What are the key components of a complete history and physical exam for diagnosing and managing acute appendicitis, Urinary Tract Infection (UTI), and Gastroesophageal Reflux Disease (GERD)?

Complete History and Physical Examination for Acute Appendicitis, UTI, and GERD

ACUTE APPENDICITIS

History - Key Elements to Elicit

The classic presentation includes periumbilical pain migrating to the right lower quadrant (RLQ), anorexia, nausea, and vomiting—this sequence is highly suggestive of appendicitis. 1

• Pain characteristics: Ask specifically about periumbilical pain that migrates to RLQ over 12-24 hours—this migration pattern increases likelihood of appendicitis 1, 2
• Sequence of symptoms: Determine if pain preceded vomiting—vomiting before pain makes appendicitis unlikely 1, 2
• Anorexia: Loss of appetite is a cardinal feature present in most cases 3, 4
• Fever: Low-grade fever (typically <38.5°C), though absent in approximately 50% of cases 5, 4
• Duration of symptoms: Prolonged symptoms (>48 hours) increase perforation risk 1, 4
• Previous abdominal surgery: History of prior surgery has 85% sensitivity for adhesive causes of pain 1
• Age considerations: Atypical presentations are more common in children <5 years and elderly patients 1, 6

Physical Examination - Specific Maneuvers

Right lower quadrant tenderness, rebound tenderness, and guarding are the most reliable physical findings in adults. 4, 2

• McBurney point tenderness: Palpate one-third the distance from anterior superior iliac spine to umbilicus—tenderness here is common but has limited specificity alone 6, 4
• Rebound tenderness: Assess for peritoneal irritation—has highest positive predictive value (65%) for complicated appendicitis in children 6
• Psoas sign: Have patient lie on left side and extend right hip—pain suggests retrocecal appendicitis and increases likelihood of appendicitis 1, 6, 2
• Obturator sign: Flex right hip and knee, then internally rotate hip—pain indicates pelvic appendicitis 6, 4
• Rovsing sign: Palpate left lower quadrant—pain in RLQ is positive and reliable in children 6, 4
• Abdominal rigidity: Involuntary guarding indicates peritoneal inflammation 4, 2
• Bowel sounds: Absent or decreased sounds are reliable for ruling in appendicitis in children 6, 4
• Vital signs: Document temperature, heart rate (tachycardia common), blood pressure (hypotension suggests sepsis) 1

Risk Stratification Using Clinical Scores

Use the Alvarado Score or Pediatric Appendicitis Score to stratify patients into low, intermediate, or high-risk categories—this guides imaging and surgical decisions. 1, 6

Alvarado Score components (maximum 10 points): 1, 4

• Migration of pain to RLQ (1 point)
• Anorexia (1 point)
• Nausea/vomiting (1 point)
• RLQ tenderness (2 points)
• Rebound tenderness (1 point)
• Elevated temperature >37.3°C (1 point)
• Leukocytosis >10,000/mm³ (2 points)
• Left shift of neutrophils >75% (1 point)

Score interpretation: 1, 6

• 0-4: Low risk—consider discharge with 24-hour follow-up
• 5-6: Intermediate risk—obtain imaging (CT in adults, ultrasound in children)
• 7-10: High risk—surgical consultation, may proceed without imaging in classic cases

Laboratory Testing

Complete blood count is essential, but normal WBC does not exclude appendicitis. 6, 4

• WBC count: Leukocytosis >10,000/mm³ has positive likelihood ratio of only 1.59-2.7 alone 6
• Neutrophil left shift: >75% segmented neutrophils increases suspicion 1, 4
• C-reactive protein: CRP ≥8-10 mg/L has positive likelihood ratio of 4.24 6
• Combined markers: WBC >10,000/mm³ AND CRP ≥8 mg/L has positive likelihood ratio of 23.32 6

Imaging Approach - Algorithm Based on Patient Population

For non-pregnant adults with intermediate clinical suspicion, CT abdomen/pelvis with IV contrast is the gold standard imaging modality. 1, 6

Adults (non-pregnant): 1, 6

• First-line: CT abdomen/pelvis with IV contrast
• Sensitivity: 94-100%
• Specificity: 93-95%
• Technical note: Oral contrast is unnecessary and delays diagnosis 1, 6

Children and adolescents: 1, 6

• First-line: Ultrasound (graded compression technique)
• Sensitivity: 76%
• Specificity: 95%
• If ultrasound inconclusive: Proceed to CT with IV contrast
• Rationale: Avoid radiation exposure when possible 1

Pregnant patients: 1, 6

• First-line: Ultrasound
• If inconclusive: MRI without IV contrast (sensitivity 94%, specificity 96%)
• Avoid CT: Due to fetal radiation exposure 1, 6

Elderly patients: 6

• Strongly recommend CT with IV contrast: Higher rates of complicated appendicitis and atypical presentations
• Lower threshold for imaging: Mortality risk is higher in this population

Critical Imaging Findings

CT findings of appendiceal diameter ≥7 mm, wall thickening, periappendiceal fat stranding, and appendicolith indicate appendicitis. 1, 3

Uncomplicated appendicitis: 1, 3

• Appendiceal diameter ≥7 mm
• Wall thickening
• Periappendiceal fat stranding
• Appendiceal non-compressibility on ultrasound

Complicated appendicitis (perforation, abscess): 1, 6, 3

• Extraluminal appendicolith
• Abscess formation
• Extraluminal air
• Appendiceal wall enhancement defect
• Appendiceal diameter >13 mm

Management Based on Findings

If imaging confirms appendicitis, proceed immediately to surgical consultation and broad-spectrum antibiotics. 1, 7

• High clinical suspicion + classic findings in males <40 years: May proceed directly to surgery without imaging 1
• Imaging confirms appendicitis: Surgical consultation, start antibiotics immediately 1, 7
• Complicated appendicitis with abscess: Consider percutaneous drainage followed by interval appendectomy 1
• Negative imaging but persistent suspicion: Observation in hospital or ED with serial exams every 6-12 hours 1, 5
• Discharge criteria: 24-hour follow-up mandatory due to false-negative imaging rates 1, 5

Common Pitfalls to Avoid

Do not rely on absence of fever to exclude appendicitis—fever is absent in 50% of cases. 5, 4

• Atypical presentations: Children <5 years and elderly patients frequently lack classic symptoms 1, 6
• Ultrasound limitations: Highly operator-dependent and may miss perforated appendicitis 1, 6
• Pain medication concerns: Opioids and NSAIDs do not delay diagnosis or increase complications—prioritize pain control 4
• Low Alvarado scores: 8.4% of patients with appendicitis had scores <5—do not use score alone to exclude diagnosis 6
• Delayed diagnosis: Increases perforation risk from 17-32%, especially in children and elderly 1, 4

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URINARY TRACT INFECTION (UTI)

History - Key Elements to Elicit

Ask specifically about dysuria, urinary frequency, urgency, suprapubic pain, and hematuria—these are cardinal symptoms of lower UTI (cystitis).

• Dysuria: Burning or pain with urination—most sensitive symptom for UTI
• Frequency: Voiding more often than usual with small volumes
• Urgency: Sudden compelling need to urinate
• Suprapubic pain: Discomfort or pressure above pubic bone
• Hematuria: Gross or microscopic blood in urine
• Fever and flank pain: Suggest upper UTI (pyelonephritis)—fever >38°C with costovertebral angle tenderness
• Vaginal symptoms: Discharge or irritation suggests vaginitis rather than UTI
• Previous UTIs: Recurrent infections (≥2 in 6 months or ≥3 in 12 months)
• Sexual activity: Recent intercourse increases risk in women
• Pregnancy status: UTI in pregnancy requires aggressive treatment
• Immunocompromised status: Diabetes, HIV, immunosuppressive medications
• Urinary catheter: Catheter-associated UTI has different management
• Recent antibiotics: May indicate resistant organisms

Physical Examination - Specific Findings

Suprapubic tenderness on palpation indicates cystitis, while costovertebral angle tenderness indicates pyelonephritis.

• Suprapubic tenderness: Palpate lower abdomen above pubic symphysis—tenderness suggests bladder inflammation
• Costovertebral angle (CVA) tenderness: Percuss or palpate flanks at 12th rib—tenderness indicates pyelonephritis
• Fever: Temperature >38°C suggests upper tract involvement
• Vital signs: Tachycardia and hypotension indicate sepsis/urosepsis
• Pelvic examination (women): Perform if vaginal discharge present to exclude vaginitis or cervicitis
• Prostate examination (men): Assess for prostate tenderness (prostatitis) or enlargement
• Abdominal examination: Rule out other causes of abdominal pain

Laboratory Testing

Urinalysis with microscopy is the cornerstone diagnostic test—pyuria (≥10 WBC/hpf) and bacteriuria are diagnostic.

• Urinalysis:

  • Pyuria: ≥10 WBC per high-power field
  • Bacteriuria: Presence of bacteria on microscopy
  • Nitrites: Positive indicates gram-negative bacteria
  • Leukocyte esterase: Positive indicates WBC presence
  • Hematuria: May be present

• Urine culture:

  • Obtain before antibiotics in complicated UTI, pyelonephritis, men, pregnant women, recurrent UTI
  • ≥10⁵ CFU/mL is diagnostic threshold
  • Not routinely needed for uncomplicated cystitis in women

• Blood tests (for pyelonephritis or sepsis):

  • Complete blood count: Leukocytosis
  • Basic metabolic panel: Assess renal function
  • Blood cultures: If sepsis suspected

Imaging

Imaging is not routinely needed for uncomplicated UTI but is essential for complicated cases or suspected obstruction.

• Uncomplicated cystitis: No imaging required
• Pyelonephritis not responding to antibiotics after 48-72 hours: CT abdomen/pelvis with IV contrast to assess for abscess or obstruction
• Recurrent pyelonephritis: Renal ultrasound or CT to evaluate for anatomic abnormalities
• Men with UTI: Consider imaging to rule out prostatitis or structural abnormalities
• Suspected obstruction: Urgent renal ultrasound or CT

Classification and Management

Uncomplicated cystitis in women requires 3-5 days of oral antibiotics, while pyelonephritis requires 7-14 days with initial consideration for IV therapy.

Uncomplicated cystitis (healthy non-pregnant women):

• First-line antibiotics: Nitrofurantoin 100 mg BID × 5 days, or trimethoprim-sulfamethoxazole DS BID × 3 days (if local resistance <20%)
• Alternative: Fosfomycin 3g single dose
• Duration: 3-5 days

Complicated UTI (men, pregnant women, immunocompromised, structural abnormalities):

• Duration: 7-14 days
• Obtain urine culture: Before starting antibiotics
• Broader coverage: Fluoroquinolones or beta-lactams

Pyelonephritis:

• Outpatient management (mild cases): Fluoroquinolone (ciprofloxacin 500 mg BID or levofloxacin 750 mg daily) × 7 days
• Inpatient management (severe cases, sepsis, unable to tolerate oral): IV ceftriaxone 1-2g daily or fluoroquinolone, transition to oral when improved
• Duration: 7-14 days total

Pregnancy:

• Safe antibiotics: Nitrofurantoin (avoid near term), amoxicillin-clavulanate, cephalexin
• Duration: 7 days minimum
• Avoid: Fluoroquinolones, trimethoprim (first trimester)

Common Pitfalls

Do not treat asymptomatic bacteriuria except in pregnant women or before urologic procedures—overtreatment promotes resistance.

• Asymptomatic bacteriuria: Do not treat except in pregnancy or pre-procedure
• Catheter-associated bacteriuria: Do not treat unless symptomatic
• Vaginitis mimicking UTI: Vaginal discharge and external dysuria suggest vaginitis—perform pelvic exam
• Sterile pyuria: Consider interstitial cystitis, tuberculosis, or sexually transmitted infections
• Recurrent UTI: Investigate for anatomic abnormalities or behavioral factors

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GASTROESOPHAGEAL REFLUX DISEASE (GERD)

History - Key Elements to Elicit

Heartburn (retrosternal burning) and regurgitation occurring ≥2 times per week are the cardinal symptoms of GERD.

• Heartburn: Burning sensation rising from epigastrium to chest—worse after meals, lying down, bending over
• Regurgitation: Effortless return of gastric contents to mouth—sour or bitter taste
• Frequency: Symptoms ≥2 times per week for several weeks
• Timing: Postprandial symptoms (within 1-2 hours after eating), nocturnal symptoms
• Aggravating factors: Large meals, fatty foods, chocolate, caffeine, alcohol, smoking, lying down after eating
• Relieving factors: Antacids, upright position
• Atypical symptoms: Chronic cough, hoarseness, throat clearing, asthma exacerbations, dental erosions
• Dysphagia: Difficulty swallowing suggests complications (stricture, esophagitis)
• Odynophagia: Painful swallowing suggests severe esophagitis or infection
• Weight loss: Concerning for malignancy—requires urgent endoscopy
• Alarm features: Dysphagia, odynophagia, weight loss, GI bleeding, anemia, persistent vomiting

Physical Examination

Physical examination is typically normal in uncomplicated GERD—the diagnosis is primarily clinical based on symptoms.

• General appearance: Assess for signs of distress or weight loss
• Vital signs: Usually normal
• Oropharynx: Examine for dental erosions (chronic acid exposure)
• Neck: Palpate for thyroid enlargement or masses
• Chest: Auscultate lungs for wheezing (asthma association)
• Abdomen:
  • Epigastric tenderness may be present but is nonspecific
  • Rule out other causes: hepatomegaly, masses, peritoneal signs
• Alarm features on exam: Lymphadenopathy, abdominal mass, jaundice

Diagnostic Approach

Empiric trial of proton pump inhibitor (PPI) therapy for 4-8 weeks is the initial diagnostic and therapeutic approach for typical GERD symptoms without alarm features.

Empiric PPI trial (first-line):

• Indication: Typical symptoms (heartburn, regurgitation) without alarm features
• Regimen: PPI once daily 30-60 minutes before breakfast × 4-8 weeks
• Examples: Omeprazole 20 mg, lansoprazole 30 mg, esomeprazole 20 mg
• Response: Symptom improvement confirms diagnosis
• No response: Consider alternative diagnosis or step up to twice-daily PPI

Upper endoscopy (EGD) - indications:

• Alarm features: Dysphagia, odynophagia, weight loss, GI bleeding, anemia
• Age >60 years with new-onset symptoms: Screen for Barrett's esophagus and malignancy
• Chronic symptoms (>5 years): Screen for Barrett's esophagus
• Failed PPI trial: Evaluate for alternative diagnoses
• Suspected complications: Stricture, severe esophagitis, Barrett's esophagus

Ambulatory pH monitoring:

• Indication: Persistent symptoms despite PPI therapy, atypical symptoms, pre-operative evaluation for anti-reflux surgery
• Technique: 24-hour esophageal pH probe or wireless pH capsule

Esophageal manometry:

• Indication: Pre-operative evaluation before anti-reflux surgery to assess esophageal motility and rule out achalasia

Management - Stepwise Approach

Lifestyle modifications combined with PPI therapy form the foundation of GERD management.

Lifestyle modifications (all patients):

• Dietary: Avoid trigger foods (fatty foods, chocolate, caffeine, alcohol, citrus, tomatoes, spicy foods)
• Meal timing: Avoid eating 2-3 hours before bedtime
• Portion size: Eat smaller, more frequent meals
• Weight loss: If overweight or obese—most effective lifestyle intervention
• Head of bed elevation: Raise head of bed 6-8 inches (not just pillows)
• Smoking cessation: Tobacco weakens lower esophageal sphincter
• Avoid tight clothing: Reduces abdominal pressure

Pharmacologic therapy:

Step 1 - Initial therapy:

• PPI once daily: 30-60 minutes before breakfast × 4-8 weeks
• Examples: Omeprazole 20 mg, lansoprazole 30 mg, esomeprazole 20 mg, pantoprazole 40 mg

Step 2 - Inadequate response:

• Increase to PPI twice daily: Before breakfast and dinner
• Duration: Additional 4-8 weeks
• Consider endoscopy: If no improvement

Step 3 - Maintenance therapy:

• Successful symptom control: Step down to lowest effective dose
• Options: On-demand PPI, intermittent PPI, or continuous low-dose PPI
• Long-term PPI use: Consider risks (C. difficile infection, osteoporosis, hypomagnesemia) vs. benefits

Alternative medications:

• H2 receptor antagonists: Less effective than PPIs—use for mild symptoms or breakthrough symptoms
  • Examples: Famotidine 20 mg BID, ranitidine (withdrawn from market)
• Antacids: Rapid but short-lived relief—use for breakthrough symptoms
• Prokinetics: Limited role—metoclopramide has significant side effects

Surgical therapy:

• Indication: Failed medical therapy, patient preference to avoid lifelong medication, large hiatal hernia
• Procedure: Laparoscopic Nissen fundoplication
• Pre-operative evaluation: Endoscopy and esophageal manometry required

Complications to Monitor

Barrett's esophagus is the most significant complication—chronic acid exposure causes intestinal metaplasia with malignancy risk.

• Barrett's esophagus: Intestinal metaplasia of distal esophagus—requires surveillance endoscopy every 3-5 years
• Esophageal stricture: Dysphagia from chronic inflammation—requires endoscopic dilation
• Severe erosive esophagitis: May cause bleeding or ulceration
• Respiratory complications: Chronic cough, asthma exacerbations, aspiration pneumonia
• Dental erosions: Chronic acid exposure damages tooth enamel

Common Pitfalls

Do not perform endoscopy for typical GERD symptoms without alarm features—empiric PPI trial is appropriate first-line management.

• Overuse of endoscopy: Not needed for typical symptoms in patients <60 years without alarm features
• Inadequate PPI trial: Must take 30-60 minutes before meals for optimal effect—many patients take incorrectly
• Premature discontinuation: Symptoms may recur—need maintenance therapy in many patients
• Missing alarm features: Always ask about dysphagia, weight loss, bleeding—these require urgent endoscopy
• Confusing with cardiac chest pain: Atypical chest pain requires cardiac evaluation first—GERD is diagnosis of exclusion
• Long-term PPI without indication: Reassess need periodically and attempt step-down therapy