THE

RIGHT LOWER QUADRANT

ABDOMINAL PAIN
HEALTH PROBLEM

AN INSTRUCTIONAL PROGRAM FOR

PRIMARY HEALTH CARE PHYSICIANS

DESIGNED FOR:

PROBLEM-BASED LEARNING
COMPETENCY-BASED LEARNING
IN- AND OFF- CAMPUS LEARNING

Author:

Reynaldo O. Joson, MD, MHPEd, MS Surg

1999
 PATIENTS WITH RLQ ABDOMINAL PAIN
GOALS AND STRATEGIES

GOALS IN THE MANAGEMENT

In all patients with a chief complaint of RLQ ABDOMINAL PAIN,

the primary health care physician must be able to:

RESOLVE the RLQ ABDOMINAL PAIN

in such a way that the patient does NOT end up

DEAD

WITH ANY KIND OF COMPLICATION

AND DISABILITY

and in such a manner that the patient

IS SATISTFIED

DOES NOT FILE A MALPRACTICE SUIT

STRATEGIES

RATIONALE, EFFECTIVE, EFFICIENT, HUMANE MANAGEMENT

IN THE TASKS OF

RAPPORT, DIAGNOSIS, TREATMENT, ADVICE

 The RLQ Abdominal Pain Health Problem

Contents
Title

Content ............................................................................................................................

About the Author ............................................................................................................ .

Preface ............................................................................................................................

The Course Pack - Content and How to Use ......................................................................

Folder 1: Instructional Design ...........................................................................................

Folder 2: Hypothetical and Actual Patient Management .....................................................

Folder 3: Problem-based Learning Issues - Form ................................................................

Folder 4: Learning Objectives ............................................................................................

General Learning Objectives ................................................................................

Clinical Competencies .........................................................................................
Biological Foundation and Basis of Clinical Management ...................................

Folder 5: Learning Resource Materials and References .....................................................

List of Recommended References ........................................................................

Learning Resource Materials

Folder 6: Evaluation ........................................................................................................ .

Pretest I
Pretest II

Folder 7: Details and Format ............................................................................................

Write-ups
Primary Health Care Physician .............................................................
Problem-based Learning in Medicine ...................................................

Guidelines and Format

Overview and Personal Perspective .......................................................
Public Health Education ........................................................................
Community Health Management ...........................................................
Case Presentation and Discussion ..........................................................
Hypothetical Patient Management .........................................................
Psychosocial Issues ...............................................................................
Bioethical Issues ...................................................................................
Medicolegal Issues ................................................................................
Research Issues .....................................................................................
Glossary ................................................................................................
Self-Evaluation .....................................................................................
Presentation in a Symposium ................................................................
 About the Author

Present Academic Positions

Dr. Reynaldo O. Joson is presently a permanent professor at the Department of Surgery of the University of
the Philippines, College of Medicine.

He is at the same time an affiliate associate professor of the University of the Philippines Open University
as well as a faculty in the University of the Philippines College of Public Health.

He is currently the Chief of the Division of Head and Neck, Breast, Esophagus, and Soft Tissue Surgery at
the Philippine General Hospital.

Academic Degrees

He obtained his Doctor of Medicine from the University of the Philippines College of Medicine in 1974;
his Master in Hospital Administration from the UP College of Public Health in 1991; his Master in Health
Profession Education from the UP National Teachers Training Center for Health Profession in 1993; his Master of
Science in Clinical Medicine (General Surgery) from the UP College of Medicine in 1998.

His finished his residency in General Surgery at the Philippine General Hospital in 1981 after which he
became a Diplomate of the Philippine Board of Surgery.

Education for Health Development in the Philippines

One of his missions in life is to contribute to the health development in the Philippines through education.
This mission started in 1990 when, as Director of the UPCM Postgraduate Institute of Medicine, he designed a
structured Department of Health-UPCM Postgraduate Circuit Courses in four provincial hospitals in the Philippines
(Ilagan, Isabela in Luzon; Aklan in the Visayas; and Koronadal, South Cotobato and Oroquieta, Misamis Occidental
in Mindanao).

He then went on to develop a structured general surgery training program using a distance education mode
from 1991 to 1994 in Zamboanga City Medical Center. With this program, he added 7 trained general surgeons to
the pool of 2 that served the 3 million population of Western Mindanao.

In 1994, he helped established the Zamboanga Medical School Foundation. He helped designed a
community-oriented, competency-based, and problem-based learning medical curriculum for the school. This
curriculum was adopted by a medical school in Legazpi, Albay in 1995 and by another medical school in Cebu in
1996.

He is presently preoccupied with the full development of this curriculum as well as designing a telehealth
program.

Hospital Administration

He is currently an assistant medical director at the Manila Doctors Hospital in charge of its quality
assurance program.

B1
Writings

He started writing books, primers, self-instructional programs, and course packs in medicine, surgery,
hospital administration, and medical education in 1985. As of December of 1998, he has about 20 finished products.

Contact Numbers

Dr. Reynaldo O. Josons email address is rjoson@pacific.net.ph

His telephone number is 523-2774.

B2
 Preface

Dear Learner,

Mabuhay!

Welcome to a learning experience in becoming a health professional.

This program has been especially designed with you, the learner, and the principles of effective teaching
and learning in mind.

As you go through this learning program, please bear in mind the following:

1. I am treating you as an adult learner which

1.1 Assumes you have learning aspirations and expectations and therefore, are
motivated;

1.2 Gives you the privilege to use other learning strategies in achieving the objectives in
this program;

1.3 Welcomes you to go beyond the learning package as you so desire; and

1.4 Expects discipline, honesty, and maturity in fulfilling your learning activities.

2. We shall define learning as a positive observable change (for the better or improvement) in
human behavior, disposition, attitude, performance, or capability which persists over a
period of time.

3. Active learning strategies and activities will be utilized as much as possible.

4. The program will contain learning materials which I think will be relevant to your being an
effective, efficient, and humane health professional.

5. The ultimate goal of the learning program is to produce health professionals who will
contribute to the health development in the Philippines.

6. When I made this program, I tried my best to facilitate your learning. Bear in mind, however,
that I am not infallible. Thus, analyze carefully everything in this program. Dont
hesitate to offer disagreements and constructive criticisms for own learning and for
the improvement of the program.

Best wishes for a fruitful learning with the help of this program.

Reynaldo O. Joson, M.D.

1999

C
 The Course Pack
Content and How to Use
Content

The Course Pack on THE RLQ ABDOMINAL PAIN HEALTH PROBLEM consists of seven (7) folders:

Folder 1: Instructional Design

Folder 2: Hypothetical and Actual Patient Management
Folder 3: Problem-based Learning Issues
Folder 4: Learning Objectives
Folder 5: Learning Resource Materials
Folder 6: Evaluation
Folder 7: Details and Formats

Folder 1: Instructional Design

This folder contains the course plan.

Folder 2: Hypothetical and Actual Patient Management

This folder contains hypothetical patient management exercises which in turn consist of
sequential patient management cases and case studies.
It also contains an instructional plan on Actual Patient Management.

Folder 3: Problem-based Learning Issues

This folder contains the instructions and a form on which a student can write down problem-
based learning issues.

Folder 4: Learning Objectives

This folder contains general and specific learning objectives of the course.

Folder 5: Learning Resource Materials

This folder contains a list of recommended learning resource materials and selected and
prepared manuscripts.

Folder 6: Evaluation
This folder contains test blueprints and pretest examinations.

Folder 7: Details and Formats

This folder contains details and formats of learning and evaluating activities.

D1
 The Course Pack
How to Use

Initial Steps:

Start by reading Folder 1 on Instructional Design.

For details on specific learning and evaluating activities encountered in Folder 1,

refer to Folder 7 on Details and Formats.

Then, scan the rest of the Folders (2-7).

Subsequent Steps:

This consists of the study and learning proper.

Start with the

Overview and Personal Perspective on the RLQ ABDOMINAL PAIN HEALTH
PROBLEM. (see Folder 7 for the guidelines.)
Note down learning issues. Use the form provided in Folder 3.
Take note that a formal report is needed for purposes of presentation in the symposium
and evaluation.

Then tackle the Pretest examinations.

Note down learning issues. Use the form provided in Folder 3.
Take note that 50% of the questions in Posttest written examinations will be derived
from the Pretest.
Take note also that the Pretest gives a guide on where to focus when studying the
course.
Studying the Pretest can also facilitate discussion in the
Hypothetical and Actual Patient Management.

Then tackle the Hypothetical and subsequently, the Actual Patient Management.
Note down learning issues. Use the form provided in Folder 3.
Take note that the exercises on Hypothetical and Actual Patient Management are
useful in preparing for the
written examinations
oral-practical examinations
project on case presentation and discussion

Overall Advice:

During the study proper, be constantly guided by the instructional design, especially the learning
objectives, which shall serve as the steering wheel in whatever that should be done in the course. This includes the
evaluation.

Reynaldo O. Joson, MD, MHPEd, MS Surg

1999

D2
 THE
RLQ ABDOMINAL PAIN
HEALTH PROBLEM

FOLDER 1

INSTRUCTIONAL DESIGN
See FOLDER 4
LEARNING OBJECTIVES
 THE
RLQ ABDOMINAL PAIN
HEALTH PROBLEM

FOLDER 2

TRIGGERS
HYPOTHETICAL AND ACTUAL
PATIENT MANAGEMENT
Patient 1A:
Sex: Female Age: 15-50
Clinical findings and data (with 2 physical exams within 30 minutes)
RLQ pain and tenderness
Onset: 3 days ago
Started in and confined to RLQ
Direct RLQ tenderness, NO rebound, NO guarding
No bowel movement disturbance
No urinary disturbance
No vaginal discharge
Not pregnant-suspect
No other associated symptoms and signs

Primary Clinical Diagnosis: Nonspecific RLQ abdominal pain

No definite sign of peritonitis
Most common cause of RLQ abdominal pain
more common than appendicitis
No other alternative diagnosis aside from appendicitis
Secondary Clinical Diagnosis: Acute appendicitis
Early appendicitis with no frank sign of peritonitis

----------------------------------------------------------------------------------------------------------------------------- ---

Assessment of certainty of primary clinical diagnosis:

Not quite certain
Just based on negative signs and prevalence
Comparison of treatment for primary and secondary clinical diagnoses:
Different
Primary diagnosis: Nonoperative
Secondary diagnosis: Operative

Decision: Need for a paraclinical diagnostic procedure

----------------------------------------------------------------------------------------------------------------------------- ---

What paraclinical diagnostic procedure?

Goal: to be more definite that it is a nonspecific RLQ abdominal pain
to be more definite that it is not acute appendicitis

Options:

For primary diagnosis: observation

For secondary diagnosis: observation
others (known to be done)
CBC
Urinalysis
Plain x-ray
Barium enema
Ultrasound
CT scan

First choice is: observation

can be useful for both primary and secondary diagnosis

If CBC is done, what is the probability that it will be informative in such a situation?
 Normal Abnormal (leukocytosis)
Greater chance Small chance
Non-specific if abnormal

If Urinalysis is done, what is the probability that it will be informative?

Normal Abnormal (leukouria)

Greater chance Small chance
Nonspecific if abnormal

If Plain x-ray is done, what is the probability that it will be informative?

Normal Abnormal (appendicolith)

Greater chance Small chance

If Barium Enema is done, what is the probability that it will be informative?

Normal Abnormal (nonfilling of appendix)

Greater chance Small chance

If ultrasound is done, what is the probability that it will be informative?

Normal Abnormal (noncompressible distended

appendix, complex mass,
appendicolith)
Greater chance Small chance

If CT scan is done, what is the probability that it will be informative?

Normal Abnormal (dilated appendix, thick walled,

complex mass, appendicolith)
Greater chance Small chance

Decision is to observe.
Observe-monitor the abdomen for progression of abdominal signs
- more obvious signs of peritonitis.

Observe every four hours

May be inpatient or outpatient with informed consent and proper advice.

If pain disappears completely, diagnosis is definitely nonspecific RLQ abdominal pain.

If pain progresses, the diagnosis may not be nonspecific RLQ abdominal pain.
It may be acute appendicitis or something else, other than nonspecific
abdominal pain.

One can safely say that it is not acute appendicitis only when the pain completely disappears.

---------------------------------------------------------------0----------------------------------------------------------------
Patient 1B:
Sex: Female Age: 15-50
Clinical findings and data (with 2 physical exams within 30 minutes)
RLQ pain and tenderness
 Onset: 3 days ago
With shifting pain - epigastric or periumbilical to RLQ
Direct RLQ tenderness, NO rebound, NO guarding
No bowel movement disturbance
No urinary disturbance
No vaginal discharge
Not pregnant-suspect
No other associated symptoms and signs

Primary Clinical Diagnosis: Acute appendicitis

Pattern recognition based on
RLQ direct tenderness and migratory pain
Prevalence - common condition presenting with this pattern

Secondary Clinical Diagnosis: Nonspecific RLQ abdominal pain

No frank signs of peritonitis
No alternative diagnosis aside from appendicitis
May also present with RLQ direct tenderness and migratory pain
A very common cause of RLQ direct tenderness

----------------------------------------------------------------------------------------------------------------------------- ---
Assessment of certainty of primary clinical diagnosis:
Not quite certain yet
No definite signs of peritonitis, may be evolving
Just based on RLQ direct tenderness (not a sensitive sign per se) and migratory pain
(symptom) and prevalence
Comparison of treatment for primary and secondary clinical diagnoses:
Different
Primary diagnosis: Operative
Secondary diagnosis: Nonoperative

Decision: Need for a paraclinical diagnostic procedure

----------------------------------------------------------------------------------------------------------------------------- ---

What paraclinical diagnostic procedure?

Goal: to be more definite that it is acute appendicitis before instituting an operative treatment
to avoid unnecessary operation

Options:

For primary diagnosis: observation

others (known to be done)
CBC
Urinalysis
Plain x-ray
Barium enema
Ultrasound
CT scan

For secondary diagnosis: observation

First choice is: observation

can be useful for both primary and secondary diagnosis

If CBC is done, what is the probability that it will be informative in such a situation?
 Normal Abnormal (leukocytosis)
Greater chance Small chance
Non-specific if abnormal

If Urinalysis is done, what is the probability that it will be informative?

Normal Abnormal (leukouria)

Greater chance Small chance
Nonspecific if abnormal

If Plain x-ray is done, what is the probability that it will be informative?

Normal Abnormal (appendicolith)

Greater chance Small chance

If Barium Enema is done, what is the probability that it will be informative?

Normal Abnormal (nonfilling of appendix)

Greater chance Small chance

If ultrasound is done, what is the probability that it will be informative?

Normal Abnormal (noncompressible distended

appendix, complex mass,
appendicolith)
Greater chance Small chance

If CT scan is done, what is the probability that it will be informative?

Normal Abnormal (dilated appendix, thick walled,

complex mass, appendicolith)
Greater chance Small chance

Decision is to observe.
Observe-monitor the abdomen for progression of abdominal signs
- more obvious signs of peritonitis.
Observe every four hours
May be inpatient or outpatient with informed consent and proper advice.

If pain disappears completely, diagnosis is definitely not acute appendicitis, most likely
nonspecific RLQ abdominal pain.
If pain progresses and there are more definite signs of peritonitis (guarding and rebound), the
diagnosis is most likely acute appendicitis.

--------------------------------------------------------------------0-----------------------------------------------------------
Patient 1C:
Sex: Female Age: 15-50
Clinical findings and data (with 2 physical exams within 30 minutes)
RLQ pain and tenderness
Onset: 3 days ago
With shifting pain - LLQ to RLQ
Direct RLQ tenderness, NO rebound, NO guarding
No bowel movement disturbance
 No urinary disturbance
No vaginal discharge
Not pregnant-suspect
No other associated symptoms and signs
Primary Clinical Diagnosis: Nonspecific RLQ abdominal pain
No definite sign of peritonitis
Most common cause of RLQ abdominal pain
more common than appendicitis
No other alternative diagnosis aside from appendicitis
Secondary Clinical Diagnosis: Acute appendicitis
Early appendicitis with no frank sign of peritonitis

----------------------------------------------------------------------------------------------------------------------------- ---

Assessment of certainty of primary clinical diagnosis:

Not quite certain
Just based on negative signs and prevalence
Comparison of treatment for primary and secondary clinical diagnoses:
Different
Primary diagnosis: Nonoperative
Secondary diagnosis: Operative

Decision: Need for a paraclinical diagnostic procedure

----------------------------------------------------------------------------------------------------------------------------- ---

What paraclinical diagnostic procedure?

Goal: to be more definite that it is a nonspecific RLQ abdominal pain
to be more definite that it is not acute appendicitis

Options:

For primary diagnosis: observation

For secondary diagnosis: observation
others (known to be done)
CBC
Urinalysis
Plain x-ray
Barium enema
Ultrasound
CT scan

First choice is: observation

can be useful for both primary and secondary diagnosis

If CBC is done, what is the probability that it will be informative in such a situation?

Normal Abnormal (leukocytosis)

Greater chance Small chance
Non-specific if abnormal

If Urinalysis is done, what is the probability that it will be informative?

Normal Abnormal (leukouria)

Greater chance Small chance
 Nonspecific if abnormal

If Plain x-ray is done, what is the probability that it will be informative?

Normal Abnormal (appendicolith)

Greater chance Small chance

If Barium Enema is done, what is the probability that it will be informative?

Normal Abnormal (nonfilling of appendix)

Greater chance Small chance

If ultrasound is done, what is the probability that it will be informative?

Normal Abnormal (noncompressible distended

appendix, complex mass,
appendicolith)
Greater chance Small chance

If CT scan is done, what is the probability that it will be informative?

Normal Abnormal (dilated appendix, thick walled,

complex mass, appendicolith)
Greater chance Small chance

Decision is to observe.
Observe-monitor the abdomen for progression of abdominal signs
- more obvious signs of peritonitis.

Observe every four hours

May be inpatient or outpatient with informed consent and proper advice.

If pain disappears completely, diagnosis is definitely nonspecific RLQ abdominal pain.

If pain progresses, the diagnosis may not be nonspecific RLQ abdominal pain.
It may be acute appendicitis or something else, other than nonspecific
abdominal pain.

One can safely say that it is not acute appendicitis only when the pain completely disappears.

--------------------------------------------------------------------0-----------------------------------------------------------

Patient 2A:
Sex: Female Age: 15-50
Clinical findings and data (with 2 physical exams within 30 minutes)
RLQ pain and tenderness
Onset: 3 days ago
Started in and confined to RLQ
Direct and rebound RLQ tenderness, NO guarding
No bowel movement disturbance
No urinary disturbance
No vaginal discharge
Not pregnant-suspect
No other associated symptoms and signs
Primary Clinical Diagnosis: Acute appendicitis
Pattern recognition based on
RLQ direct and rebound tenderness (possible RLQ peritonitis
even in the absence of guarding - evolving peritonitis)
Prevalence - most common cause of RLQ peritonitis in the
absence of alternative diagnosis like ectopic pregnancy and
pelvic inflammatory disease.

Secondary Clinical Diagnosis: Nonspecific RLQ abdominal pain

The RLQ direct and rebound tenderness in the absence of guarding
may not be signs of peritonitis
No alternative diagnosis aside from appendicitis
A very common cause of RLQ direct and rebound tenderness
--------------------------------------------------------------------------------------------------------------------------------
Assessment of certainty of primary clinical diagnosis:
Not quite certain yet, in the absence of guarding
Signs of peritonitis, may be evolving
Just based on RLQ direct and rebound tenderness and prevalence
Comparison of treatment for primary and secondary clinical diagnoses:
Different
Primary diagnosis: Operative
Secondary diagnosis: Nonoperative

Decision: Need for a paraclinical diagnostic procedure

----------------------------------------------------------------------------------------------------------------------------- ---

What paraclinical diagnostic procedure?

Goal: to be more definite that it is acute appendicitis before instituting an operative treatment
to avoid unnecessary operation

Options:

For primary diagnosis: observation

others (known to be done)
CBC
Urinalysis
Plain x-ray
Barium enema
Ultrasound
CT scan
For secondary diagnosis: observation

First choice is: observation

can be useful for both primary and secondary diagnosis

If CBC is done, what is the probability that it will be informative in such a situation?
Normal Abnormal (leukocytosis)
Smaller chance Greater chance
May be non-specific if abnormal

If Urinalysis is done, what is the probability that it will be informative?

Normal Abnormal (leukouria)

Greater chance Small chance
 Nonspecific if abnormal

If Plain x-ray is done, what is the probability that it will be informative?

Normal Abnormal (appendicolith)

Greater chance Small chance

If Barium Enema is done, what is the probability that it will be informative?

Normal Abnormal (nonfilling of appendix)

Greater chance Small chance

If ultrasound is done, what is the probability that it will be informative?

Normal Abnormal (noncompressible distended

appendix, complex mass,
appendicolith)
Dont know Dont know

If CT scan is done, what is the probability that it will be informative?

Normal Abnormal (dilated appendix, thick walled,

complex mass, appendicolith)
Dont know Dont know

Decision is to observe.
Observe-monitor the abdomen for progression of abdominal signs
- more obvious signs of peritonitis.

Repeat physical examination after 30-60 min (at the emergency department or inpatient)

If pain disappears completely, diagnosis is definitely not acute appendicitis, most likely
nonspecific RLQ abdominal pain.
If pain progresses and there are more definite signs of peritonitis (guarding), the
diagnosis is most likely acute appendicitis.

--------------------------------------------------------------------0-----------------------------------------------------------

Patient 2B:
Sex: Female Age: 15-50
Clinical findings and data (with 2 physical exams within 30 minutes)
RLQ pain and tenderness
Onset: 3 days ago
With shifting pain - epigastric or periumbilical to RLQ
Direct and rebound RLQ tenderness, NO guarding
No bowel movement disturbance
No urinary disturbance
No vaginal discharge
Not pregnant-suspect
No other associated symptoms and signs

Primary Clinical Diagnosis: Acute appendicitis

Pattern recognition based on
RLQ direct and rebound tenderness (possible RLQ peritonitis
 even in the absence of guarding - evolving
peritonitis) and migratory pain
Prevalence - most common cause of RLQ peritonitis in the
absence of alternative diagnosis like ectopic pregnancy and
pelvic inflammatory disease.

Secondary Clinical Diagnosis: Nonspecific RLQ abdominal pain

The RLQ direct and rebound tenderness in the absence of guarding
may not be signs of peritonitis
No alternative diagnosis aside from appendicitis
A very common cause of RLQ direct and rebound tenderness
----------------------------------------------------------------------------------------------------------------- ---------------
Assessment of certainty of primary clinical diagnosis:
Not quite certain yet, in the absence of guarding
Signs of peritonitis, may be evolving
Just based on RLQ direct and rebound tenderness, migratory pain and prevalence
Comparison of treatment for primary and secondary clinical diagnoses:
Different
Primary diagnosis: Operative
Secondary diagnosis: Nonoperative

Decision: Need for a paraclinical diagnostic procedure

--------------------------------------------------------------------------------------------------------------------------------

What paraclinical diagnostic procedure?

Goal: to be more definite that it is acute appendicitis before instituting an operative treatment
to avoid unnecessary operation

Options:

For primary diagnosis: observation

others (known to be done)
CBC
Urinalysis
Plain x-ray
Barium enema
Ultrasound
CT scan
For secondary diagnosis: observation

First choice is: observation

can be useful for both primary and secondary diagnosis

If CBC is done, what is the probability that it will be informative in such a situation?
Normal Abnormal (leukocytosis)
Smaller chance Greater chance
May be non-specific if abnormal

If Urinalysis is done, what is the probability that it will be informative?

Normal Abnormal (leukouria)

Greater chance Small chance
Nonspecific if abnormal
 If Plain x-ray is done, what is the probability that it will be informative?

Normal Abnormal (appendicolith)

Greater chance Small chance

If Barium Enema is done, what is the probability that it will be informative?

Normal Abnormal (nonfilling of appendix)

Greater chance Small chance

If ultrasound is done, what is the probability that it will be informative?

Normal Abnormal (noncompressible distended

appendix, complex mass,
appendicolith)
Dont know Dont know

If CT scan is done, what is the probability that it will be informative?

Normal Abnormal (dilated appendix, thick walled,

complex mass, appendicolith)
Dont know Dont know

Decision is to observe.
Observe-monitor the abdomen for progression of abdominal signs
- more obvious signs of peritonitis.

Repeat physical examination after 30-60 min (at the emergency department or inpatient)

If pain disappears completely, diagnosis is definitely not acute appendicitis, most likely
nonspecific RLQ abdominal pain.
If pain progresses and there are more definite signs of peritonitis (guarding), the
diagnosis is most likely acute appendicitis.

--------------------------------------------------------------------0-----------------------------------------------------------
Patient 2C:
Sex: Female Age: 15-50
Clinical findings and data (with 2 physical exams within 30 minutes)
RLQ pain and tenderness
Onset: 3 days ago
With shifting pain - LLQ to RLQ
Direct and rebound RLQ tenderness, NO guarding
No bowel movement disturbance
No urinary disturbance
No vaginal discharge
Not pregnant-suspect
No other associated symptoms and signs

Primary Clinical Diagnosis: Acute appendicitis

Pattern recognition based on
RLQ direct and rebound tenderness (possible RLQ peritonitis
even in the absence of guarding - evolving
peritonitis)
Prevalence - most common cause of RLQ peritonitis in the
absence of alternative diagnosis like ectopic pregnancy and
 pelvic inflammatory disease.

Secondary Clinical Diagnosis: Nonspecific RLQ abdominal pain

The RLQ direct and rebound tenderness in the absence of guarding
may not be signs of peritonitis
No alternative diagnosis aside from appendicitis
A very common cause of RLQ direct and rebound tenderness
----------------------------------------------------------------------------------------------------------------------------- ---
Assessment of certainty of primary clinical diagnosis:
Not quite certain yet, in the absence of guarding
Signs of peritonitis, may be evolving
Just based on RLQ direct and rebound tenderness and prevalence
Comparison of treatment for primary and secondary clinical diagnoses:
Different
Primary diagnosis: Operative
Secondary diagnosis: Nonoperative

Decision: Need for a paraclinical diagnostic procedure

----------------------------------------------------------------------------------------------------------------------------- ---

What paraclinical diagnostic procedure?

Goal: to be more definite that it is acute appendicitis before instituting an operative treatment
to avoid unnecessary operation

Options:

For primary diagnosis: observation

others (known to be done)
CBC
Urinalysis
Plain x-ray
Barium enema
Ultrasound
CT scan
For secondary diagnosis: observation

First choice is: observation

can be useful for both primary and secondary diagnosis

If CBC is done, what is the probability that it will be informative in such a situation?
Normal Abnormal (leukocytosis)
Smaller chance Greater chance
May be non-specific if abnormal

If Urinalysis is done, what is the probability that it will be informative?

Normal Abnormal (leukouria)

Greater chance Small chance
Nonspecific if abnormal

If Plain x-ray is done, what is the probability that it will be informative?

Normal Abnormal (appendicolith)

Greater chance Small chance
 If Barium Enema is done, what is the probability that it will be informative?

Normal Abnormal (nonfilling of appendix)

Greater chance Small chance

If ultrasound is done, what is the probability that it will be informative?

Normal Abnormal (noncompressible distended

appendix, complex mass,
appendicolith)
Dont know Dont know

If CT scan is done, what is the probability that it will be informative?

Normal Abnormal (dilated appendix, thick walled,

complex mass, appendicolith)
Dont know Dont know

Decision is to observe.
Observe-monitor the abdomen for progression of abdominal signs
- more obvious signs of peritonitis.

Repeat physical examination after 30-60 min (at the emergency department or inpatient)

If pain disappears completely, diagnosis is definitely not acute appendicitis, most likely
nonspecific RLQ abdominal pain.
If pain progresses and there are more definite signs of peritonitis (guarding), the
diagnosis is most likely acute appendicitis.

--------------------------------------------------------------------0-----------------------------------------------------------

Patient 3A:
Sex: Female Age: 15-50
Clinical findings and data (with 2 physical exams within 30 minutes)
RLQ pain and tenderness
Onset: 3 days ago
Started in and confined to RLQ
Direct and rebound RLQ tenderness, with guarding
No bowel movement disturbance
No urinary disturbance
No vaginal discharge
Not pregnant-suspect
No other associated symptoms and signs

Primary Clinical Diagnosis: Acute appendicitis

Pattern recognition based on
RLQ direct and rebound tenderness and guarding
Prevalence - most common cause of RLQ peritonitis in the
absence of alternative diagnosis like ectopic pregnancy and
pelvic inflammatory disease.

Secondary Clinical Diagnosis: Gynecologic disorders

Twisted ovarian cyst
 Pelvic inflammatory disease
----------------------------------------------------------------------------------------------------------------------------- ---
Assessment of certainty of primary clinical diagnosis:
Quite certain
Based on RLQ direct and rebound tenderness and guarding and prevalence
Comparison of treatment for primary and secondary clinical diagnoses:
Different
Primary diagnosis: Operative
Secondary diagnosis: Operative

Decision: No need for a paraclinical diagnostic procedure

Quite certain of primary clinical diagnosis
Treatment for primary and secondary diagnosis is essentially the same.

--------------------------------------------------------------------0-----------------------------------------------------------

Patient 3B:
Sex: Female Age: 15-50
Clinical findings and data (with 2 physical exams within 30 minutes)
RLQ pain and tenderness
Onset: 3 days ago
With shifting pain - epigastric or periumbilical to RLQ
Direct and rebound RLQ tenderness, with guarding
No bowel movement disturbance
No urinary disturbance
No vaginal discharge
Not pregnant-suspect
No other associated symptoms and signs

Primary Clinical Diagnosis: Acute appendicitis

Pattern recognition based on
RLQ direct and rebound tenderness and guarding
Prevalence - most common cause of RLQ peritonitis in the
absence of alternative diagnosis like ectopic pregnancy and
pelvic inflammatory disease.

Secondary Clinical Diagnosis: Gynecologic Disorders

Pelvic inflammatory disease
Twisted ovarian cyst

----------------------------------------------------------------------------------------------------------------------------- ---
Assessment of certainty of primary clinical diagnosis:
Quite certain
Based on RLQ direct and rebound tenderness, guarding, migratory pain and prevalence
Comparison of treatment for primary and secondary clinical diagnoses:
Different
Primary diagnosis: Operative
Secondary diagnosis: Operative

Decision: No need for a paraclinical diagnostic procedure

Quite certain of primary clinical diagnosis
Treatment fpr primary and secondary diagnoses is essentially the same.
----------------------------------------------------------------------------------------------------------------------------- ---

Patient 3C:
Sex: Female Age: 15-50
 Clinical findings and data (with 2 physical exams within 30 minutes)
RLQ pain and tenderness
Onset: 3 days ago
With shifting pain - LLQ to RLQ
Direct and rebound RLQ tenderness, with guarding
No bowel movement disturbance
No urinary disturbance
No vaginal discharge
Not pregnant-suspect
No other associated symptoms and signs

Primary Clinical Diagnosis: Acute appendicitis

Pattern recognition based on
RLQ direct and rebound tenderness and guarding,
very likely there is RLQ peritonitis
Prevalence - most common cause of RLQ peritonitis in the
absence of alternative diagnosis like ectopic pregnancy and
pelvic inflammatory disease.

Secondary Clinical Diagnosis: Gynecologic disorders

Twisted ovarian cyst
Pelvic inflammatory disease

----------------------------------------------------------------------------------------------------------------------------- ---
Assessment of certainty of primary clinical diagnosis:
Quite certain
Based on RLQ direct and rebound tenderness and guarding and prevalence
Comparison of treatment for primary and secondary clinical diagnoses:
Different
Primary diagnosis: Operative
Secondary diagnosis: Operative

Decision: No need for a paraclinical diagnostic procedure

Quite certain
Treatment for primary and secondary diagnoses are essentially the same, operative.

4a-c
No rebound, positive guarding

same process as No guarding, positive rebound

5a-c
Rebound tenderness, no direct tenderness, no guarding

nonspecific RLQ abdominal pain

acute appendicitis
6a
direct tenderness with yellowish vaginal discharge

PID
Acute appendicitis

6b
PID
Acute appendicitis

6c
PID
Acute appendicitis

6d
PID
acute appendicitis

7a

pregnancy-related pain
acute appendicitis

7b
pregnancy-related pain
acute appendicitis

7c acute appendicitis
ectopic pregnancy

7d
acute appendicitis
ectopic pregnancy
 THE
RLQ ABDOMINAL PAIN
HEALTH PROBLEM

FOLDER 3

PROBLEM-BASED LEARNING
ISSUES
 Problem-based Learning Issues

Instructions

Given hypothetical and actual patients, pretest questions and any kind of
PULMONARY HEALTH PROBLEM to solve, list down deficiencies and uncertainties in
competences as learning issues and decide on a specific learning plan. Use the form below.

Trigger* Learning Issues Learning Plan**

*Hypothetical Patient Management (HPM)

Actual Patient Management (APM)
Pretest

**Reading - what and which books, journals

Asking - whom, where, when
Doing - what, where, when
 THE
RLQ ABDOMINAL PAIN
HEALTH PROBLEM

FOLDER 4

LEARNING OBJECTIVES
 Basic Terminal Competencies Expected of a Primary Health Care Physician
in Individual Patient Management

RE: Right Lower Quadrant Abdominal Pain

Prepared by
Reynaldo O. Joson, MD, MHPEd, MS Surg

Overview of Abdominal Pain

Overview of Right Lower Quadrant Abdominal Pain
Anatomy of Right Lower Quadrant Abdomen and Structures Within It
Clinical Diagnosis
Recognize
Acute Appendicitis
Ectopic Pregnancy
Reproductive Tract Infection
Acute Gastroenteritis
Urinary Tract Infection
Nonspecific RLQ Abdominal Pain

Algorithm for
Acute Appendicitis
Ectopic Pregnancy
Reproductive Tract Infection
Acute Gastroenteritis
Urinary Tract Infection
Nonspecific RLQ Abdominal Pain

Paraclinical Diagnostic Procedures for Patients with RLQ Abdominal Pain

For
Acute Appendicitis
Ectopic Pregnancy
Reproductive Tract Infection
Acute Gastroenteritis
Urinary Tract Infection
Nonspecific RLQ Abdominal Pain

Indications for:
Observation
Rectal Exam
Internal Pelvic Exam
CBC
Urinalysis
Plain Abdominal X-rays
Barium enema
Ultrasound
CT scan
Pregnancy Test

Treatment
Nonoperative
Indications for
 Analgesics
Antibiotics

Referral
Indications
When
To whom

Advice
Clinical Diagnosis
Paraclinical Diagnostic Process
Selection of Treatment Process
Operative
Nonoperative

reyjoson0399
 THE RLQ ABDOMINAL PAIN HEALTH PROBLEM

GENERAL LEARNING OBJECTIVES

At the end of the course, the student must be able to:

1. Write an overview and a personal perspective on RLQ ABDOMINAL PAIN in general and
APPENDICITIS in particular, as a global, national and local health problem.

2. Manage any patient presenting with a RLQ ABDOMINAL PAIN.

2.1 Demonstrate skills in

2.1.1 Establishing rapport
2.1.2 Clinical diagnostic process
2.1.3 Paraclinical diagnostic process
2.1.4 Treatment process
2.1.5 Giving advice
2.1.6 Making referrals

2.2 Demonstrate qualities of an effective, efficient, and humane physician.

2.3 Discuss/explain the biological foundation and basis of the clinical management of a
patient with a RLQ ABDOMINAL PAIN.

3. Discuss the following issues on RLQ ABDOMINAL PAIN.

3.1 Clinical management issues

3.2 Psychosocial or behavioral issues
3.3 Bioethical issues
3.4 Medicolegal issues

4. Conduct a public health education program on the

4.1 Early detection of a SURGICAL ABDOMEN in Patients with RLQ Pain
4.2 Early detection of ACUTE APPENDICITIS in Patients with RLQ Pain

5. Perform a research activity on RLQ ABDOMINAL PAIN.

6. Formulate a community health plan on the RLQ ABDOMINAL PAIN.

7. Pass examinations on RLQ ABDOMINAL PAIN.

IVA
 THE RLQ ABDOMINAL PAIN HEALTH PROBLEM

CLINICAL COMPETENCY
General Clinical Competencies:

A primary health care physician must be able to manage any patient with a RLQ ABDOMINAL PAIN.

He must be able to:

1. Outline the goals in the management.

2. Demonstrate skills in:

2.1 Establishing rapport.

2.2 Clinical diagnostic process.
2.3 Paraclinical diagnostic process.
2.4 Treatment process
2.5 Giving advice.
2.6 Making referrals.

3. Demonstrate qualities of an effective, efficient, and humane physician.

Specific clinical competencies:

Given actual and simulated patients with a RLQ ABDOMINAL PAIN, a primary health care physician
must be able to:

1. Diagnose the presence of the RLQ ABDOMINAL PAIN (and its kinds and causes) through
interviewing and examining.
1.1 Recognize signs of acute surgical abdomen, when present.
1.2 Recognize signs of peritoneal irritations, when present.
1.3 Suspect acute appendicitis as the most probable cause of RLQ ABDOMINAL PAIN,
when present.
1.4 Suspect the following as the cause of the RLQ ABDOMINAL PAIN, when present:
Urinary tract infection
Ureteral stone
Gastroenteritis
Pelvic inflammatory disease (or reproductive infections)
Ectopic pregnancy
Nonspecific RLQ abdominal pain
Mesenteric adenitis
Mittelschmertz
1.5 Decide when to settle for a diagnosis of a nonspecific RLQ ABDOMINAL PAIN.

2. Decide on how to stop the RLQ ABDOMINAL PAIN process, if possible.

IVB1
3. Determine the severity of the RLQ ABDOMINAL PAIN and how it will affect management.

4. Determine indications for cardiopulmonary resuscitation. If indicated, perform.

5. Determine indications for ventilatory therapy (oxygen, endotracheal intubation,

tracheostomy). If indicated, prescribe.

6. Determine indications for intravenous fluid therapy. If indicated, prescribe the type of
fluids, amount, and rate of administration during the first 24 hours after decision.

7. Determine indications for blood therapy. If indicated, prescribe the type of blood,
amount, and rate of administration during the first 24 hours after decision.

8. Determine indications for analgesic therapy. If indicated, prescribe the type, dosage, and route
of administration.

9. Determine indications for antibiotic therapy. If indicated, prescribe the type, dosage,
and route of administration.

10. Determine indications for paraclinical diagnostic procedures. If indicated, advice on

selection.
10.1 Determine the most cost-effective paraclinical diagnostic procedures for the
following suspected conditions and stating their respective diagnostic
result:
Acute appendicitis
Urinary tract infection
Ureteral stone
Gastroenteritis
Pelvic inflammatory disease (or reproductive infections)
Ectopic pregnancy
Nonspecific RLQ abdominal pain
Mesenteric adenitis
Mittelschmertz
10.2 Determine the indications for active observation as a paraclinical diagnostic
procedure. Describe briefly the procedure to be done, by whom, and the
intervals or frequency of monitoring.

11. Advice on treatment, on options, and selection..

11.1 Determine the most cost-effective treatment for the following diagnoses:
Acute appendicitis
Urinary tract infection
Ureteral stone
Gastroenteritis
Pelvic inflammatory disease (or reproductive infections)
Ectopic pregnancy
Nonspecific RLQ abdominal pain
Mesenteric adenitis
Mittelschmertz

IVB2
12. Determine indications for hospitalization. If indicated, write an admitting order.

13. Determine indications for referrals. If indicated, write a letter of referral.

14. Determine the indications for discharge. If indicaated, advice patient or relatives on
diagnosis and home care.

15. Prescribe an outpatient/clinic/home treatment.

16. Advice on prognosis and recovery.

17. Advice on preventive and promotive health measure.

18. Perform the following procedures:

1. Establish rapport with the patient and her relatives

2. Interview a patient with a RLQ ABDOMINAL PAIN and gather relevant core data
3. Gently and accurately perform a physical examination on a patient with
RLQ ABDOMINAL PAIN
4. Perform cardiopulmonary resuscitation
5. Establish an intravenous line
6. Administer parenteral medications
7. Prescribe a drug
7.1 Prescribe analgesics for ureteral colic
7.2 Prescribe antibiotics for urinary tract infection
7.3 Prescribe antibiotics for reproductive tract infections
8. Write an admitting order
9. Write a letter of referral
10. Write a medical certificate
11. Fill up a death certificate

IVB3
 THE RLQ ABDOMINAL PAIN HEALTH PROBLEM
BIOLOGICAL FOUNDATION AND BASIS OF CLINICAL MANAGEMENT
General Learning Objectives:

A primary health care physician must be able to discuss/explain the biological foundation and
basis in the clinical management of a patient with a RLQ ABDOMINAL PAIN HEALTH PROBLEM.

Enabling objectives:

A primary health care physician must be able to answer the questions and accomplish the tasks
listed below:

Epidemiology

1a. What is a RLQ ABDOMINAL PAIN?

1b. How common is RLQ ABDOMINAL PAIN as a health problem in the community? Support
your answer.
Common/uncommon
Global -
National -
Local -

2a. What are the different causes of RLQ ABDOMINAL PAIN? Give at least 5.
2b. What do you think is/are the 2 more common causes of RLQ ABDOMINAL PAIN in the
community? Why do you say so?
2c. What do you think is/are the least common causes of RLQ ABDOMINAL PAIN in the
community? Why do you say so?

3a. What type(s) of persons (based on age groups, occupations, behaviors, and other factors), if
any, are commonly at risk for the various causes of RLQ ABDOMINAL PAIN?
3b. What type(s) of social environment (cultural practices, folk beliefs), if any, predispose
persons to the various causes of RLQ ABDOMINAL PAIN?
3c. What type(s) of occupations and physical environment, if any, predispose persons to the
various causes of RLQ ABDOMINAL PAIN?

Pathophysiology

1. What are the different types/kinds of abdominal pain? Desccribe their pathophysiology.
1.1 Visceral pain
1.2 Parietal or somatic pain
1.3 Referred abdominal pain

2.1 Make a diagram of a conceptual framework on the general pathophysiology of

RLQ ABDOMINAL PAIN.

IVC1
2.2 Make a diagram of a conceptual framework on the pathophysiology of the more common
causes of RLQ ABDOMINAL PAIN.
RLQ abdominal wall pain
Acute appendicitis
Urinary tract infection
Gastroenteritis
Pelvic inflammatory disease (or reproductive infections)
Ectopic pregnancy
Nonspecific RLQ abdominal pain
Mesenteric adenitis
Mittelschmertz

3. What structures (systems, organs, tissues, and cells are usually involved in patients with
RLQ ABDOMINAL PAIN?
1. Draw the layers of abdominal wall at the RLQ.
2. Draw the structures and organs inside the abdomen that are involved
in RLQ ABDOMINAL PAIN.
2.1 Gastrointestinal anatomy
distal ileum, appendix, cecum, ascending colon
2.2 Urinary anatomy
kidney, ureter, bladder
2.3 Female reproductive tract anatomy
uterus, ovary, fallopian tube

4. What are the usual functions of the different systems, organs, tissues, and cells that are usually
involved in RLQ ABDOMINAL PAIN?
4.1 RLQ abdominal wall physiology
4.2 Gastrointestinal physiology
distal ileum, appendix, cecum, ascending colon
4.3 Urinary physiology
kidney, ureter, bladder
4.4 Female reproductive tract physiology
uterus, ovary, fallopian tube

For questions 5-7:

For the following causes of RLQ ABDOMINAL PAIN.
RLQ abdominal wall pain
Acute appendicitis
Urinary tract infection
Gastroenteritis
Pelvic inflammatory disease (or reproductive infections)
Ectopic pregnancy
Nonspecific RLQ abdominal pain
Mesenteric adenitis
Mittelschmertz

IVC2
 5. Describe the usual gross and microscopic changes in structure that may occur in the
systems, organs, tissues, and cells involved.

Usual Changes in Structure

(in general terms)
System
Organ
Tissue
Cell

6. How does the human body respond to the different causes of RLQ ABDOMINAL PAIN,
specifically, what are the endocrine, metabolic, and psychologic responses?

7a. Name three possible outcomes that may happen to the patient in the absence of a physicians
intervention.
7b. Name three possible outcomes that may happen to the patient in the presence of a physicians
intervention.
7c. What are the usual causes of disability in the involved patients?
7d. What are the usual causes of death in the involved patients?
CAUSES
DISABILITY
DEATH

Diagnosis

1. What are the core data needed in the clinical diagnosis of RLQ ABDOMINAL PAIN?

2. What are the usual presenting signs and symptoms of the following causes of RLQ
ABDOMINAL PAIN? What are their reliable clinical diagnostic cues?

Acute appendicitis
Urinary tract infection
Ureteral stone
Gastroenteritis
Ectopic pregnancy
Pelvic inflammatory disease (reproductive tract infection)
Nonspecific RLQ abdominal pain

3. For the following causes of RLQ ABDOMINAL PAIN, name at least 3 paraclinical
diagnostic procedures that are known to be done. Briefly describe how they are being
done. Then, compare them in terms of benefit- risk-cost-availability in the community.
Identify an indication for each procedure.
Acute appendicitis
Urinary tract infection
Ureteral stone
Gastroenteritis
Ectopic pregnancy
Pelvic inflammatory disease (reproductive tract infection)
Nonspecific RLQ abdominal pain

IVC3
 PCD1 PCD2 PCD3

BENEFIT
RISK
COST
AVAILABILITY

Treatment

For each of the following causes of RLQ ABDOMINAL PAIN,

Acute appendicitis
Urinary tract infection
Ureteral stone
Gastroenteritis
Ectopic pregnancy
Pelvic inflammatory disease (reproductive tract infection)
Nonspecific RLQ abdominal pain

1. State the objective of treatment.

2. Name at least 3 options and then compare them in terms of benefit-risk-cost-availability in the
community. Choose what you think is the most cost-effective treatment.

T1 T2 T3
BENEFIT
RISK
COST
AVAILABILITY

3. Briefly describe the recommended treatment. Include description of the pretreatment,

intratreatment, and postreatment phases.

4. Describe the pharmacology (pharmacodynamics, pharmacokinetics, and

pharmacotherapeutics) of the following that are commonly used in the treatment of
patients with RLQ ABDOMINAL PAIN.
4.1 Analgesics
4.2 Antispasmodics
4.3 Antibiotics

5. Describe the following operative procedures:

5.1 Laparotomy
5.2 Laparoscopy
5.3 Appendectomy
5.4 Salpingectomy
5.5 Drainage of abscess

Management Plan, Algorithm, or Protocol

1. Outline the goals in the management of patients with RLQ ABDOMINAL PAIN.

2. Write a plan, algorithm, or protocol illustrating the general steps in the management of
patients with RLQ ABDOMINAL PAIN.

IVC4
 3. Write a plan, algorithm, or protocol illustrating the general steps in the management of
patients with following causes of RLQ ABDOMINAL PAIN:
Acute appendicitis
Urinary tract infection
Ureteral stone
Gastroenteritis
Ectopic pregnancy
Pelvic inflammatory disease (reproductive tract infection)
Nonspecific RLQ abdominal pain

Preventive and Promotive Health Program

For the various causes of RLQ ABDOMINAL PAIN,

Acute appendicitis
Urinary tract infection
Ureteral stone
Gastroenteritis
Ectopic pregnancy
Pelvic inflammatory disease (reproductive tract infection)
Nonspecific RLQ abdominal pain

1. Based on known risk factors, suggest ways, if any, to prevent.

2. Formulate (outline) a preventive and promotive health program for yourself.
3. Formulate (outline) a preventive and promotive health program for your community.

Identification of Issues

1. Identify at least one psychosocial factor that may promote occurrence of RLQ ABDOMINAL
PAIN or that may affect recovery of these types of patients.
2. Identify at least one bioethical issue that may be encountered in the management of patients
with RLQ ABDOMINAL PAIN.
3. Identify at least one medicolegal issue that may be encountered in the management of patients
with RLQ ABDOMINAL PAIN?
4. Identify at least one personal research question in patients with RLQ ABDOMINAL PAIN and
briefly state the reasons why you consider it as such.
 IVC5

THE
RLQ ABDOMINAL PAIN
HEALTH PROBLEM

FOLDER 5

LEARNING RESOURCE
MATERIALS AND REFERENCES
 Overview and Personal Perspective on RLQ Abdominal Pain

Reynaldo O. Joson, MD, MHPEd, MS Surg

I. Concept of RLQ Abdominal Pain

A. Definition of RLQ Abdominal Pain

Pain felt by a patient at his/her right lower quadrant of the abdomen

B. Effect of RLQ Abdominal Pain on the health of individual, family, and community

It can affect the biopsychosocial well-being of individuals who have it.

It can lead to disability and death.
It can affect the socioeconomic productivity of individuals, families, and communities.

II. Common Types of RLQ Abdominal Pain

Acute or chronic
Tolerable or intolerable - mild, moderate, severe
Constant or intermittent
Colicky or noncolicky
Pain originating from
RLQ anterior abdominal wall
Within RLQ peritoneal cavity
Associated with peritonitis
Not associated with peritonitis
Within RLQ retroperitoneal areas
Referred or nonreferred pain

III. Common Causes of RLQ Abdominal Pain

Trauma Inflammatory/ Stones Tumors Obstruction Pregnancy Non-

Blunt/penetrating infectious related specific
condition
Anterior / / x / x /
abdominal wall
Intraperitoneal / Appendicitis x / / /
W/ peritonitis Diverticulitis
PID
Ruptured
ectopic
pregnancy
Intraperitoneal / Mesenteritic x / / / /
W/o peritonitis adenitis
Gastroenteritis
UTI
Mittelschmert
z
Retroperitoneal / Psoas abscess Ureteral stone, / / /
area right
IV. Magnitude of RLQ Abdominal Pain Health Problem
True worldwide ---

Very common in all ages and in both sexes

Main problem lies in difficulty in differentiating surgical from nonsurgical causes.

Specifically, the problem consists mainly of making a definitive diagnosis of acute appendicitis,
which is a surgical cause. The problem has resulted in the high percentage of negative
appendectomy due to overdiagnosis on one hand and high percentage of perforation due
to missed diagnosis, on the other hand.

Nonsurgical causes more common than surgical causes.

Surgical abdominal causes may lead to disability and death, if not treated early and properly.

V. Personal Perspective on the possible solutions to the RLQ Abdominal Pain Health Problem in the Community

Goals/objectives:
RLQ abdominal pain is due to both preventable and nonpreventable causes.
For preventable causes - the goal is to reduce their incidence and prevalence
thereby reducing the RLQ abdominal pain health problem.
For nonpreventable causes - the goal is early accurate diagnosis and treatment
to reduce morbidity and mortality in patients with RLQ abdominal pain.

Strategies and Programs

Community participation: People
Intersectoral linkages
Appropriate technology

Evaluation indicators

Reduction in incidence and prevalence of RLQ abdominal pain.

Preventable causes - reduction in incidence and prevalence rates

Nonpreventable ones - reduction in morbidity and mortality rates

VI. References
 THE
RLQ ABDOMINAL PAIN
HEALTH PROBLEM

FOLDER 6

EVALUATION
 RLQ Abdominal Pain Health Problem

Appendicitis

1. The MOST important finding in the diagnosis of appendicitis is

D
A. vomiting
B. fever
C. leukocytosis
D. right lower quadrant tenderness
E. referred rebound tenderness (Rovsings sign)

41. A 20-year-old male with rebound tenderness in the right lower quadrant, fever, and a normal white blood cell
count should be managed with
C
A. intravenous antibiotics and nasogastric suction
B. 24-hour observation
C. exploratory laparotomy through a right lower quadrant incision
D. exploratory laparotomy through a lower midline incision
E. colonoscopy and identification of the appendiceal os

Diverticulitis

42. Indications for emergency operation of diverticulitis or diverticulosis include all of the following EXCEPT
D
A. perforation
B. fistula
C. bleeding
D. repeated attacks
E. obstruction

General

23. All of the following substances are irritating to the peritoneum EXCEPT
C
A. bile
B. meconium
C. blood
D. gastric content
E. pus

24. Nonsurgical causes of abdominal pain include all of the following EXCEPT
D
A. pneumonia
B. diabetic ketoacidosis
C. acute salpingitis
D. head trauma
E. myocardial infarction

14. Common characteristics of small bowel obstruction include all of the following EXCEPT
A
A. ascites
B. frequent progression to strangulation
C. failure to pass flatus
D. distention
E. vomiting
 THE
RLQ ABDOMINAL PAIN
HEALTH PROBLEM

FOLDER 7

DETAILS AND FORMATS