Karnataka PGET Surgery MCQ Answer 2

Assessing for appendicitis

• Appendicitis is a relatively common but still challenging clinical diagnosis. The majority of cases can be diagnosed by a good history and physical examination although confirmatory laboratory and/or imaging studies are usually done.
• Patients with appendicitis almost always present with the symptom of abdominal pain.
• Typically the pain is initially periumbilical and poorly localized. This is a result of the visceral autonomic stimulation caused by distention of the wall of the appendix.
• Once the inflammatory mediators of appendicitis reach the more precise parietal nerve endings then the pain becomes localized. This is usually in the RLQ, classically at McBurney’s point, which is two thirds of the way along a line from the umbilicus to the right anterior superior iliac spine.
• Have patients localize their pain by pointing to the point of maximum tenderness with one finger.
• The key findings (or signs) in appendicitis are localized
• tenderness.
• guarding
• involuntary guarding (or rigidity)
• Usually these signs will be localized to the RLQ by light or if light palpation is normal then deep palpation
• Sometimes it is necessary to distract the patient (to prevent voluntary guarding caused by anxiety) by palpating
• while having them answer questions
• while breathing deeply
• with your stethoscope after auscultation
• Other areas of localized tenderness can be elicited by
• Rectal examination
• When the inflamed appendix is deep in the pelvis
• Pelvic examination
• When the inflamed appendix is deep in the pelvis
• Psoas sign - tenderness elicited when the patient
• raises the right thigh against resistance, or
• extends the right thigh when laying on their left side
• When the inflamed appendix is retroperitoneal against the psoas muscle that is either flexed or stretched with these moves.
• Obturator sign – tenderness elicited when the patient’s knee is bent and hip flexed and the hip is internally rotated
• When the inflamed appendix is adjacent to the internal obturator muscle that is stretched with this move.
• Other signs that may localize the tenderness include
• Rovsing’s sign - RLQ pain during LLQ palpation
• Referred RLQ rebound tenderness to LLQ palpation/release

Category: Karnataka PGET 2007 MCQs