OSCE Mock Scenario – Consultant-Level Clerking: Suspected Acute Appendicitis

Candidate Instructions:

You are a final-year medical student. Clerk a 22-year-old male presenting with abdominal pain. Take a focused history, verbalize examination, suggest a differential diagnosis with reasoning, propose investigations, and outline a justified management plan.

PATIENT DETAILS

Name: Musa Ibrahim
Age: 22
Sex: Male
Date: [Insert]
Clerked By: [Your Name]

CHIEF COMPLAINT

"I’ve had belly pain since yesterday morning. It's getting worse."

HISTORY OF PRESENTING COMPLAINT

  • Onset: Began 24 hours ago as a dull, crampy discomfort around the umbilicus.

  • Progression: Over ~8 hours, pain localized to the right lower quadrant (RIF) — sharp, constant, worse on movement and coughing.

  • Severity: Initially 3/10; now 7–8/10. Patient is lying still to avoid aggravation.

  • Associated symptoms:

    • Anorexia — hasn’t eaten since pain started.
    • Nausea and one episode of vomiting (non-bilious).
    • Low-grade fever last night (felt "hot and cold").
    • No diarrhea or rectal bleeding.
    • No dysuria or urinary frequency.
    • No jaundice.

  • Bowel/Bladder: Passed stool 2 days ago; not constipated chronically. Last urination normal.

  • Aggravating factors: Movement, coughing.

  • Relieving factors: Lying supine.

  • Previous episodes: None.

PAST MEDICAL HISTORY

  • No chronic illnesses
  • No prior abdominal surgeries
  • No known hernias
  • Fully immunized

DRUG HISTORY

  • Took over-the-counter paracetamol — minimal relief
  • No regular meds

ALLERGIES

  • NKDA

FAMILY HISTORY

  • Non-contributory
  • No IBD, GI malignancies

SOCIAL HISTORY

  • 4th-year university student
  • Lives in hostel, cooks own meals
  • No recent travel
  • No known sick contacts
  • Non-smoker, occasional alcohol
  • Sexually active with one partner, uses condoms consistently

SYSTEMIC REVIEW

  • No weight loss
  • No chest pain or cough
  • No urinary frequency or hematuria
  • No rashes or joint pains

SUMMARY

22-year-old male with acute onset abdominal pain migrating from periumbilical to RIF, associated with anorexia, nausea, localized tenderness, and fever. No red flags for GI bleed, UTI, or testicular pathology. No prior similar episodes or medical conditions.

EXAMINATION (VERBALIZED FINDINGS)

General:

  • Alert, uncomfortable, lying still with hips flexed
  • T: 38.2°C | HR: 98 bpm | BP: 118/72 | RR: 18 | SpO₂: 98% on room air

Abdomen:

  • Inspection: Flat, no distension or surgical scars
  • Palpation:
    • Tenderness maximal at McBurney’s point
    • Localized guarding in RIF
    • Rebound tenderness present
    • Positive Rovsing’s and psoas signs
  • Percussion: Tenderness over RIF, no shifting dullness
  • Auscultation: Hypoactive bowel sounds

Hernial orifices: Normal

Testes: Normal lie, no tenderness

PR: Deferred (no signs indicating need)

DIFFERENTIAL DIAGNOSIS (with justification)

  1. Acute appendicitis — classical migratory pain, RIF tenderness, systemic inflammation.
  2. Mesenteric adenitis — possible mimic in young patients, but less likely with migration and peritoneal signs.
  3. Meckel’s diverticulitis — anatomical mimic, but rare; consider if imaging negative for appendicitis.
  4. Early Crohn’s disease — chronicity and systemic features absent.
  5. Renal colic — no flank pain, hematuria or radiation.
  6. Testicular torsion — ruled out clinically.

INVESTIGATIONS

Bedside:

  • Urinalysis – exclude UTI
  • Pregnancy test – not applicable here but mandatory in females with abdominal pain
  • ECG – if abdominal pain atypical or older age

Bloods:

  • FBC – expect leukocytosis with neutrophilia
  • CRP/ESR – elevated inflammatory markers
  • U&E – assess dehydration, pre-op workup
  • LFT/amylase – exclude hepatobiliary or pancreatic cause if RUQ/epigastric symptoms present

Imaging:

  • Ultrasound abdomen – first-line in lean males; operator-dependent
  • CT abdomen with contrast – if diagnosis uncertain or atypical features

    Note: In young adults, clinical diagnosis often sufficient to proceed to theatre

ALVARADO SCORE

  • Migratory pain: +1
  • Anorexia: +1
  • Nausea/vomiting: +1
  • Tenderness in RIF: +2
  • Rebound: +1
  • Temp >37.5°C: +1
  • Leukocytosis: +2 (pending)

= 7/10 → High probability → surgical referral

MANAGEMENT PLAN

  1. NPO – strict nil per os
  2. IV access – wide-bore cannula ×2
  3. IV fluids – 0.9% saline bolus (dehydrated)
  4. IV antibiotics – e.g., Ceftriaxone + Metronidazole per hospital protocol
  5. Analgesia – IV paracetamol ± morphine
  6. Surgical review – urgent; appendectomy indicated unless imaging contradicts
  7. Pre-op labs & consent – including group & save, clotting
  8. Observation – monitor vitals 4-hourly, reassess if worsening
  9. Escalation plan – if perforated/peritonitis suspected → resuscitate + urgent laparotomy

REFLECTION

“This is a high-probability case of appendicitis in a young male with textbook evolution of symptoms. While imaging may be helpful in equivocal cases, I would not delay surgical referral in the presence of localized peritonism and classic clinical signs.”

CONSULTANT-LEVEL NOTES

  • Watch for atypical presentations (retrocecal, pelvic)
  • Always examine testes in lower quadrant pain
  • Don’t fixate on CT when the diagnosis is clinically evident
  • Pre-empt complications — perforation, abscess, ileus
  • Think escalation, decision timelines, and post-op care

OSCE Mock Scenario – Consultant-Level Clerking: Acute Appendicitis in a Young Female

Candidate Instructions:

You are a final-year medical student. Clerk a 19-year-old female presenting with abdominal pain. Take a focused history, verbalize examination findings, list differentials with justification, suggest investigations, and propose a management plan.

PATIENT DETAILS

Name: Blessing Obasi
Age: 19
Sex: Female
Date: [Insert]
Clerked By: [Your Name]

CHIEF COMPLAINT

"Lower belly pain for the past day."

HISTORY OF PRESENTING COMPLAINT

  • Onset: Pain began 18 hours ago as dull discomfort around the umbilicus.

  • Progression: Localized to right lower quadrant (RIF) over ~6 hours; now sharp, constant.

  • Severity: 6/10 at rest; worsens on movement, coughing.

  • Associated symptoms:

    • Nausea, no vomiting
    • Loss of appetite
    • Felt mildly feverish last night
    • Mild urinary frequency, no dysuria
    • No vaginal discharge, bleeding, or recent intercourse
    • No diarrhea or constipation

  • Menstrual history:

    • LMP: 16 days ago
    • Regular 28-day cycles
    • Moderate flow, no menorrhagia
    • No known menstrual-related pain (not dysmenorrheic)
    • No contraceptive use

  • Previous episodes: None.

PAST MEDICAL HISTORY

  • No known chronic illnesses
  • No surgeries
  • No known STIs or PID

DRUG HISTORY

  • Occasional ibuprofen for headaches
  • No regular meds
  • No OCP use

ALLERGIES

  • None known

FAMILY HISTORY

  • Non-contributory

SOCIAL HISTORY

  • University student
  • Lives in campus accommodation
  • Sexually active with one partner, uses condoms irregularly
  • No alcohol, non-smoker
  • No recent travel

SYSTEMIC REVIEW

  • No chest pain, dyspnea
  • No weight loss or night sweats
  • No urinary retention or flank pain
  • No rashes, joint pains

SUMMARY

19-year-old female with 18-hour history of abdominal pain migrating to the RIF, associated with anorexia and mild fever. Denies significant gynecologic or urinary symptoms, but appendicitis vs ovarian pathology remains key differential.

EXAMINATION (VERBALIZED FINDINGS)

General:

  • Alert, lying still, appears uncomfortable
  • T: 37.8°C | HR: 94 bpm | BP: 116/70 | RR: 18 | SpO₂: 99% RA

Abdomen:

  • Inspection: Flat, no distension, no scars
  • Palpation:
    • RIF tenderness and guarding
    • No rebound tenderness
    • Rovsing’s sign negative
    • Psoas sign equivocal
  • Percussion: Mild localized tenderness
  • Auscultation: Normal bowel sounds

Pelvic exam (verbalized only):

  • No cervical motion tenderness
  • No adnexal tenderness or masses
  • No vaginal discharge

PR: Deferred

Urinalysis: Trace leukocytes, negative nitrites

Pregnancy test (urine): Negative

DIFFERENTIAL DIAGNOSIS

  1. Acute appendicitis – classic migratory pain, RIF tenderness, systemic inflammation.
  2. Ovarian torsion – lower quadrant pain in a young woman; ruled out clinically due to absence of adnexal mass or severe tenderness on pelvic exam.
  3. Mittelschmerz – mid-cycle ovulation pain, typically milder, no systemic signs.
  4. Ectopic pregnancy – ruled out by negative pregnancy test.
  5. PID – ruled out by absence of discharge, dyspareunia, or cervical motion tenderness.
  6. UTI – mild urinary frequency present, but no dysuria, no significant findings on urinalysis.

INVESTIGATIONS

Bedside:

  • Urinalysis – done
  • Pregnancy test – negative
  • ECG – if doubt about cardiac causes (not indicated here)

Bloods:

  • FBC – check WBC count
  • CRP – assess inflammation
  • U&E – pre-op screen
  • LFTs, amylase – if upper abdominal symptoms emerge

Imaging:

  • Transabdominal pelvic ultrasound – evaluate ovaries, exclude torsion or cyst
  • Abdominal US/CT – if diagnosis remains uncertain after pelvic scan

    Note: Avoid CT unless US is inconclusive; radiation risk in young female

ALVARADO SCORE

  • Migratory pain: +1
  • Anorexia: +1
  • Nausea: +1
  • RIF tenderness: +2
  • Fever >37.5°C: +1
  • WBC: pending

= At least 6/10 → moderate to high risk

MANAGEMENT PLAN

  1. NPO
  2. IV access ×2
  3. Fluids: Normal saline bolus
  4. Analgesia: IV paracetamol + consider morphine
  5. IV antibiotics: Ceftriaxone + Metronidazole
  6. Gynae consult for pelvic US
  7. Surgical review – early referral once torsion and ectopic ruled out
  8. Consent and pre-op bloods
  9. Observation: Vitals q4h, monitor for clinical deterioration

REFLECTION

“In a reproductive-age female, pelvic pathology must always be ruled out before labeling abdominal pain as appendicitis. Here, the clinical picture leans toward appendicitis, but a pelvic ultrasound is necessary to exclude ovarian torsion or a hemorrhagic cyst before surgical intervention.”

CONSULTANT NOTES

  • In women <40, never skip a pregnancy test
  • Always consider gynae pathology in RIF pain
  • CT is a last resort — preserve fertility, avoid over-radiation
  • Communicate early with gynae + surgery in unclear cases
  • Appendectomy can proceed once alternate diagnoses are reasonably excluded

OSCE Mock Scenario – Consultant-Level Clerking: Appendicitis in an Elderly Patient

Candidate Instructions:

You are the senior clinical student on-call. Clerk a 74-year-old man with abdominal pain. Take a focused history, suggest relevant investigations, and outline your management plan.

PATIENT DETAILS

Name: Mr. Edward Adigun
Age: 74
Sex: Male
Date: [Insert]
Clerked By: [Your Name]

CHIEF COMPLAINT

“Abdominal pain and fever for 3 days.”

HISTORY OF PRESENTING COMPLAINT

  • Onset: 3 days ago, sudden dull ache in central abdomen, became generalized

  • Progression: Now more severe in right lower quadrant

  • Character: Vague, deep ache, sometimes crampy

  • Severity: 7/10, worse with coughing and movement

  • Associated symptoms:

    • Anorexia
    • Low-grade fever, chills
    • 1 episode of vomiting yesterday
    • Loose stools x2, no overt diarrhea
    • No urinary symptoms
    • No GI bleeding

  • No previous similar episodes

PAST MEDICAL HISTORY

  • Type 2 Diabetes Mellitus – poorly controlled (last HbA1c 8.4%)
  • Hypertension – on medications
  • Chronic constipation
  • No known diverticular disease
  • No previous surgeries

DRUG HISTORY

  • Metformin, Lisinopril, Amlodipine
  • No steroids, no anticoagulants

ALLERGIES

  • NKDA

FAMILY HISTORY

  • Non-contributory

SOCIAL HISTORY

  • Retired accountant
  • Lives with wife
  • Smokes occasionally (5 pack-year history)
  • Alcohol: rare social use
  • Independent in ADLs

SYSTEMIC REVIEW

  • No chest pain or dyspnea
  • No cough or hemoptysis
  • No recent weight loss
  • No rashes or joint pain
  • No neurological deficits

SUMMARY

74-year-old diabetic male with 3-day history of generalized → RIF abdominal pain, anorexia, and low-grade fever. Concerned for atypical appendicitis or intra-abdominal sepsis. High risk of perforation and delayed presentation.

EXAMINATION (VERBALIZED FINDINGS)

General:

  • Elderly, appears tired but not septic
  • T: 38.3°C | HR: 102 bpm | BP: 118/68 | RR: 22 | SpO₂: 97% RA

Abdomen:

  • Inspection: Mildly distended, no visible peristalsis
  • Palpation:
    • Diffuse lower abdominal tenderness
    • Localized guarding in RIF
    • Mild rebound tenderness
  • Percussion: Mild tympany
  • Bowel sounds: Hypoactive

PR:

  • Empty rectum
  • No masses or bleeding

DIFFERENTIAL DIAGNOSIS

  1. Acute appendicitis with delayed presentation – consistent with RIF signs, systemic symptoms
  2. Diverticulitis (right-sided or caecal) – possible in elderly with no prior diagnosis
  3. Perforated viscus – especially in diabetics; consider imaging urgently
  4. Colonic carcinoma with subacute obstruction – vague symptoms, constitutional features
  5. Mesenteric ischemia – needs to be ruled out; pain is usually out of proportion to findings
  6. UTI or prostatitis – less likely due to absence of dysuria, but worth screening

INVESTIGATIONS

Bedside:

  • ECG – baseline
  • Urinalysis – to exclude infection
  • Blood glucose – capillary + serum
  • ABG – assess for lactic acidosis if septic
  • VBG – lactate, glucose

Bloods:

  • FBC – likely leukocytosis
  • CRP – inflammatory marker
  • U&E – renal function
  • LFTs, amylase
  • Blood cultures – if febrile
  • Group and save + clotting screen

Imaging:

  • Erect CXR – rule out free air
  • Abdominal CT with contrast – gold standard in elderly with suspected intra-abdominal infection

    Consider risk of contrast in diabetic patients – assess renal function first

MANAGEMENT PLAN

  1. NPO
  2. IV fluids: Start resuscitation (e.g., NS 500 mL bolus)
  3. IV access ×2
  4. Empirical antibiotics: IV Ceftriaxone + Metronidazole
  5. Analgesia: Paracetamol ± cautious opioids
  6. Surgical consult: For urgent review
  7. CT abdomen/pelvis: Priority – to confirm diagnosis and assess for perforation or abscess
  8. Monitor vitals and urine output closely
  9. Consider DVT prophylaxis
  10. Diabetic management: Adjust insulin/sliding scale if necessary
  11. Consent for surgery if diagnosis confirmed

KEY POINTS FOR CONSULTANT REVIEW

  • Elderly patients have blunted inflammatory responses
  • High risk of late or complicated appendicitis
  • Imaging is mandatory – do not rely on clinical judgment alone
  • Mortality increases with perforation – be proactive
  • Always exclude malignancy, ischemia, diverticulitis in elderly abdominals
  • Initiate early sepsis treatment bundle if criteria met

REFLECTION

“Appendicitis is often missed in the elderly due to vague symptoms and muted signs. This case requires a high index of suspicion, urgent imaging, and a broad differential approach to avoid delay in treatment and poor outcomes.”

OSCE Mock Scenario – Consultant-Level Clerking: Perforated Appendicitis

Candidate Instructions:

You are the senior medical student in A&E. Clerk a 23-year-old man presenting with abdominal pain and fever. Take a focused history, perform relevant examinations, and present your working diagnosis and management plan.

PATIENT DETAILS

Name: Mr. Bako Joseph
Age: 23
Sex: Male
Date: [Insert]
Clerked By: [Your Name]

CHIEF COMPLAINT

“Severe abdominal pain and vomiting for two days.”

HISTORY OF PRESENTING COMPLAINT

  • Onset: 48 hours ago

  • Initial pain: Central periumbilical ache

  • Progression: Migrated to right lower quadrant, then became generalized yesterday

  • Current status: Severe, continuous pain, worsened overnight

  • Severity: 9/10, exacerbated by movement and coughing

  • Associated symptoms:

    • Persistent vomiting x3 (non-bilious, no blood)
    • Fever, chills, sweats
    • Anorexia, nausea
    • No stool passed in 24 hrs, mild abdominal bloating
    • No dysuria or urinary complaints
    • No chest pain, no cough

  • Denies previous similar episodes

  • Denies trauma or recent foreign travel

PAST MEDICAL HISTORY

  • No known chronic illnesses
  • No previous abdominal surgeries
  • Fully vaccinated

DRUG HISTORY

  • Nil regular medications
  • No recent antibiotics or NSAID use
  • No anticoagulants or steroids

ALLERGIES

  • None known

FAMILY HISTORY

  • Non-contributory

SOCIAL HISTORY

  • University student, lives in hostel
  • No smoking, no alcohol or drug use
  • No recent sick contacts

SYSTEMIC REVIEW

  • No weight loss, jaundice, or rashes
  • No neck stiffness, photophobia, or headache
  • No urinary symptoms
  • No recent respiratory or ENT infections

SUMMARY

23-year-old previously well male with acute-onset abdominal pain that migrated to RIF and became generalized, associated with fever, vomiting, and abdominal rigidity. High suspicion of perforated appendicitis with generalized peritonitis.

EXAMINATION (VERBALIZED FINDINGS)

General:

  • Ill-looking, lying still
  • Diaphoretic, shallow breathing
  • T: 38.9°C | HR: 126 bpm | BP: 98/62 | RR: 28 | SpO₂: 96% RA

Abdomen:

  • Inspection: Abdominal wall guarding, minimal movement
  • Palpation:
    • Generalized severe tenderness, maximal in RIF
    • Board-like rigidity
    • Rebound tenderness present throughout
  • Percussion: Diffuse tenderness, some dullness in flanks
  • Auscultation: Absent bowel sounds

PR:

  • Empty rectum
  • No blood or masses

DIFFERENTIAL DIAGNOSIS

Primary:

  1. Perforated appendicitis → severe generalized peritonitis
  2. Perforated peptic ulcer → less likely (no NSAID history, pain pattern less epigastric)
  3. Mesenteric ischemia → rare at this age, but severe pain raises concern
  4. Ruptured Meckel's diverticulum → important mimic in young adults
  5. Torsion of intra-abdominal organ (ovarian/testicular) → not applicable here

INVESTIGATIONS

Bedside:

  • ECG
  • Capillary glucose
  • ABG – likely metabolic acidosis with raised lactate
  • Urinalysis
  • Pregnancy test – N/A (if female)

Bloods:

  • FBC – raised WBC, neutrophilia
  • CRP – markedly elevated
  • U&E – assess dehydration, electrolyte derangement
  • LFTs, amylase – exclude hepatobiliary/pancreatic pathology
  • Crossmatch 4 units
  • Coagulation screen
  • Blood cultures ×2

Imaging:

  • Erect CXR – look for free air under diaphragm
  • Urgent abdominal CT with contrast – confirms perforation, extent of contamination

DIAGNOSIS

Perforated appendicitis with generalized peritonitis and early sepsis.

MANAGEMENT PLAN

  1. ABC + Resuscitation

    • Oxygen 15L non-rebreather
    • 2 large-bore IV cannulas
    • IV fluids: 1L bolus NS, reassess after each
    • Monitor HR, BP, UO hourly

  2. IV Antibiotics (STAT)

    • Triple therapy: IV Ceftriaxone + Metronidazole ± Gentamicin (or as per local policy)

  3. Analgesia

    • IV paracetamol ± cautious morphine after surgical consult

  4. Nil by mouth

    • NG tube if vomiting persists or bowel obstruction suspected
    • Urinary catheter for strict input/output monitoring

  5. Surgical Team – URGENT Review

    • Laparotomy/laparoscopy likely
    • Discuss with consultant on-call
    • Pre-op labs and ECG

  6. Consent for Surgery (if stable)

  7. Inform theatre team – possible emergency laparotomy

  8. Sepsis Six bundle within 1 hour

RED FLAGS / CONSULTANT EXPECTATIONS

  • Perforated appendix = surgical emergency
  • Don’t delay imaging if it would delay surgery – decision is clinical
  • Beware silent abdomen with high pain – impending sepsis
  • Fluid resuscitation is as critical as antibiotics
  • CT may confirm, but do not delay referral to surgical team for imaging

REFLECTION

“In suspected perforation, act fast. Clinical signs override waiting for labs or imaging. Time to theatre saves lives — this is where diagnosis must be decisive, and delays are deadly.”

Comparison Table: Appendicitis Presentations

Feature Young Female (Early Appendicitis) Elderly Male (Atypical) Young Male (Perforated Appendicitis)
Age & Sex 19-year-old female 72-year-old male 23-year-old male
Duration of Symptoms <24 hrs ~4 days 48 hrs
Pain Migration Periumbilical → RIF Vague generalized to mild RIF Periumbilical → RIF → Generalized
Pain Character Colicky, localized Dull, vague, low-grade Constant, severe, sharp
Fever Low-grade (~38°C) Often absent or mild High-grade (38.9°C) with chills
Systemic Signs Mild tachycardia May be subtle, altered mental status Sepsis: tachycardia, hypotension, tachypnea
Peritoneal Signs RIF guarding and rebound Minimal or absent early Generalized rigidity, rebound, silent abdomen
Vomiting Occasional, preceded pain May be absent Persistent, follows pain
Bowel Sounds Present, maybe reduced in RIF Often normal Absent
Complications Early appendicitis High risk of perforation or abscess Confirmed perforation and peritonitis
Differential Diagnosis Ovarian torsion, PID, ectopic Diverticulitis, malignancy, AAA Perforated ulcer, Meckel’s, mesenteric ischemia
Investigations Priority Rule out gyn causes, pelvic US CT abdomen often required to localize pathology ABG, erect CXR, urgent CT if unclear
Management Approach IV antibiotics + diagnostic imaging Broad-spectrum ABX, early surgical consult Emergency resus + surgical referral + ABX
Surgical Urgency Semi-urgent (after imaging) High suspicion: do not delay for imaging Emergency laparotomy indicated
Teaching Point Think pelvic pathology in young females Elderly have blunted inflammatory response Diagnosis is clinical; delays increase mortality

Clinical Reasoning Table – Appendicitis Symptom Analysis

Symptom / Sign Etiology / Pathophysiology Clinical Interpretation Complications If Missed Associated Exam Findings
Periumbilical pain Visceral innervation of midgut (T10) → vague, poorly localized Early appendicitis – inflamed appendix irritates visceral peritoneum Delayed diagnosis if misattributed to gastroenteritis Normal or mild tenderness on deep palpation
Pain migration to RIF Inflammation extends to parietal peritoneum → somatic innervation localizes pain Hallmark of classic appendicitis Missed opportunity for early diagnosis Localized guarding, McBurney’s point tenderness
Generalized pain Peritoneal contamination after perforation Suggests rupture and diffuse peritonitis Septic shock, abscess formation Board-like rigidity, rebound, absent bowel sounds
Anorexia CNS-mediated response to inflammation, vagal activation One of the earliest symptoms in appendicitis Missed in elderly or subtle presentations Not directly exam-detectable
Nausea & vomiting Visceral irritation, ileus, or later bowel obstruction Common but non-specific. Vomiting usually after pain onset Persistent vomiting = concern for perforation Dehydration, epigastric tenderness (early)
Fever Cytokine release due to inflammation → hypothalamic set point change Low-grade in simple appendicitis; high-grade suggests perforation or abscess Sepsis, delayed surgical referral Warm peripheries early, cool clammy in late sepsis
Tachycardia Systemic inflammatory response or dehydration Marker of systemic involvement, early SIRS Precursor to shock Rapid pulse, hypotension in late stages
Guarding Reflex muscle contraction due to peritoneal irritation Indicates local peritonitis (early) or generalized peritonitis (late) Missed guarding → missed surgical belly Voluntary (early) or involuntary (advanced)
Rebound tenderness Pain from sudden release of pressure = peritoneal stretch High specificity for peritonitis Suggests progression beyond mucosal inflammation Positive Rovsing’s or McBurney’s sign
Silent abdomen Paralytic ileus from widespread inflammation Seen in late/perforated cases Indicates bowel shutdown, risk of perforation No bowel sounds, distension
Absent fever in elderly Blunted immune response Atypical; don’t rely on fever for diagnosis in elderly Missed or delayed diagnosis, higher mortality May appear well despite serious pathology
Right-sided rectal tenderness Inflamed appendix irritating posterior peritoneum or pelvic structures Especially in retrocecal or pelvic appendix Overlooked if PR not done when indicated Tenderness on DRE
Diarrhea or urinary symptoms Pelvic appendix irritates rectum/bladder May mimic UTI or gastroenteritis Incorrect diagnosis → wrong management Suprapubic or pelvic tenderness
Severe abdominal rigidity Diffuse peritonitis and muscle spasm due to chemical irritation Classic of perforation or ruptured viscera Indicates urgent surgical need Board-like abdomen
Hypotension Sepsis-induced vasodilation or fluid loss from third spacing Pre-terminal sign unless addressed rapidly Septic shock Delayed cap refill, cool peripheries