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Q1: Pathophysiology (2 min)
"Explain why appendicitis progresses to perforation."
- Luminal obstruction (fecalith 60%, lymphoid hyperplasia in children)
- Mucus accumulation behind obstruction → bacterial overgrowth
- Rising intraluminal pressure → venous compression → ischemia
- Appendicular artery is an END artery (no collaterals) → gangrene → perforation
- Timeline: hours to days
Q2: Clinical signs (2 min)
"Name and demonstrate the signs of appendicitis."
- McBurney point tenderness (1/3 from ASIS to umbilicus)
- Rovsing sign: LIF pressure → RIF pain
- Psoas sign: retrocaecal — pain on hip extension
- Obturator sign: pelvic — pain on internal rotation
- Blumberg sign: rebound tenderness = peritonism
Q3: Appendicular mass (3 min)
"A patient presents after 5 days with a palpable RIF mass. How do you manage?"
- Diagnosis: appendicular mass (phlegmon) — omentum and bowel walling off inflamed appendix
- If STABLE: conservative Ochsner-Sherren regimen (NBM, IV fluids, IV antibiotics, observe)
- Serial observations (temp, pulse, abdominal exam)
- If resolves: INTERVAL APPENDECTOMY at 6-8 weeks
- If deteriorates: emergency surgery
- Abscess: percutaneous drainage + antibiotics → interval appendectomy
Q4: Special situations (2 min)
"How does appendicitis differ in pregnancy and the elderly?"
- Pregnancy: appendix displaced UPWARD by gravid uterus → may present as RUQ pain. US first-line (no radiation). Laparoscopic appendectomy safe in all trimesters. Delay increases perforation and fetal loss risk.
- Elderly: vague symptoms, delayed presentation, 70% perforation rate at presentation. Low threshold for CT. Consider malignancy as cause.
- Always: check beta-hCG in women of reproductive age.