Problem refinement

To further support your differential diagnosis, asking about previous history would be helpful. In appendicitis no previous history should be present. Chris confirms this is the first time he has had such symptoms. This also helps to further rule out causes such as complications of ulcers, diverticulitis, IBD and IBS.

At this point you suspect appendicitis. Checking against the list of possible diagnoses that have yet to be considered, abdominal wall haematoma and hernias are associated with older age. Nausea and vomiting are also seen with abdominal wall haematoma, diverticulitis and kidney stones. It seems these other possible causes can reasonably be discounted.  

If you are competent to perform a physical examination, this should also be done. Findings of right lower quadrant tenderness would support appendicitis as the diagnosis.

Red flags

The critical diagnoses that need to be considered do not fit the age profile of our patient. Carcinoma, intestinal obstruction and perforated ulcer are associated with older people and testicular torsion in younger men. Other symptoms beside pain are also common in all conditions other than testicular torsion – however, pain here is in the testes rather than the right lower quadrant.

Self-care options

Not applicable.

Prescribing options

A second opinion from a medically qualified practitioner should be sought urgently and onward referral to A&E arranged if appendicitis is still considered likely.

Safety netting

You tell Chris you suspect he has appendicitis and you advise him to go to A&E immediately.