What is the appropriate assessment and plan documentation for a patient presenting with right lower‑quadrant pressure, no associated symptoms or abnormal findings, who should be referred urgently to the emergency department for further evaluation?

Documentation for Right Lower Quadrant Pressure with Emergency Department Referral

For a patient with isolated right lower quadrant pressure and no other abnormal findings who requires emergency department evaluation, document the clinical assessment emphasizing the absence of classic appendicitis features while acknowledging that these findings do not exclude serious pathology, and clearly state the rationale for urgent imaging-based evaluation.

Assessment Documentation

Clinical Presentation

• Document the specific character of pain as "pressure" rather than sharp or colicky, noting its localization to the right lower quadrant 1
• Explicitly state the absence of fever, as fever is present in only approximately 50% of appendicitis cases, making its absence unreliable for excluding the diagnosis 1
• Record the absence of classic appendicitis features including anorexia, nausea/vomiting, and migration from periumbilical location 1
• Note the absence of rebound tenderness, guarding, or other peritoneal signs on examination 1, 2

Critical Clinical Context

• Clinical assessment alone misdiagnoses acute appendicitis in 34-68% of cases, with negative appendectomy rates reaching 25% when imaging is omitted 1
• Document that normal inflammatory markers (if obtained) do not exclude appendicitis, as many patients with early appendicitis present with normal white blood cell counts and absence of fever 1
• State that the physical examination, while currently benign, requires definitive imaging because serial examinations have measurable false-negative rates in low-risk presentations 1

Plan Documentation

Immediate Emergency Department Referral

• Recommend immediate ED evaluation for contrast-enhanced CT of abdomen and pelvis with IV contrast, which provides 85.7-100% sensitivity and 94.8-100% specificity for appendicitis while identifying alternative diagnoses in 23-45% of patients with right lower quadrant pain 3, 1, 4
• Document that CT is indicated despite the absence of classic features because early appendicitis frequently lacks typical presentation, and imaging prevents both missed diagnoses and unnecessary surgery 1, 4

Rationale for Urgent Imaging

• State that the American College of Radiology recommends CT abdomen/pelvis with IV contrast as the definitive diagnostic test for patients with right lower quadrant pain, regardless of the presence or absence of fever and leukocytosis 3, 1
• Note that CT will simultaneously evaluate for alternative surgical emergencies including right-sided diverticulitis (8% of cases), small bowel obstruction (3% of cases), gynecologic pathology (21.6% of alternative diagnoses), and other gastrointestinal conditions (46% of alternative diagnoses) 1
• Document that delaying definitive imaging increases the risk of perforation, which carries higher morbidity and, in reproductive-age patients, elevated risk of fetal loss 1

Safety Netting Instructions

• Instruct the patient to proceed directly to the emergency department without delay 1
• Document specific return precautions: immediate ED presentation if pain worsens, fever develops, vomiting occurs, or inability to tolerate oral intake 1
• Note that the patient should remain NPO (nothing by mouth) until surgical evaluation is complete 5

Common Documentation Pitfalls to Avoid

• Never document that "appendicitis is unlikely" based solely on absence of fever, normal vital signs, or benign initial examination—these findings are present in a substantial proportion of confirmed appendicitis cases 1
• Do not delay ED referral for outpatient follow-up or observation, as patients with isolated right lower quadrant symptoms require same-day definitive imaging 1
• Avoid documenting that the patient can "follow up if symptoms worsen," as this creates dangerous delays; instead, document immediate ED referral for imaging 1
• Do not recommend ultrasound as the initial imaging modality in adults, as it has 20-81% non-visualization rates and equivocal results require CT anyway, causing diagnostic delay 5

Alternative Diagnoses to Consider in Documentation

• Note that CT will evaluate for cecal diverticulitis, which can present with normal inflammatory markers and isolated right lower quadrant tenderness 1, 6
• Document consideration of gynecologic emergencies in reproductive-age women, including ovarian torsion, ruptured ovarian cyst, and ectopic pregnancy 1
• State that ureteral calculi, Crohn's disease (terminal ileitis), and other gastrointestinal pathology will be assessed by CT 1