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A 24-year-old man presents with 18 hours of abdominal pain that started around the umbilicus and has now moved to the right iliac fossa. He has anorexia, nausea, and one episode of vomiting. Temperature 37.8C, pulse 96, WBC 14.2 x10⁹/L with neutrophilia.
Questions
a) Calculate his Alvarado (MANTRELS) score and interpret it. (3 marks)
MANTRELS scoring:
- Migration of pain: YES = 1
- Anorexia: YES = 1
- Nausea/vomiting: YES = 1
- Tenderness in RIF: YES = 2
- Rebound tenderness: likely YES = 1
- Elevated temperature (37.8C ≥37.3): YES = 1
- Leukocytosis (14.2 >10): YES = 2
- Shift to left (neutrophilia): YES = 1
Total: 10/10 — very probable appendicitis. Appendectomy indicated.
b) Name three physical signs specific to appendicitis and what each indicates about appendix position. (3 marks)
- Rovsing sign — LIF palpation causes RIF pain. Indicates peritoneal irritation (not position-specific).
- Psoas sign — pain on extending the right hip. Indicates a retrocaecal appendix irritating the psoas muscle.
- Obturator sign — pain on internal rotation of the flexed right hip. Indicates a pelvic appendix irritating the obturator internus muscle.
c) Describe the surgical management options for this patient and one alternative. (4 marks)
Surgical (gold standard): Laparoscopic appendectomy — 3 ports, appendix identified, mesoappendix divided (appendicular artery clipped), base ligated with endoloop/stapler, specimen removed. Pre-op: IV fluids, IV antibiotics (cefuroxime 1.5g + metronidazole 500mg), analgesia.
Open alternative: Lanz incision (transverse skin crease at McBurney point), muscle-splitting approach.
Alternative (CODA trial): Antibiotic-first therapy — IV then oral antibiotics for 7-10 days. 71% avoid surgery at 90 days, but 29% recurrence at 1 year. Patient choice via shared decision-making. Only for uncomplicated cases.