Right iliac fossa pain since last night — appendicitis history
PLAB 2 & PRES 3 · surgery · medium · 8 minutes
Candidate brief
You are an FY2 doctor in the Emergency Department. Mr Jack Thompson, 26, presents with abdominal pain that started last night. Take a focused history of the pain and discuss your likely diagnosis and management plan with him.
What examiners look for
The classical appendicitis sequence is visceral before parietal pain: vague periumbilical discomfort first (midgut visceral afferents), then localisation to the right iliac fossa as the parietal peritoneum becomes inflamed. Migration happens in roughly half of patients — its presence is valuable, its absence does not exclude appendicitis. Anorexia is one of the most consistent features: a hungry patient with right iliac fossa pain should make you think harder about alternatives. Vomiting that comes AFTER pain supports a surgical cause; vomiting before pain points more towards gastroenteritis. Always screen the mimics in a young man: testicular torsion can present as lower abdominal pain with a normal-feeling abdomen — ask and examine; urinary infection and ureteric stone usually bring urinary symptoms or colicky loin-to-groin pain; gastroenteritis brings diarrhoea; and inflammatory bowel disease may bring a longer history. Clinical scores such as Alvarado can support, but never make or exclude, the diagnosis on their own. The disposition that matters is timely surgical assessment, not a score. Analgesia should not be withheld for fear of "masking" signs — that idea is outdated. Treat pain, give an antiemetic, establish IV access, and keep the patient nil by mouth once appendicitis is seriously suspected. Ask "when did you last eat and drink?" in every acute abdomen station. It changes anaesthetic planning and it is the question candidates forget. Perforation risk rises with delay, particularly at the extremes of age and in atypical presentations. Early referral is the safe behaviour this station rewards. If the story had been a woman of childbearing age instead, a pregnancy test and gynaecological differentials (ectopic pregnancy, ovarian pathology) become mandatory parts of the same history — know the variant, even though this patient is male.
Guideline references
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