ACUTE APPENDICITIS EXAM
QUESTIONS WITH COMPLETE
ANSWERS
Rovsing: Appendicitis - Answer-Rovsing's sign is a sign of appendicitis. If palpation of
the left lower quadrant of a person's abdomen increases the pain felt in the right lower
quadrant, the patient is said to have a positive Rovsing's sign and may have
appendicitis.
In acute appendicitis, palpation in the left iliac fossa may produce pain in the right iliac
fossa.
Heel Jar (Markle) test - Answer-Clinical sign in which pain in the right lower quadrant of
the abdomen is elicited by dropping from standing on the toes to the heels with a jarring
landing. It is found in patients with localized peritonitis due to acute appendicitis. It is
similar to rebound tenderness, but may be easier to elicit when the patient has firm
abdominal wall muscles. Abdominal pain on walking or running is an equivalent sign.
Carnett's sign: - Answer-Carnett's sign is a finding on clinical examination in which
(acute) abdominal pain remains unchanged or increases when the muscles of the
abdominal wall are tensed. For this part of the abdominal examination, the patient can
be asked to lift the head and shoulders from the examination table to tense the
abdominal muscles. An alternative is to ask the patient to raise both legs with straight
knees.
A positive test increases the likelihood that the abdominal wall and not the abdominal
cavity is the source of the pain (for example, due to rectus sheath hematoma instead of
appendicitis).
A negative Carnett's sign is said to occur when the abdominal pain decreases when the
patient is asked to lift the head; this points to an intra-abdominal cause of the pain.
Murphy's sign: Cholecystitis - Answer-Murphy's sign is tested for during an abdominal
examination; it is performed by asking the patient to breathe out and then gently placing
the hand below the costal margin on the right side at the mid-clavicular line (the
approximate location of the gallbladder). The patient is then instructed to inspire
(breathe in). Normally, during inspiration, the abdominal contents are pushed downward
as the diaphragm moves down (and lungs expand). If the patient stops breathing in (as
the gallbladder is tender and, in moving downward, comes in contact with the
examiner's fingers) and winces with a 'catch' in breath, the test is considered positive. In
order for the test to be considered positive, the same maneuver must not elicit pain
when performed on the left side.
, Mantrel's Scoring - Answer-M = migration of pain 1
A = anorexia 1
N = nausea, vomiting 1
T = tenderness in RLQ 2
R = Rebound tenderness/Rovsing 1
E = Elevation of temperature 1
L = leukocystosis 2
S = shift to left (inc. stabs or seg. neuts) 1
5 or 6 is compatible with the diagnosis of acute appendicitis
7 or 8 indicates probable appendicitis
9 or 10 is very likely appendicitis
***The presence of rebound or Rovsing requires surgical referral
Appendicitis in Pediatrics - Answer-*Afebrile or have a low grade fever* unless
perforation has occurred
*Vomiting is often the first sign*
Child prefers to lie still
Observe facial expression during abdominal examination
Misdiagnosed 25 to 30% of time as gastroenteritis, URI, lower respiratory infection
Rate of misdiagnosis is inversely related to the age of the patient
Infants- observe for change in the pitch of crying, facial grimacing, rejection of the
opportunity to suck, and drawing of knees to chest
Intussusception -colicy pain, *currant jelly stools* and RUQ mass and ultimately
distention
Appendicitis in Child Bearing Women - Answer-Misdiagnosed 33% of the time as PID,
gastroenteritis and UTI
If pain and anorexia more than 14 days after menses, more likely to be appendicitis
Previous PID, urinary symptoms, or vaginal discharge, more likely PID
Ask about what type of contraception used, evaluate for use of an IUD.
Last menstrual period
Meds used such as laxatives, hx of falls or trauma, bowel habits, urinary frequency
Rectal Examination - Answer-PERFORM RECTAL EXAM IN PATIENTS WITH
INCREASED ABDOMINAL PAIN, LITIGATION IF NOT DONE!
QUESTIONS WITH COMPLETE
ANSWERS
Rovsing: Appendicitis - Answer-Rovsing's sign is a sign of appendicitis. If palpation of
the left lower quadrant of a person's abdomen increases the pain felt in the right lower
quadrant, the patient is said to have a positive Rovsing's sign and may have
appendicitis.
In acute appendicitis, palpation in the left iliac fossa may produce pain in the right iliac
fossa.
Heel Jar (Markle) test - Answer-Clinical sign in which pain in the right lower quadrant of
the abdomen is elicited by dropping from standing on the toes to the heels with a jarring
landing. It is found in patients with localized peritonitis due to acute appendicitis. It is
similar to rebound tenderness, but may be easier to elicit when the patient has firm
abdominal wall muscles. Abdominal pain on walking or running is an equivalent sign.
Carnett's sign: - Answer-Carnett's sign is a finding on clinical examination in which
(acute) abdominal pain remains unchanged or increases when the muscles of the
abdominal wall are tensed. For this part of the abdominal examination, the patient can
be asked to lift the head and shoulders from the examination table to tense the
abdominal muscles. An alternative is to ask the patient to raise both legs with straight
knees.
A positive test increases the likelihood that the abdominal wall and not the abdominal
cavity is the source of the pain (for example, due to rectus sheath hematoma instead of
appendicitis).
A negative Carnett's sign is said to occur when the abdominal pain decreases when the
patient is asked to lift the head; this points to an intra-abdominal cause of the pain.
Murphy's sign: Cholecystitis - Answer-Murphy's sign is tested for during an abdominal
examination; it is performed by asking the patient to breathe out and then gently placing
the hand below the costal margin on the right side at the mid-clavicular line (the
approximate location of the gallbladder). The patient is then instructed to inspire
(breathe in). Normally, during inspiration, the abdominal contents are pushed downward
as the diaphragm moves down (and lungs expand). If the patient stops breathing in (as
the gallbladder is tender and, in moving downward, comes in contact with the
examiner's fingers) and winces with a 'catch' in breath, the test is considered positive. In
order for the test to be considered positive, the same maneuver must not elicit pain
when performed on the left side.
, Mantrel's Scoring - Answer-M = migration of pain 1
A = anorexia 1
N = nausea, vomiting 1
T = tenderness in RLQ 2
R = Rebound tenderness/Rovsing 1
E = Elevation of temperature 1
L = leukocystosis 2
S = shift to left (inc. stabs or seg. neuts) 1
5 or 6 is compatible with the diagnosis of acute appendicitis
7 or 8 indicates probable appendicitis
9 or 10 is very likely appendicitis
***The presence of rebound or Rovsing requires surgical referral
Appendicitis in Pediatrics - Answer-*Afebrile or have a low grade fever* unless
perforation has occurred
*Vomiting is often the first sign*
Child prefers to lie still
Observe facial expression during abdominal examination
Misdiagnosed 25 to 30% of time as gastroenteritis, URI, lower respiratory infection
Rate of misdiagnosis is inversely related to the age of the patient
Infants- observe for change in the pitch of crying, facial grimacing, rejection of the
opportunity to suck, and drawing of knees to chest
Intussusception -colicy pain, *currant jelly stools* and RUQ mass and ultimately
distention
Appendicitis in Child Bearing Women - Answer-Misdiagnosed 33% of the time as PID,
gastroenteritis and UTI
If pain and anorexia more than 14 days after menses, more likely to be appendicitis
Previous PID, urinary symptoms, or vaginal discharge, more likely PID
Ask about what type of contraception used, evaluate for use of an IUD.
Last menstrual period
Meds used such as laxatives, hx of falls or trauma, bowel habits, urinary frequency
Rectal Examination - Answer-PERFORM RECTAL EXAM IN PATIENTS WITH
INCREASED ABDOMINAL PAIN, LITIGATION IF NOT DONE!
