Appendicitis Clinical Pathway — Emergency Department

History and Physical Examination

Older children and teenagers in which appendicitis is more prevalent are more likely to have the classic signs of appendicitis. Symptoms progress from anorexia to peri-umbilical pain followed by migration to the RLQ. In younger children, migration of pain may not occur but focal abdominal tenderness (usually right sided) is often present. Appendicitis is uncommon in children < 5 yr; these children present with diffuse abdominal tenderness. Ovarian pathology must be considered in females, especially if post-pubertal.

Common diagnoses that may mimic appendicitis include GE, mesenteric lymphadenitis, UTI, renal stone, PID, TOA, ovarian torsion and ovarian cyst.

History
Onset/progression of symptoms
Pain	Duration, location, migration Severity (use pain scale score) Worse on walking, squatting, riding in the car Evidence of peritoneal irritation
Anorexia/Nausea	Last good meal Oral intake since symptom onset Fluid intake, urine output
Vomiting	Time of onset Before or after abdominal pain Number of episodes, last episode Bilious / bloody
Stool	Time of last stool Diarrhea, blood / mucous
Fever	Duration Medications given
Past Medical History	Prior abdominal pain episodes Constipation Previous UTI
	Menarche, last menses Hx/concern for UTI, pregnancy Hx of ovarian cyst
Physical Examination
General Appearance, VS
Abdomen	Focal tenderness,guarding/rebound psoas Obdurator Rovsing signs CVA tenderness
Genital	Tanner stage Inguinal canal abnormality/hernia Scrotum/testicles abnormalities Bimanual exam, as indicated Rectal exam, as indicated

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.