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