Continuous mild or upper abdominal pain is the initial characteristic manifestation of acute appendicitis. During the first 4 hours the pain intensifies and localized in the RLQ of the abdomen. This pain is aggravated by moving, walking and coughing. Extension or internal rotation of the right hip increases the pain. Low grade fever, anorexia, nausea, and vomiting are often present. Pain and local tenderness may be less acute in older adults, delaying the diagnosis.