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Pain that moves to the right lower quadrant
A 19-year-old has had dull pain around the umbilicus since last night. This morning it has moved to the right lower quadrant, and he has lost his appetite and feels nauseated.
Step 1 of 4
Why did the pain begin around the umbilicus?
Correct answer: D
The vermiform appendix is midgut; its visceral afferents travel with sympathetic fibers to about T10, so early pain is poorly localized and periumbilical. When the parietal peritoneum becomes inflamed, the pain localizes to the RLQ.
Show answer
D
The vermiform appendix is midgut; its visceral afferents travel with sympathetic fibers to about T10, so early pain is poorly localized and periumbilical. When the parietal peritoneum becomes inflamed, the pain localizes to the RLQ.
Step 2 of 4
Where is McBurney point?
Correct answer: D
McBurney point lies one-third of the distance from the right ASIS to the umbilicus and marks the base of the appendix.
Show answer
D
McBurney point lies one-third of the distance from the right ASIS to the umbilicus and marks the base of the appendix.
Step 3 of 4
Lying on his left side, he has right lower quadrant pain when the examiner passively extends his right hip.
What does this sign suggest?
Correct answer: D
This is the psoas sign, typical of a retrocecal appendix against psoas major. The obturator sign (internal rotation of the flexed hip) suggests a pelvic appendix.
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D
This is the psoas sign, typical of a retrocecal appendix against psoas major. The obturator sign (internal rotation of the flexed hip) suggests a pelvic appendix.
Step 4 of 4
He is not pregnant. Which imaging test is the most accurate?
Correct answer: D
CT with IV contrast is the most accurate test in adults. Ultrasound comes first in children and in pregnancy, with MRI if ultrasound is non-diagnostic in pregnancy.
Show answer
D
CT with IV contrast is the most accurate test in adults. Ultrasound comes first in children and in pregnancy, with MRI if ultrasound is non-diagnostic in pregnancy.
Key points
- Periumbilical (T10) pain → RLQ as the parietal peritoneum is involved.
- Psoas sign → retrocecal; obturator sign → pelvic appendix.
- CT in adults; ultrasound first in children and pregnancy.
Study: Vermiform appendix, Colon, Psoas major, Superior mesenteric artery