Onset of pain. The time to presentation from initial onset of pain is important since it may alter management decisions. If the symptoms have been present for more than 3 days, perform a CT to seek perforation with abscess or phlegmon. Patients who present earlier and with diagnostic uncertainty after examination and imaging should either be admitted and followed by serial examinations or
taken to the operating room for diagnostic laparoscopy, with possible appendectomy.

Quality of pain. Early in the course of the classical presentation of appendicitis, the pain is typically poorly localized, constant, and dull in nature (visceral pain). As the inflammatory process becomes transmural and the parietal peritoneum becomes involved, the quality may change to a sharper and more localized pain that is exacerbated by movement, urination, defecation, cough, sneezing, and palpation.

Localization. The initial pain is usually periumbilical in location. This pain tends to progress to pain localized in the right lower quadrant over the next several hours as the appendiceal lumen becomes increasingly distended and irritates the parietal peritoneum. Less than 50% of patients present with this “classic” history.

Children and elderly. It may be more difficult to elicit a complete history and physical examination in young children. The elderly may have a vague abdominal pain or no pain at all. In either age extreme, fever of unknown origin or septic shock can be the sole presentation.

Relief of pain. Traditional surgical teaching indicates that spontaneous relief of pain in a patient who has continued abdominal pain from appendicitis for over 24 hours indicates rupture. This should be soon followed by generalized peritonitis and more diffuse pain, malaise and systemic signs of peritonitis.

Anorexia is common with appendicitis, but this finding does not have the sensitivity or specificity to assure or exclude the diagnosis.

Fever. Appendicitis is often associated with low grade pyrexia (less than 38.5°C (101°F). If the fever is greater than 39.4°C (103°F), alternative diagnoses or a ruptured appendix are more likely present.

Tenderness at McBurney’s point. Physical examination findings will be dictated by the anatomic location of the inflamed appendix. If the appendix is located in the typical anterior location, the patient has tenderness in the right lower quadrant. If the appendix is retrocecal, the patient may have minimal anterior abdominal tenderness. Once the appendix has ruptured, abdominal findings are more diffuse, less localized.

Rectal examination. For most patients, this has little utility. On rare occasions, tenderness may suggest appendicitis if the tip is in the pelvis. In cases of delayed presentation, rectal examination may elicit a mass and tenderness indicating an abscess or phlegmon.

Psoas sign. Performed with patient laying on the left side and the examiner slowly extends the right thigh. If extension produces pain, this suggests a retrocecal appendix.

Rovsing’s sign. Pain in the right lower quadrant when left lower quadrant is palpated. Suggests localized peritoneal process in the right lower quadrant.

Obturator sign. Performed with patient laying supine while the examiner internally rotates the patient’s flexed thigh and knee. Pain in hypogastric region suggests irritation of the obturator muscle by a low lying pelvic appendix.

Use of opioids for pain control in patients with suspected appendicitis is safe and does not increase errors of diagnosis or management. The key is titration and continuing the search for the cause while relieving pain—not just relieving pain alone.