When obtaining the history, the physician needs to consider other nonsurgical causes of abdominal pain that may mimic appendicitis (see Chapter 53 Pain: Abdomen ) Concurrent GI illness in other family members or close contacts suggests the possibility of an infectious gastroenteritis Constipation, streptococcal pharyngitis, urinary tract infection, lower lobe pneumonia, mesenteric adenitis, and ovarian cyst are common conditions often masquerading as appendicitis Although the presentation is generally more rapid and severe, torsion of the ovary and ectopic pregnancy should be considered in female patients with sudden onset of severe pain Anorexia and nausea are common; vomiting is more common in younger children In early stages the patient may complain of pain with motion or walking, and as peritoneal irritation worsens, the child will prefer to lay motionless in the bed On examination, palpation is usually reliable in demonstrating focal tenderness at the site of the inflamed appendix Because the position of the appendix may vary in children, the localization of the pain and the tenderness on examination may also vary An appendix that is located in the lateral gutter may produce flank pain and lateral abdominal tenderness; an inflamed appendix pointing toward the left lower quadrant may produce hypogastric tenderness and pain with urination (from bladder contraction) An inflamed low-lying, pelvic appendix may not cause significant pain at McBurney point, but instead may cause diarrhea from direct irritation of the sigmoid colon When the inflamed appendix is not close to the anterior abdominal wall, as in the case of retrocecal appendix, tenderness may be more impressive on deep palpation of the abdomen or by palpating in the flank Percussive tenderness, shake tenderness, and pain with coughing or hopping suggests peritoneal irritation Rovsing sign, pain in the right lower quadrant upon palpating the left lower quadrant, is difficult to assess in young children but when present is highly suggestive of appendicitis A properly performed rectal examination can contribute to the clinical impression: the examining finger should be inserted as fully as possible without touching the area of presumed tenderness and then, when the child is relaxed and taking deep breaths, the examiner can indent an area high on the right rectal wall A sudden involuntary reaction implies localized tenderness In a child with a history of probable appendicitis for more than or days, a boggy, full mass may also be in this location, suggesting an abscess Management