How to Avoid Missing
Appendicitis
Abdominal pain is the chief complaint in about 4%
of primary care visits and 5% of emergency room
(ER) visits. In 10% of those visits, surgery is
required. Missed appendicitis is 1 of the top 10
conditions that lead to malpractice claims. Among
ER physicians, it is in the top 5. On the other hand,
about 20% of patients taken to surgery for pre-
sumed appendicitis do not have it.
There is no easy way to diagnose appendicitis,
which can masquerade as a number of more
benign conditions, including gastroenteritis, gastri-
tis, urinary tract infection (UTI), and constipation.
The differential for acute abdominal pain also
includes pelvic inflammatory disease (PID), small
bowel obstruction, abdominal aortic aneurysm,
mesenteric ischemia, myocardial infarction with
atypical presentation, perforated viscus, cholecysti-
tis, nephrolithiasis, and ectopic pregnancy. A failure
to diagnose appendicitis in a timely fashion can
lead to appendiceal rupture and peritonitis. The
nature of the patients injury can be unnecessary
medical expenses, pain and suffering, lost wages,
and, in the worst-case scenario, death.
Clinicians can learn from the legal records of
those who missed a diagnosis and were sued.
Clinicians sued for malpractice for failure to diag-
nose appendicitis have failed to:
1. Evaluate a patient serially over hours
2. Suspect appendicitis in the afebrile, stoic,
elderly patient
3. Suspect appendicitis in the young child
who is afebrile, has an appetite, a normal
complete blood count (CBC), a soft
abdomen, no definite rebound, and normal
bowel sounds, but who does have localized
right lower quadrant tenderness. A child
with a ruptured appendix presented in
this way.
4. Rule out appendicitis in female patients in
whom PID or UTI has been diagnosed.
Some patients will present with PID or UTI
and appendicitis.
5. Collect complete data
www.npjournal.org
LEGAL LIMITS
Carolyn Buppert, JD
The Basics
Generally, appendicitis occurs when the appen-
diceal lumen is obstructed by a fecalith or lymphoid
hyperplasia. Although appendicitis may occur at any
age, it is rare in infants. It is most common in ado-
lescents and young adults.
The classic symptom description is as follows:
Chief complaint: Abdominal pain
Onset: Gradual in adults, may be acute or
gradual in children
Location: Periumbilical for hours to days, local-
izing to right lower quadrant. Pain may refer to
back or pelvis.
Duration: Several to 72 hours
Severity: Moderate to severe
Quality: Sharp or dull
Quantity: Constant, steady
Associated symptoms: Nausea, vomiting,
anorexia. Pain precedes vomiting. Little or no
diarrhea.
Alleviating factors: Lying still, fetal position
Aggravating factors: Moving, coughing, or
walking; palpation of abdomen
Symptoms are less likely to be classic in the
young and the elderly, pregnant women, patients
whose appendix is not in the typical anatomical
position, the immune suppressed, and the stoic
patient. The most consistent symptoms are
anorexia, right lower quadrant tenderness, and
rebound tenderness.
As far as signs, the patient may or may not be
febrile. Children and elderly patients are less likely
to be febrile. Fever is generally low grade until per-
foration occurs. Bowel sounds are likely to be pres-
The Journal for Nurse Practitioners - JNP 237
JNP

ent in early stages and absent in peritonitis. White obstruction, abdominal aortic aneurysm, mesen-
count may be normal or elevated moderately with teric ischemia, myocardial infarction with atypical
left shift. Urinalysis may show ketonuria or a few presentation, perforated viscus, cholecystitis,
red and/or white cells or may be normal. Other nephrolithiasis, and ectopic pregnancy.
signs may include:
Positive abdominal tenderness in the right Carolyn Buppert, CRNP, JD, practices law in Bethesda, MD.
She can be reached at cbuppert@buppert.com.
lower quadrant
Positive rebound tenderness
1555-4155/12/$ see front matter
Positive guarding 2012 American College of Nurse Practitioners
doi: 10.1016/j.nurpra.2012.01.011
Positive psoas sign and
Local rectal tenderness and/or mass in
the rectum
To avoid missing appendicitis:
1. Conduct a careful history of present illness
and abdominal exam. History and physical
examination are at least as reliable as any lab-
oratory testing in diagnosing appendicitis.
2. If signs and symptoms are minimal, especially
in the elderly, consider observation for several
hours with repeated exams and a CBC every 4
hours.
3. Conduct the following office-based exams and
tests, in addition to careful abdominal exam
and vital signs, to rule out other diagnoses:
a. Pelvic exam in female patients. If PID is
unlikely (no cervical motion tenderness or
discharge) pending cervical swab cultures,
raise the index of suspicion for appendicitis.
b. Urinalysis for leukocytes, protein, and blood
c. Electrocardiogram (ECG)
4. Perform a rectal exam for tenderness or mass.
If positive for either, suspicion of appendicitis
should increase.
5.If a patient presenting with abdominal pain has
anorexia, right lower quadrant tenderness, or
rebound tenderness, and the patients pelvic
exam, urinalysis, and ECG are normal, conduct
further evaluation to rule out appendicitis or
refer to the ER or surgeons office for a same-
day appointment.
6. If you suspect appendicitis, order an urgent
surgical consultation.
As always, it makes sense to rule out the worst
thing first. When a patient complains of abdominal
pain, you are in risky territory. Before diagnosing
viral gastroenteritis, rule outeither through a care-
ful history and physical or through appropriate
testsnot only appendicitis but PID, small bowel

238 The Journal for Nurse Practitioners - JNP Volume 8, Issue 3, March 2012