30 yo M PMHx of HTN sent in by PMD for RLQ pain and elevated WBC. Pt reports pain is moderate, non-radiating, present x 2 days. Pain has been worsening. Associated with urinary frequency, nausea, watery non-bilious, non-bloody diarrhea. No dysuria, penile discharge. No hx of abdominal surgery.
Eyes: No visual changes, eye pain or discharge.
ENMT: No hearing changes, pain, discharge or infections.
Cardio: No chest pain, SOB or edema.
Respiratory: No cough or respiratory distress.
GI: + abd pain as per HPI.
GU: + increased frequency
MS: No myalgia, muscle weakness, joint pain or back pain.
Neuro: No headache or weakness. No LOC.
Skin: No skin rash.
Endocrine: No history of thyroid disease or diabetes.
VITAL SIGNS: T 100.7 HR 123 RR 18 BP135/76 S100 ra
CONSTITUTIONAL: Well-developed; well-nourished; in no acute distress, appears to be uncomfortable but nn toxic.
SKIN: No acute rashes and normal skin exam
HEAD: Normocephalic; atraumatic.
EYES: PERRL, EOM intact; conjunctiva and sclera clear.
ENT: No nasal discharge; airway clear.
CARD: S1, S2 normal; no murmurs, gallops, or rubs. Regular rate and rhythm.
RESP: No wheezes, rales or rhonchi. CTAB
ABD: Normal bowel sounds; soft; non-distended; +ttp in the rlq , w/o guarding, + rebound, no CVAT b/l
EXT: Normal ROM.
NEURO: Alert, oriented, grossly unremarkable
PSYCH: Cooperative, appropriate.
LACTIC ACID: 2.0
- In this patient with chief complaint of RLQ pain what is in your differential?
- What are your landmarks for the RLQ US?
- What are the primary and secondary signs of appendicitis?
- What do you see in the images below?
- If this were a female patient, what other ultrasound imaging would you perform?
- Appendicitis, diverticulitis, cholecystitis and biliary colic, pancreatitis, ureterolithiasis and renal colic, Crohn disease, colonic carcinoma, rectus sheath hematoma, omental torsion, UTI, gastroenteritis, enterocolitis, perforated ulcer
- Psoas muscle, external iliac artery and vein. The terminal ileum can be recognized as crossing over the psoas muscle to the cecum; just caudal to this area is the cecal tip. To locate a tip of the appendix, a careful inspection with graded-compression technique should be done at the point of maximal abdominal tenderness. The linear probe should be used for the exam.
- Primary: Non-compressible, blind-ended tubular structure without peristalsis that is > 6mm in diameter and appears to be a "target" sign in transverse view.
Secondary: appendicolith, hyperemia, extraluminal fluid collection
- In the top figure (image 1), a appendicolith can be seen with shadowing posterior to hyperechoic structure.
In the bottom image (image 2), you can identify a blind-ended, tubular structure >6 mm.
- Pelvic ultrasound to evaluate for cysts, torsion, abscess