Pediatric emergency medicine trisk 3740 3740

TABLE 116.1
PROGRESSION OF SYMPTOMS AND SIGNS OF APPENDICITIS
Nonperforated appendicitis
Poorly defined midabdominal or periumbilical pain
Low-grade fever
Anorexia
Vomiting
Migration of pain to right lower quadrant
Localization depends on position of appendix
Appendix in gutter → lateral abdominal tenderness
Appendix pointing toward pelvis → tenderness near pubis may cause
diarrhea or bladder irritation
Retrocecal appendix → tenderness elicited by deep palpation
Pain on coughing, hopping, or to percussion
Rectal examination: pain on palpation of right rectal wall
WBC count: 10,000–15,000/mm3
Urinalysis: ketosis, few WBCs
Perforated appendicitis
Increasing signs of toxicity
Rigid abdomen with extreme tenderness
Absent bowel sounds
Dyspnea and grunting; tachycardia
Fever: 39°C–41°C (102.2°F–105.8°F)
WBC count: >15,000/mm3 with left shift
Eventual overwhelming sepsis and shock
WBC, white blood cell.

Triage Considerations
Children with abdominal pain and localized right lower quadrant tenderness or
guarding should be evaluated promptly for appendicitis. Associated fever,
extreme pain, and ill appearance may imply perforation and demand emergent

treatment and surgical consultation. Shock related to peritonitis, sepsis, or severe
dehydration is rare.
Clinical Assessment