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CE ARTICLE As Michael continues questioning his female patient, she explains that she woke up this morning with nausea and generalized lower abdominal pain. She says she feels feverish and has not wanted to eat anything all day. She began vomiting about a half-hour ago, and the pain has shifted to the right side of her umbilicus. She does not want to move, because any movement or vibra- tion is unbearably painful. This is a classic presentation for acute appendicitis. While more than 95% of patients with appendicitis have abdom- inal pain, only about 50% have the other classic symptoms. Appendicitis occurs usually from stool obstructing the outlet of the appendix, lymphoid hyperplasia, or inflammation/obstruction blocking the ongoing production of mucus by the appendix. While definitive treatment is surgical removal of the appendix, emer- gency management consists of hydra- tion with IV fluids, keeping the patient NPO (nothing by mouth) and comfort measures. The old dogma used to be not to give pain medication in order to have an accurate abdominal exam; however, studies continue to show that pain medication does not interfere with the diagnostic accuracy of abdominal examinations, and it adds to patient comfort.6 It is also helpful FAST FACT Several studies show that pain medications do not interfere with the diagnostic accuracy of abdominal examinations. (PID).7 to keep in mind that one-third of women of childbearing age with appendicitis are misdiag- nosed with pelvic inflammatory disease In order to differentiate appendi- citis from PID, the following three char- acteristics are 99% sensitive for ruling out appendicitis: 1) no migration of pain, 2) bilateral abdominal tenderness, 3) no nausea or vomiting.8 While this does not necessarily rule in PID, it can rule out appendicitis. Clinically, you can look for these things to help point the hospital receiving team in the right direction. Pelvic inflammatory disease is char- acterized by an ascending infection of 62 JULY 2011 | EMSWORLD.com Table 3: High-Yield Patient History Questions4 1. How old are you? Age-appropriate diff erential diagnosis 2. Which came fi rst—pain or vomiting? Pain fi rst is worse (i.e., more likely to be caused by surgical disease). 3. How long have you had the pain? Pain for less than 48 hours is acute. 4. Have you ever had abdominal surgery? Consider obstruction in patients who report previous abdominal surgery. 5. Is the pain constant or intermittent? Constant pain is worse. 6. Have you ever had this before? A report of no prior episodes is concerning. 7. Do you have a history of cancer, diverticulosis, pancreatitis, kidney failure, gallstones or infl ammatory bowel disease? All increase the potential for a serious etiology. 8. Do you have human immunodefi ciency virus (HIV)? Consider occult infection or drug-related pancreatitis. 9. How much alcohol do you drink per day? Consider pancreatitis, hepatitis or cirrhosis in patients with history or signs of signifi cant intake. 10. Could you be pregnant? Consider ectopic pregnancy. 11. Are you taking antibiotics or steroids? Eff ects of these drugs may mask infection. 12. Did the pain start centrally and migrate to the right lower quadrant? High specifi city for appendicitis. 13. Do you have a history of vascular or heart disease, hypertension or atrial fi brillation? Consider mesenteric ischemia and abdominal aneurysm. vaginal bacteria into the pelvic cavity, which can manifest in uterine, fallopian or ovarian pain. The most important clinical impact of PID is the damage it causes to the fallopian tubes. If not treated thoroughly and quickly, it can cause scarring and increase the chance of an ectopic pregnancy six- to 10-fold, and increase the risk of chronic pelvic pain four-fold. Proper management of pelvic inflammatory disease includes broad-spectrum antibiotics, because both aerobic and anaerobic bacteria can cause PID. Significant risk factors for PID include younger age of first sexual inter- course, older sex partners, alcohol use before intercourse, concurrent chlamydia infection or prior suicide attempt. High- risk behaviors are generally risk factors for developing PID because of their asso- ciation with sexually transmitted infec- tions and alteration of the vaginal flora. Unfortunately, the signs and symp- toms of pelvic inflammatory disease are generally non-specific. Non-specific abdominal pain in a female must always be considered for PID because of its impact on female fertility. The CDC suggests minimum criteria for diagnosing and beginning treatment of PID, including lower abdominal tender- ness, adnexal tenderness or cervical motion tenderness. Other supporting criteria include oral temperature >38°C, abnormal cervical or vaginal discharge (macropurulent), presence of abundant WBCs on microscopy of vaginal secre- tions, elevated erythrocyte sedimenta- tion rate, elevated C-reactive protein, or laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.10 It is important to know about PID in the field because it will be a presenting problem in a number of patients. Remember that diagnosis is not neces- sary, particularly in new cases; however, be sure to ask about a history of PID, since supportive measures can be performed without a differential diag- nosis. These include IV fluids and trans- port in a position of comfort to a facility that can provide definitive diagnosis and treatment. Pelvic examinations in the field are not indicated, as they only allow for increased discomfort and undue pain and will not affect acute prehospital management. This is not to say a visual exam of the external vagina is unwarranted to ensure there is no gross bleeding that needs to be cared for urgently. Case #2: One piece of information can change a differential diagnosis. Continued questioning reveals that your patient got drunk a few months ago and had unprotected intercourse at a party. She hasn’t told anyone or done