Appendicitis

Clinical findings most consistent with appendiceal rupture include all of the following except: A. abdominal discomfort less than 48 hours in duration. B. fever greater than 102°F (>38°C). C. palpable abdominal mass. D. marked leukocytosis with total WBC greater than 20,000/mm3.

A. abdominal discomfort less than 48 hours in duration.

Commonly encountered diagnoses other than acute appendicitis can include which of the following in a 28-year-old with a 2-day history of lower abdominal pain and with right-sided pain slightly worse than left? (More than one can apply.) A. constipation B. pelvic inflammatory disease C. ectopic pregnancy D. splenetic infarct

A. constipation B. pelvic inflammatory disease C. ectopic pregnancy

The psoas sign can be best described as abdominal pain elicited by: A. passive extension of the hip. B. passive flexion and internal rotation of the hip. C. deep palpation. D. asking the patient to cough.

A. passive extension of the hip.

You see a 72-year-old woman who reports vomiting and abdominal cramping occurring over the past 24 hours. In evaluating a patient with suspected appendicitis, the clinician considers that: A. the presentation can differ according to the anatomical location of the appendix. B. this is a common reason for acute abdominal pain in elderly patients. C. vomiting before onset of abdominal pain is often seen. D. the presentation is markedly different from the presentation of pelvic inflammatory disease.

A. the presentation can differ according to the anatomical location of the appendix.

Which of the following imaging studies potentially exposes the patient being evaluated for abdominal pain to the lowest ionizing radiation burden? A. ultrasound B. barium enema C. CT scan D. abdominal flat plate

A. ultrasound

An 18-year-old man presents with periumbilical pain, vomiting, and abdominal cramping over the past 48 hours. Physical examination reveals rebound tenderness, and laboratory analysis shows the presence of bandemia and a total WBC of 28,000 mm3. To support the diagnosis of acute appendicitis with suspected appendiceal rupture, you consider obtaining the following abdominal imaging study: A. magnetic resonance image (MRI). B. computed tomography (CT) scan. C. ultrasound. D. flat plate.

B. computed tomography (CT) scan. Abdominal computerized tomography (CT) of the abdomen is generally considered the imaging of choice in suspected appendicitis; its ability to define better the anatomical abnormality associated with appendicitis is superior to other imaging options.

The obturator sign can be best described as abdominal pain elicited by: A. passive extension of the hip. B. passive flexion and internal rotation of the hip. C. deep palpation. D. asking the patient to cough.

B. passive flexion and internal rotation of the hip.

Rebound tenderness is best described as abdominal pain that worsens with: A. light palpation at the site of the discomfort. B. release of deep palpation at the site of the discomfort. C. palpation on the contralateral side of the abdomen. D. deep palpation at the site of the discomfort.

B. release of deep palpation at the site of the discomfort. Rebound tenderness, which is abdominal pain that worsens with release of deep palpation, indicates the like lihood of peritoneal irritation and helps with the diagnosis of acute appendicitis.

Which of the following best represents the peak ages for occurrence of acute appendicitis? A. 1 to 20 years B. 20 to 40 years C. 10 to 30 years D. 30 to 50 years

C. 10 to 30 years

Abdominal palpation that yields rebound tenderness is also known as a positive _______ sign. A. Markel's B. Murphy's C. Blumberg's D. Nikolsky's

C. Blumberg's The presence of rebound tenderness is also known as a positive Blumberg's sign.

A 26-year-old man presents with acute abdominal pain. As part of the evaluation for acute appendicitis, you order a white blood cell (WBC) count with differential and anticipate the following results: A. total WBCs, 4500 mm3; neutrophils, 35%; bands, 2%; lymphocytes, 45%. B. total WBCs, 14,000 mm3; neutrophils, 55%; bands, 3%; lymphocytes, 38%. C. total WBCs, 16,500 mm3; neutrophils, 66%; bands, 8%; lymphocytes, 22%. D. total WBCs, 18,100 mm3; neutrophils, 55%; bands, 3%; lymphocytes, 28%.

C. total WBCs, 16,500 mm3; neutrophils, 66%; bands, 8%; lymphocytes, 22%. The most typical WBC count pattern found in this situation is the "left shift." A "left shift" is usually seen in the presence of severe bacterial infection, such as acute appendicitis, bacterial pneumonia, and pyelonephritis. The following are typically noted in the "left shift": • Leukocytosis: An elevation in the total WBC. • Neutrophilia: An elevation in the number of neutrophils in circulation. • Bandemia: An elevation in the number of bands or young neutrophils in circulation.

Which of the following findings would you expect to encounter in a 33-year-old man with appendiceal abscess? A. leukopenia with lymphocytosis B. positive Cullen's sign C. protracted nausea and vomiting D. dullness to percussion in the abdominal right lower quadrant

D. dullness to percussion in the abdominal right lower quadrant

All of the following are typically noted in a young adult with the diagnosis of acute appendicitis except: A. epigastric pain. B. positive obturator sign. C. rebound tenderness. D. marked febrile response.

D. marked febrile response. There is no true classic presentation of acute appendicitis. Vague epigastric or periumbilical pain often heralds its beginning, with the discomfort shifting to the right lower quadrant over the next 12 hours. Pain is often aggravated by walking or coughing.

Which of the following WBC forms is an ominous finding in the presence of severe bacterial infection? A. neutrophil B. lymphocyte C. basophil D. metamyelocyte

D. metamyelocyte Although additional neutrophil forms exist, these do not belong in circulation even with severe infection. Myelocytes and metamyelocytes are immature neutrophil forms that are typically found in only the granulopoiesis pool. The presence of these cells is an ominous marker of life-threatening infection, and these are occasionally found in the presence of appendiceal rupture.

Rotation or right flexed hip is known as what diagnostic maneuver?

Obturator sign

Hip extension is known as what diagnostic sign?

Psoas stretch sign

Palpation of LLQ that causes pain in RLQ is known as:

Rovsing' sign

Diagnostic tests for appendicitis:

Ultrasound: May diagnose acute appendicitis - Negative ultrasound does not rule out appendicitis CT : More accurate - Has high sensitivity and specificity for evaluating suspected acute appendicitis Abdominal and pelvic with or without contrast Addition of IV and oral contrast may increase sensitivity for appendicitis

Lab tests for appendicitis include:

WBC Left shift (increase in bands) - sepsis Combination of WBC count ≥ 10 x 109/L and C-reactive protein level ≥ 8 mg/L may be diagnostic if both are positive and exclusionary if both are negative Pregnancy test in all females of childbearing potential Rule out ectopic pregnancy! Urinalysis