Ep 6: A 23-year-old with right lower quadrant abdominal pain

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A 23-year-old woman presents to the emergency department with a 12-hour history of right lower quadrant (RLQ) abdominal pain.

The pain originated in the umbilical region and radiated diffusely across the lower abdomen and is now localized in the right lower quadrant. It was of sudden onset, sharp, and constant with increasing intensity. Severity was rated 8 out of 10 on a scale of 1-10 with one being no pain and 10 being the most pain possible. She took over-the-counter Ibuprofen 400mg but this did not alleviate the pain. The pain was exacerbated by lifting the right leg.

She has vomited twice and reports that she has not eaten for 24 hours due to a lack of appetite. She opened her bowel post-onset of the pain with no change in the consistency of the stool, and no blood or mucus. She does not have abdominal swelling, dysuria, increased frequency of micturition, vaginal bleeding, or purulent vaginal discharge. She is nulliparous and her last menstrual period was 2 weeks ago with no complaints of dysmenorrhoea. She also has no history of unintentional weight loss, episodes of dyspepsia, strenuous physical activity or abdominal trauma.

There is no significant past medical and surgical history. Drug history includes the oral contraceptive pill. She has no known drug allergies. There is no relevant family history. She does not smoke nor does she use recreational drugs. She drinks alcohol occasionally.

On examination, she has a temperature of 38.5 degrees Celsius, absent bowel sounds, and marked tenderness to palpation at 1/3 the distance from the anterior superior iliac spine to the umbilicus. While palpating the left lower quadrant, she reports pain in the right lower quadrant. Active flexion and internal rotation of her right hip reproduces the pain. The skin on the RLQ is hypersensitive to touch. Gentle percussion over the right lower quadrant elicits rebound tenderness. There are no hernias. No abnormalities were detected on pelvic and digital rectal exam.

A complete blood count reveals leukocytosis of 13.5 x 10^3/uL with 15% bands. Urinalysis demonstrates 1+ WBCs without bacteria. The pregnancy test is negative.