Combining history, physical examination, blood studies, and radiologic tests will give an accurate diagnosis in 70%-80% of cases. Unfortunately, atypical presentations of appendicitis, like the one in our opener, can delay diagnosis and increase morbidity and mortality. John’s sudden onset of pain should have been concerning and might have prompted earlier abdominal imaging. Typical right lower-quadrant pain is not present in all cases. Rather than being a sign of improvement, the decrease in John’s pain may have coincided with perforation, with fever related to subsequent abscess formation.
Missed diagnosis is more common in children (likely due to communication difficulties in those younger than 3 years) and in those older than 60, who may delay seeking care. In the elderly and immunosuppressed, appendicitis symptoms may be atypical or absent. In women, diagnosis may be made difficult by confounding gynecologic pathology and pregnancy.