Appendictis

1)Pathophysiologyofappendicitis:
A.Obstructionofthelumenbylymphoidhyperplasiaorfecalith
B.Continuedmucousproductionwithdistentionoftheappendix
C.Venousobstruction
D.Arterialobstruction
E.Ischemia
F.Gangrene
G.Perforation
2)Appendicitisisthoughttobecausedby:

obstructionoftheappendiceallumen

idiopathicinflammation

subclinicaltrauma

amucoceletumor

abacterialinfection

Explanation:
Thepathophysiologyofappendicitisisnotuniformacrossages.Thus,whileappendicitiscanoccur(much
lesscommonly)duetoischemic,infectious,oroncologicprocess,theoverallprevailingmechanismis
lumenalobstructionthatcausesproximalappendicealinflammationandsubsequentrupture.

3)Whichofthefollowingsymptomsismostindicativeofacuteappendicitisinapatientwithrightlower
quadrantpain?

Priorepisodesofabdominalpain

Rigorsandhighfever

Bloodydiarrhea

Anorexia

Painprecedingvomiting

Explanation:
Appendicitisstartswithobstructionoftheappendixwhichcausespain,andprogressestoileuswhichleads
tothesymptomsofnauseaandvomiting.Rigorsandhighfeverwouldbesignsofadvancedappendicitis
duetoperforationandperitonitis.Priorepisodesofabdominalpainarerarewithappendicitis.Anorexiais
almostalwaysassociatedwithappendicitis,butisnotspecific.Bloodystoolsarenotseenwithappendicitis
butcanbeseenwithMeckel'sdiverticulumduetoheterotopicgastricmucosaandacidproductionleading
toulceration.
4)Rovsing'ssignissaidtobepositivewhenthepatientfeelspainintherightlowerquadrantwithwhich
ofthefollowingmaneuvers?
passiveextensionoftherighthip

passivestretchoftherighthip

activeflexionoftherighthip
internalrotationoftherighthip

deeppalpationintheleftlowerquadrant

Explanation:Rovsing'ssigniselicitedwhenpressureappliedintheleftlowerquadrantproducespainto
therightlowerquadrant.
Thepsoassigniselicitedbystretchoractiveflexionoftherighthip;thepatientwithacuteappendicitis
andaretrocecalappendixwilltypicallyhavepainwiththesemaneuversastheinflamedorganliesuponthe
rightiliopsoasmuscle.
Theobturatorsigniselicitedwiththepatientinthesupineposition,withpassiverotationoftheflexed
rightthigh;painwiththismaneuversuggestsapelviclocationoftheacutelyinflamedappendix.
Alloftheseareconsideredperitonealsignsandshouldbesoughtintheexaminationofapatientwithacute
appendicitis.Notethat,dependingupontheanatomiclocationoftheappendix,notallsignsmaybepresent.

5)An18yearoldmanpresentstotheEmergencyDepartmentwitha14hourhistoryofabdominalpain
whichhasnowlocalizedtotherightlowerquadrant.Onphysicalexamination,thereistendernessofdeep
palpationintherightlowerquadrant,withoutguardingorrebound.TheRovsing'ssignisnegative.Which
ofthefollowingadditionalphysicalfindingswouldbemostconsistentwithadiagnosisofappendicitisif
positive?

Murphy'ssign

Chvostek'ssign

Psoassign

Carnett'ssign

Romberg'ssign

Explanation:
Sign
Chvostek'ssign

Carnett'ssign

Murphy'ssign

Psoassign

Romberg'ssign

Description
Typicallyseenin
Abnormalreactionofthefacialnerveto Electrolyteabnormality,most
stimulation
commonlyhypocalcemia
Abdominalwallpaindecreaseswhenthe
abdominalwallmusculatureistensed;
Rectussheathhematoma
typicallyindicatingthatthesourceofthe
abdominalwalltrauma
painistheabdominalwall,asopposedto
theabdominalcavity.
Painandtendernesstopalpationofthe
RUQduringinspirationandresultingin
Acutecholecystitis
cessationofinspiration;canbeassociated
Liverpathology
withphysicalexaminationor
ultrasonography
Rightlowerquadrantpainwithpassive(or
active)extensionoftherightlower
Appendicitis(typically
extremity.Thistypicallyindicatesa
retrocecal)
processthatisirritatingtherightpsoas
Psoasmuscleabscessor
muscle.(Note:thepatientisontheirside hematoma
duringthisexamination)
Anyprocessthatcauses
Teststhebody'sabilitytosense
dysfunctioninsensory
proprioception(positioning)andthus
perception.Thiscanbe
assessfunctionofthedorsalcolumnsof
metabolic(ETOHintoxication)
thespinalcord.
orneuroanatomicalinetiology.

6)Examinationoftheabdomeninapatientsuspectedofhavingappendicitisbeginswith:
rightheeltap
deeppalpation
inspection
auscultation
lightpalpation

Explanation:
Aswithanexaminationforanypurpose,physicalexamshouldbedonethesamewayineverypatientand
shouldalwaysbeginwithinspection.Theabdomenisexposedandthoroughlyinspectedforevidenceofold
surgicalscars,distention,symmetry,masses,visibleperistalsis,hernias,andpulsations,anyofwhichmay
beassociatedwithanacuteabdomen.Inspectionisfollowedbyauscultation,thenlightpalpation,deep
palpationandexaminationforspecialsigns.(Notethatpercussion,whileusefulforageneralorientationto
anontenderabdomen,willbepainfulforthepatientwithperitonitisandshouldnotberoutinelyperformed
beforelightpalpation.)

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.