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History
The most common mnemonic used for pain is SOCRATES:
Site
Begin centrally, moving over to the right iliac fossa (RIF) within a
number of hours.
A point of particular tenderness can be localised 1/3's of the way
between the anterior superior iliac spine and the umbilicus, and
is known as McBurney's point.
Character: colicky
Pain may not be severe to begin with but once localisation occurs
and/or peritonism develops, pain levels will increase and there will be
particular tenderness over the RIF.
Examination
Some key points to the abdominal examination in a child with suspected
appendicitis:
How does the child walk into the examination room or get onto the
bed? The child who comfortably walks over to you standing tall and
upright is very unlikely to have appendicitis. The child who walks
hunched over, like 'an old man', you must be thinking of peritonitis.
Obviously appendicitis is much more likely in this case.
If they have pain in a number of areas, e.g. both LIF and RIF,
designate each a number and ask 'Which is more painful, 1 or 2?'
Special tests
Three such tests are Rovsing's sign, obturator test and the psoas sign. It is
important to know at least Rovsing's sign.
The psoas sign is performed by asking the patient to lie on their left
hand side and then extending the right hip. An inflamed retrocaecal or
pelvic appendix close to the right psoas muscle is irritated by this
movement. This causes pain in the RIF.
Investigations
- A full blood count should be ordered to look for a raised white blood
cell (WBC) count. Group & save should be taken for any possible surgical
presentation.
- Urine dipstix and microscopy and culture should be performed to exclude
infection.
- An abdominal ultrasound can be used if the diagnosis is in doubt and can
be used to rule out ovarian pathology.
- Appendicitis itself is not apparent on an abdominal plain flim but X-ray
may help to make diagnoses such as intestinal obstruction, constipation
and intussusception less likely.
Appendicitis is largely a clinical diagnosis, but the Alvarado appendicitis
score is occasionally used as a useful scoring system for assessing the
likelihood of appendicitis. It can be tallied up after a full history,
examination and some initial blood tests have been taken.
Alvarado score