Vivian Zhao: A 32-Year-Old Female With Right Lower Quadrant Pain

Vivian Zhao

Vivian Zhao is a 32-year-old secretary with the chief complaint of, “My tummy hurts and I feel pretty crappy.” Vivian noted that she woke up last night with a stomachache. She thought is must have been the spicy food she had eaten for dinner. She took some antacids, but the pain really did not get any better. Vivian went on to say that she wouldn’t have bothered coming in, but the pain had changed and she really wasn’t feeling any better. “Doctor, at first the pain was just a dull ache around my belly button, but as the day has progressed, it has moved down over my right ovary. I looked it up on the Internet, and I wonder if I have appendicitis. I haven’t felt like eating anything, and my partner said she thought I was running a temperature. We didn’t have a thermometer, and because I was feeling worse, we just decided to come on over to your office. The ride over was pretty special. Every time we hit a bump, it really hurt. When I got out of the car, it was hard to stand straight up, and walking really hurts.”

I asked Vivian if anything like this has happened before. She shook her head, and said, “Absolutely not. I never get sick, but I really think that something bad is happening! Doctor, do you think I have appendicitis? Jenny, that’s my partner, says it’s probably just an ovarian cyst or something.” Vivian denied any other gynecologic symptoms, blood in her urine, or bowel or bladder symptomatology. Her last menstrual period was about 10 days ago.

I asked Vivian if she had any change in her bowel habits over the last couple of days, and she said she was kind of constipated and now she felt like she needed to throw up. I asked Vivian to point with one finger to show me where it hurt the most. She quickly pointed to McBurney point as if she had read the textbook. I asked her if the pain radiated anywhere else, and she said not really, that over the last couple of hours, the pain seemed to have focused right on that spot.

On physical examination, Vivian was mildly febrile with a temperature of 100.8°F. Her respirations were 18, and her pulse was 84 and regular. Her blood pressure was normal at 122/74. Her head, eyes, ears, nose, throat (HEENT) exam was normal, as was her cardiopulmonary examination. Her thyroid was normal. Her abdominal examination revealed rebound tenderness at McBurney point, as well as positive Rovsing, Blumberg, and obturator signs ( Figs. 14.1 and 14.2 ). There was no costovertebral angle (CVA) tenderness, although percussion over the CVA exacerbated her abdominal pain. There was no peripheral edema. Her low back examination was unremarkable. I did a rectal exam, which revealed tenderness on the right. Visual inspection of the abdomen was unremarkable. “Vivian,” I said, “I think we are going to take a little trip to the hospital and get that appendix out.” She gave me a weak smile and said, “I knew it. I need to call my mom to come be with me.”

Key Clinical Points—What’s Important and What’s Not