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I am a newly qualified intern in South Africa, on my call last night I had a 29 year old male with a peri umbilical pain for 3 days, not localizing in this time, on examination there is local tenderness just peri umbilically with only voluntary gaurding, no rebound or percussion tenderness, no rovsigs sign, with bowel sounds present, on blood investigations the CRP was 96 and WCC 12. 45 so I therefore admitted the patient for observation as in our hospital there is not after hours facility for ultra sound or CT scan, what is the likelyhood that this is an appendicitis as it did not localize in 3 days and clinically the patient was well, any advice for an unexperienced new doctor to pick up appendicitis better as I am worried about missing this in a patient because they do not present classically

Thank you

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may be the appendix is not in retro ceacal position .. do per rectal examination and elicit tenderness...may be ilicaecal type..?

At the moment, the best would be the ultrasound examination, however, as you do not have it available, try performing various maneuvers semiological abdomen to find out the problem.

Remember that in cases of appendicitis it starts with periumbilical pain that later evolves into the right iliac fossa pain associated with anorexia, nausea, vomiting and low fever.

Assess the following signs:

Lenander's sign -> differences in rectal and axillary temperature.

Dunphy's sign -> right iliac fossa pain that worsens with coughing.

Lapinsky's sign -> pain to compression of the right iliac fossa rises while the right leg stretched.

Aaron's sign -> epigastric pain on palpation of McBurney's point.

Iliopsoas's sign -> pain on extension and abduction of the right thigh with the patient in the left lateral position.

Shutter's sign -> hypogastric pain with flexion and internal rotation of the hip.

Frankly, I was not aware of all the above signs!!

Thank you, Dr.Adevair Marques Filho. :o)


Thank you very much for all the advice. Will provide feedback ASAP, condition  of the patient still the same.

What are you treating with? IVF and antibiotics?



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