common diagnoses that may mimic appendicitis include GE, mesenteric lymphadenitis, UTI, renal stone, PID, TOA, ovarian torsion and ovarian cyst.

 
History
Onset/progression
of symptoms
Pain
  • Duration, location, migration
  • Severity (use pain scale score)
  • Worse on walking, squatting, riding in the car
    • Evidence of peritoneal irritation
Anorexia/Nausea
  • Last good meal
  • Oral intake since symptom onset
  • Fluid intake, urine output
Vomiting
  • Time of onset
    • Before or after abdominal pain
    • Number of episodes, last episode
  • Bilious / bloody
Stool
  • Time of last stool
  • Diarrhea, blood / mucous
Fever
  • Duration
  • Medications given
Past Medical History
  • Prior abdominal pain episodes
  • Constipation
  • Previous UTI
 
  • Menarche, last menses
  • Hx/concern for UTI, pregnancy
  • Hx of ovarian cyst
Physical Examination
General Appearance, VS  
Abdomen
  • Focal tenderness,guarding/rebound
    • psoas
    • Obdurator
  • Rovsing signs
  • CVA tenderness
Genital
  • Tanner stage
  • Inguinal canal abnormality/hernia
  • Scrotum/testicles abnormalities
  • Bimanual exam, as indicated
  • Rectal exam, as indicated