Clinical case involving abdominal right lower quadrant or RLQ pain

Take the case: develop differential diagnoses for a patient with right lower quadrant abdominal pain.
Last update22nd Feb 2021

Before we look at a clinical case involving right lower quadrant (RLQ) pain, let’s review two key components of a medical evaluation.

First, remember the OLD CARTS (onset, location, duration, character, alleviating factors, radiation, temporal patterns, and symptoms) acronym, which can help you develop your history of present illness questions. Also, recall how to take SOAP (subjective, objective, assessment, and plan) notes. The subjective portion involves allowing the patient to tell you their symptoms. The objective portion includes your physical exam findings. As well, the assessment portion involves your differential diagnoses. Finally, the plan portion is how you plan to treat the patient.

Clinical case involving RLQ pain

This clinical case involves a 19-year-old, healthy, thin male with a three-day history of RLQ pain.

Figure 1. Case study of a 19-year-old, healthy, thin male presenting with a three-day history of right lower quadrant (RLQ) pain.

Subjective findings

First, think of your history of present illness questions using the OLD CARTS acronym, and ask the patient what brings them in today. The patient reports that the pain started suddenly three nights ago around his belly button and was intermittent.

He also reports that yesterday evening the pain moved to his right lower side. It is stabbing and constant. Nothing makes it better, and movement makes it worse. He also admits to nausea, vomiting, and diarrhea, but denies constipation. He has no appetite and has not eaten anything for the last two days.

The patient has provided a lot of detail about the pain. You can organize his description using the OLD CARTS acronym, which will guide your questions and help create the differential diagnosis

The onset (O) of the pain was three days ago, it’s located (L) in the RLQ, and the duration (D) has been three days. He characterizes (C) the pain as stabbing, constant pain. Lying still alleviates (A) the pain. Associated symptoms (S) include nausea, vomiting, diarrhea, and anorexia.

The patient has not told you anything about the radiation of pain (R) or temporal patterns (T), so you directly ask him about those details. He reports that the pain radiates into his right lower back and suprapubic region. The pain has no specific pattern and has been constant for the past day.

Figure 2. Organize your patient’s description of pain using the OLD CARTS acronym. The patient’s pain onset was three days ago, location is the right lower quadrant (RLQ), and the duration is three days. Currently, the pain is stabbing and constant, lying still alleviates it, and the pain radiates to the right lower back and suprapubic region. It has no temporal pattern, and the associated symptoms include nausea, vomiting, diarrhea, and anorexia.

In addition to the details of his history of present illness, you remember to get other pertinent history details:

  • He denies any past medical history.
  • He has a history of tonsillectomy and adenoidectomy.
  • He is not on any medications.
  • He has no allergies to medications.

Objective findings

Except for a 101.7°F (e.g., 38.7°C) fever, the patient’s vitals are normal and stable. The patient is a thin male and appears to be in distress with his knees flexed up toward his abdomen. When asked to straighten out his legs, it causes pain.

No surgical scars are noted, and he has normal-appearing male genitalia with no visible inguinal bulges. He has bowel sounds, but are diminished in the left lower quadrant (LLQ) and RLQ. No abdominal aortic bruits are present.

There is appropriate dullness over his liver and mild tympany over the small bowel near his umbilicus. He has referred pain with palpation of his LLQ (e.g., Rovsing’s sign), a positive psoas sign, and tenderness at McBurney’s point (e.g., McBurney’s sign). No inguinal hernia is found on palpation.

Figure 3. Objective findings for the patient include fever, distress, diminished bowel sounds in the lower left quadrant (LLQ) and right lower quadrant (RLQ), referred pain with LLQ palpation (a positive Rovsing’s sign), a positive psoas sign, and tenderness at McBurney’s point (a positive McBurney’s sign).

Here’s a quick refresher for the signs present in the patient’s exam:

  1. Psoas sign:
  1. Pain occurs with passive extension of the hip with the patient in the left lateral decubitus position.
  2. This indicates irritation to the iliopsoas muscle (a retroperitoneal hip flexor).
  3. An inflamed appendix that is retrocecal will irritate this muscle.
  1. Rovsing’s sign:
  1. Pain occurs in the RLQ during palpation of the LLQ.
  2. This indicates irritation of the entire peritoneum due to increased pain from the RLQ.
  1. McBurney’s sign:
  1. Pain occurs with palpation at McBurney’s point (one-third of the distance from the anterior superior iliac spine to the umbilicus), which is the most common location of the appendix base.
  2. When the appendix is inflamed, pressure on this point will generate pain.

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Assessment

Based on the patient’s presentation, appendicitis is high on the differential diagnosis. Ischemic colitis is also in the differential, but the physical exam findings are suggestive of appendicitis.

Testicular torsion must be considered in all young male patients with abdominal pain. But, there was no testicular pain and the testicles appeared normal on the exam.

Figure 4. Potential differential diagnoses for this 19-year-old patient with right lower quadrant pain include ischemic colitis, testicular torsion, and appendicitis. But, the most likely differential is appendicitis.

The Alvarado score for appendicitis

The Alvarado score is a scale created to further aid in the diagnosis of appendicitis. It is a clinical scoring system that predicts the likelihood of appendicitis. This patient displays all three symptoms, as well as at least two of the listed signs (Fig. 5).

The scale is based on six clinical findings and two laboratory measures. A score of five to six indicates that appendicitis is possible, seven to eight means that appendicitis is probable, and greater than nine means that appendicitis is highly probable.

Figure 5. The Alvarado score is a clinical scoring system that can help predict the likelihood of a patient having appendicitis.

Now that you have a differential diagnosis based on the patient’s history and physical exam, you’re well on your way to diagnosing and treating the cause of the pain. The diagnosis may require further assessment with imaging modalities and laboratory findings.

Plan

The plan could involve surgery with or without the addition of antibiotics. This final component completes the SOAP for your patient with RLQ pain.

That’s it for now. If you want to improve your understanding of key concepts in medicine, and improve your clinical skills, make sure to register for a free trial account, which will give you access to free videos and downloads. We’ll help you make the right decisions for yourself and your patients.

Recommended reading

  • de Dombal, FT. 1988. The OMGE acute abdominal pain survey. Progress report, 1986. Scand J Gastroenterol Suppl144: 35–42. PMID: 3043646
  • Jin, XW, Slomka, J, and Blixen, CE. 2002. Cultural and clinical issues in the care of Asian patients. Cleve Clin J Med69: 50, 53–54, 56–58. PMID: 11811720
  • Tseng, W-S and Streltzer, J. 2008. “Culture and clinical assessment”. In: Cultural Competence in Health Care. Boston: Springer. 
  • Wong, C. 2020. Liver fire in traditional Chinese medicine. verywellhealthhttps://www.verywellhealth.com

About the author

Olutayo A. Sogunro, DO, FACS, FACOS
Breast Surgical Oncologist at Johns Hopkins Howard County General Hospital and Assistant Professor of Surgery at Johns Hopkins University Hospital, Maryland, USA
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