RLQ Pain Differential Mnemonic: “APPENDICITIS”

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RLQ Pain DDx Mnemonic

There’s a special place in medicine reserved for the mysterious and often misleading Right Lower Quadrant (RLQ) pain. It’s the abdominal equivalent of “It’s complicated.” 👀

From my time in the emergency bay at Sheikh Khalifa Hospital, one thing is clear — RLQ pain doesn’t read textbooks, and neither do the patients. Just last week, a lady from Tump walked in insisting it was her appendix, but turned out to have an ovarian torsion, caught just in time by our sharp-eyed Dr. Bilal Chaudhary.

So how do we not get blindsided?

Enter: the APPENDICITIS mnemonic — a comprehensive, memorable, and annoyingly accurate list of RLQ differentials that’ll keep you from calling surgery on every case with rebound tenderness. 🥼

RLQ Pain DDx Mnemonic

Letter Condition Clinical Clues / Pearls
A Appendicitis / Abscess Classic: periumbilical to RLQ migration, fever, McBurney’s point tenderness 🔥
P Pelvic Inflammatory Disease / Period Cervical motion tenderness, vaginal discharge, missed period? Time to call Gyn 👩‍⚕️
P Pancreatitis (radiating pain) Not classic, but tail inflammation can confuse you — check lipase, and don’t trust the location 🥴
E Ectopic Pregnancy / Endometriosis hCG test before you order anything — always. Endometriosis pain may be cyclical 🩸
N Neoplasia Ovarian or colonic — consider if chronic, cachexia, or constitutional symptoms 🤔
D Diverticulitis (usually LLQ but…) Think right-sided diverticulitis in Asian populations or in odd presentations
I Intussusception Sausage-shaped mass, red currant jelly stool — pediatrics gold. Dr. Bilal loves these 👶
C Crohn’s Disease / Cyst (ovarian) Terminal ileitis or a ruptured ovarian cyst — both can mimic appendicitis 🎭
I Inflammatory Bowel Disease Chronic diarrhea, weight loss, family history — and yes, it can flare suddenly 📉
T Torsion (ovarian/testicular) Sudden, severe, nauseating — do not delay ultrasound. Surgical emergency 🚨
I Irritable Bowel Syndrome (IBS) The great pretender. Crampy, relieved by defecation, and no red flags 🧘
S Stones (ureteric) Flank to groin pain, hematuria, can mimic appendicitis. CT KUB is your friend 🪨

 

🏥 Real-World Confusion: The Mashkhel Mix-Up

A 22-year-old woman from Mashkhel, Balochistan came in crying, curled up on the bed, guarding her RLQ. Surgical resident says “appendicitis,” and the OT is booked.

But something felt off — she wasn’t febrile, leukocytes were low, and pain started mid-cycle. A quick pelvic ultrasound (thanks to Dr. Danish Ramzan) revealed a ruptured hemorrhagic ovarian cyst. Appendix was innocent. Again.

That moment reminded me why mnemonics like this exist — not just to impress the FCPS/PLAB examiners, but to protect real patients from unnecessary scalpels.

💬 Clinical Tips

  • Don’t forget the pregnancy test. Even in the “I’m sure I’m not pregnant” cases. Trust me.
  • Always examine the groin — hernias love to be dramatic in unexpected places.
  • Ask about previous episodes — Crohn’s, IBS, and even kidney stones often have a pattern.
  • Beware of anchoring — just because the last 5 RLQ patients had appendicitis doesn’t mean the 6th one does. Medicine isn’t cricket. 🏏

Happy learning, folks! 🙂

Author: Dr. Aurangzaib Qambrani
Qualifications: MBBS, PLAB, MRCP-UK
Hospital: Sheikh Khalifa Bin Zayed Hospital, Quetta

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