Appendictis

1) Pathophysiology of appendicitis:

A. Obstruction of the lumen by lymphoid hyperplasia or fecalith

B. Continued mucous production with distention of the appendix

C. Venous obstruction

D. Arterial obstruction

E. Ischemia

F. Gangrene

G. Perforation

2) Appendicitis is thought to be caused by:

obstruction of the appendiceal lumen 

idiopathic inflammation

  subclinical trauma

  a mucocele tumor a bacterial infection  Explanation:

The pathophysiology of appendicitis is not uniform across ages. Thus, while appendicitis can occur (much

less commonly) due to ischemic, infectious, or oncologic process, the overall prevailing mechanism is

lumenal obstruction that causes proximal appendiceal inflammation and subsequent rupture.

3) Which of the following symptoms is most indicative of acute appendicitis in a patient with right lower

quadrant pain?

Prior episodes of abdominal pain 

Rigors and high fever

  Bloody diarrhea 

Anorexia Pain preceding vomiting  Explanation:

Appendicitis starts with obstruction of the appendix which causes pain, and progresses to ileus which leads

to the symptoms of nausea and vomiting. Rigors and high fever would be signs of advanced appendicitis

due to perforation and peritonitis. Prior episodes of abdominal pain are rare with appendicitis. Anorexia is

almost always associated with appendicitis, but is not specific. Bloody stools are not seen with appendicitis

but can be seen with Meckel's diverticulum due to heterotopic gastric mucosa and acid production leading

to ulceration.

4) Rovsing's sign is said to be positive when the patient feels pain in the right lower quadrant with which of the following maneuvers?

passive extension of the right hip 

passive stretch of the right hip 

active flexion of the right hip  

internal rotation of the right hip 

deep palpation in the left lower quadrant  Explanation: Rovsing's sign is elicited when pressure applied in the left lower quadrant produces pain to the right lower quadrant.The psoas sign is elicited by stretch or active flexion of the right hip; the patient with acute appendicitis and a retrocecal appendix will typically have pain with these maneuvers as the inflamed organ lies upon the right iliopsoas muscle.The obturator sign is elicited with the patient in the supine position, with passive rotation of the flexed right thigh; pain with this maneuver suggests a pelvic location of the acutely inflamed appendix.All of these are considered peritoneal signs and should be sought in the examination of a patient with acute appendicitis. Note that, depending upon the anatomic location of the appendix, not all signs may be present.

5) An 18 year old man presents to the Emergency Department with a 14 hour history of abdominal pain which has now localized to the right lower quadrant. On physical examination, there is tenderness of deep palpation in the right lower quadrant, without guarding or rebound. The Rovsing's sign is negative. Which of the following additional physical findings would be most consistent with a diagnosis of appendicitis if positive?

Murphy's sign Chvostek's sign 

Psoas sign 

Carnett's sign Romberg's sign 

Explanation:

Sign Description Typically seen in

Chvostek's sign Abnormal reaction of the facial nerve to stimulation

Electrolyte abnormality, most commonly hypocalcemia

Carnett's sign

Abdominal wall pain decreases when the abdominal wall musculature is tensed; typically indicating that the source of the pain is the abdominal wall, as opposed to the abdominal cavity.

Rectus sheath hematomaabdominal wall trauma

Murphy's sign

Pain and tenderness to palpation of the RUQ during inspiration and resulting in cessation of inspiration; can be associated with physical examination or ultrasonography

Acute cholecystitisLiver pathology

Psoas sign

Right lower quadrant pain with passive (or active) extension of the right lower extremity. This typically indicates a process that is irritating the right psoas muscle. (Note: the patient is on their side during this examination)

Appendicitis (typically retrocecal)Psoas muscle abscess or hematoma

Romberg's sign

Tests the body's ability to sense proprioception (positioning) and thus assess function of the dorsal columns of the spinal cord.

Any process that causes dysfunction in sensory perception. This can be metabolic (ETOH intoxication) or neuroanatomical in etiology.

6) Examination of the abdomen in a patient suspected of having appendicitis begins with:

right heel tap

deep palpation

inspection

auscultationlight palpation Explanation:

As with an examination for any purpose, physical exam should be done the same way in every patient and

should always begin with inspection. The abdomen is exposed and thoroughly inspected for evidence of old

surgical scars, distention, symmetry, masses, visible peristalsis, hernias, and pulsations, any of which may

be associated with an acute abdomen. Inspection is followed by auscultation, then light palpation, deep

palpation and examination for special signs. (Note that percussion, while useful for a general orientation to

a non-tender abdomen, will be painful for the patient with peritonitis and should not be routinely performed

before light palpation.)

7) The most common cause of a symmetrically enlarged uterus is intrauterine pregnancy. Fibroids can also be associated with uterine enlargement.

Ovarian cysts and tumors may be detected as adnexal masses on one or both sides, usually non-tender. Cysts tend to be smooth and compressible, tumors more solid and often nodular. A tender unilateral adnexal mass in a patient with a positive pregnancy test is an ectopic pregnancy until proven otherwise. Acute pelvic inflammatory disease is associated with very tender bilateral adnexa and purulent cervical discharge; movement of the uterine cervix produces severe pain. Note that severe pelvic peritonitis of any etiology can also be associated with cervical motion tenderness.