A 46-year-old Man with Right-sided Abdominal Pain, Slight Fever

History. A 46-year-old man with no significant past medical history presents to the emergency department for 3 days of slowly progressive, constant, right-sided abdominal pain. He notes that the pain is worse with movement or coughing. He reports no nausea, vomiting fever, diarrhea, or other complaints.

Examination. Vital signs are normal except for a temperature of 99.2°F and respirations at 22 per minute. The abdomen is soft. The area of maximal pain indicated by the patient is also the area of maximal tenderness and is located midway between McBurney's and Murphy's points. There is no guarding or rebound. He also has mild right-sided costovertebral angle tenderness.

Initial Concerns: gallstone, kidney stone, appendicitis

Testing:

• WBC = 9.2 with 74% PMNs
• AST/ALT = 83/70 U/L
• UA negative
• CT image at right