Appendicitis: Clinical

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Appendicitis: Clinical

USMLE® Step 2 questions

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USMLE® Step 2 style questions USMLE

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A 24-year-old woman presents to the emergency department with nausea, vomiting, and worsening abdominal pain for the last 12 hours. She states the pain started all of sudden with no inciting factors. Her symptoms were not associated with any particular meal, and she denies any recent travel. The patient has a history of mild asthma, for which she takes an albuterol inhaler as needed. Her temperature is 39°C (102.2°F), pulse is 84/min, respirations are 18/min, and blood pressure is 128/74 mmHg. Physical examination shows right lower abdominal pain that is elicited with deep palpation. There is no hepatosplenomegaly. Cardiac and pulmonary exams are noncontributory. A urine β-hCG test is ordered and returns negative. Leukocyte count is 12,000/mm3. Which of the following is the next best step in management?  


Appendicitis is when the appendix gets inflamed, and it’s the most common surgical emergency of the abdomen.

Normally, the appendix can be found in a retrocecal location, as well as preileal, postileal, pelvic and subcecal.

Since the appendix is a hollow tube, the most common cause of inflammation is something getting stuck in or obstructing that tube.

That something could be a fecalith, a hardened lump of fecal matter, an undigested seed, or even intestinal parasites like pinworms.

Another cause of obstruction, especially in children and adolescents, is lymphoid follicle growth, also called lymphoid hyperplasia.

Lymphoid follicles in the appendix grow in size during adolescence, and they can sometimes obstruct the tube.

Exposure to viral infections like adenovirus and measles can also cause these follicles to grow as well.

Early on acute appendicitis causes periumbilical abdominal pain, nausea, and vomiting.

Sometimes there can be other atypical symptoms like indigestion, flatulence, diarrhea, and malaise.

Within 24 to 48 hours, the appendix becomes more swollen and inflamed, and it begins to irritate the abdominal wall, causing the pain to get more severe and localized to the right lower quadrant, as well as causing a fever.

This classic migration of pain may not be seen in children under three years old.

McBurney’s sign is tenderness at McBurney's point - which is located one-third of the distance from the anterior superior iliac spine to the belly button, and it’s a classic sign of appendicitis.

Another sign of appendicitis is Rovsing’s sign, which is when palpation of the left lower quadrant causes pain in the right lower quadrant.

The obturator sign when the inflamed appendix lies in the pelvis and causes irritation of the obturator internus muscle.


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