In a 45‑year‑old man presenting to the emergency department with cough‑induced pain radiating to the back, could this be appendicitis?

This is NOT Appendicitis

The provider's suspicion of appendicitis is incorrect. Pain upon coughing that radiates to the back is not consistent with the typical presentation of acute appendicitis and suggests an alternative diagnosis such as musculoskeletal pain, pleurisy, pneumonia, or possibly a renal/ureteral process.

Why This Presentation Does Not Fit Appendicitis

Classic Appendicitis Presentation

The hallmark features of appendicitis that are absent in this patient include:

• Periumbilical pain migrating to the right lower quadrant is one of the strongest discriminators for appendicitis in adults, not pain radiating to the back 1, 2
• Right lower quadrant tenderness with guarding is the most reliable physical finding for ruling in appendicitis, which is not described here 3, 2
• Anorexia, nausea, and vomiting are classic associated symptoms that typically accompany appendicitis 2, 4
• Low-grade fever is commonly present (though rates vary from 30-80%) 2, 1

The Cough-Pain-Back Radiation Pattern is Atypical

Pain worsened by coughing that radiates to the back strongly suggests pathology outside the appendix. This pattern is more consistent with:

• Musculoskeletal strain or rib pathology (cough increases intrathoracic pressure and stresses chest wall/back muscles)
• Pleuritic chest pain from pneumonia or pleuritis (cough exacerbates pleural irritation)
• Renal/ureteral pathology (though typically flank pain, not triggered specifically by cough)
• Pancreatic pathology (back radiation is classic, though cough-trigger is less typical)

Appendicitis pain is typically constant and localized to the right lower quadrant, not triggered by coughing or radiating to the back 2, 4.

What the Provider Should Do Instead

Immediate Clinical Assessment

Perform a focused physical examination looking for:

• Chest examination: Listen for decreased breath sounds, crackles, or pleural rub that would suggest pneumonia or pleuritis 3
• Musculoskeletal examination: Palpate the chest wall and back for reproducible tenderness; assess for costochondritis or muscle strain
• Abdominal examination: Check specifically for McBurney's point tenderness, rebound tenderness, Rovsing sign, psoas sign, and obturator sign—if these are absent, appendicitis is unlikely 2, 3
• Flank examination: Assess for costovertebral angle tenderness suggesting renal pathology

Diagnostic Workup Based on Findings

If chest/pulmonary symptoms predominate:

• Order chest X-ray to evaluate for pneumonia, pleural effusion, or pneumothorax
• Consider basic labs including CBC and inflammatory markers

If musculoskeletal findings are present:

• Clinical diagnosis may be sufficient if pain is reproducible with palpation and no red flags exist
• Consider chest X-ray if trauma history or concern for rib fracture

If abdominal pathology is still suspected despite atypical presentation:

• CT abdomen and pelvis with IV contrast is the gold standard, with sensitivity of 90-100% and specificity of 94.8-100% for appendicitis 1, 2
• However, given this atypical presentation, CT would more likely identify alternative diagnoses such as pancreatitis, renal pathology, or other intra-abdominal processes 1

Critical Pitfalls to Avoid

Do not anchor on appendicitis when the clinical presentation does not fit. The classic triad of migrating right lower quadrant pain, fever, and leukocytosis is present in only about 50% of appendicitis cases, but pain triggered by coughing and radiating to the back is simply not part of the appendicitis spectrum 2, 1.

Do not rely solely on laboratory values to rule in or out appendicitis. Even if inflammatory markers are elevated, they are non-specific and can be elevated in many conditions including pneumonia, musculoskeletal inflammation, or other infections 5, 1.

In a 45-year-old male, consider age-appropriate differential diagnoses including cardiac causes (though less likely with this presentation), pulmonary embolism (if risk factors present), and malignancy-related pain if symptoms are chronic 6.

If clinical suspicion for appendicitis persists despite atypical features, imaging is mandatory—never proceed to surgery based on clinical suspicion alone when the presentation is atypical 1, 5.