# A 12-year-old adolescent is brought to the emergency department with complaints of abdominal pain that started around the umbilicus and has now moved to the right lower quadrant. Which assessment finding would be most characteristic of appendicitis in this patient?

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## 문제

A 12-year-old adolescent is brought to the emergency department with complaints of abdominal pain that started around the umbilicus and has now moved to the right lower quadrant. Which assessment finding would be most characteristic of appendicitis in this patient?

## 보기

1. Rebound tenderness at McBurney's point **✔ 정답**
2. High-grade fever above 102°F (38.9°C)
3. Projectile vomiting with bile
4. Cramping pain that comes and goes

**정답: 1**

## 해설

Rebound tenderness at McBurney's point is the most specific sign of appendicitis, indicating peritoneal irritation. Other findings (high fever, projectile vomiting, cramping pain) are less characteristic or associated with other conditions.

## 심화 해설

Clinical Reasoning: Recognizing the Hallmark Sign of Appendicitis

The classic presentation of appendicitis involves a progression of symptoms directly linked to the underlying pathophysiology. Initially, luminal obstruction of the appendix—often by a fecalith, lymphoid hyperplasia, or, as noted in rare cases, a parasitic infection such as *Taenia saginata* [1]—triggers distension and stimulates visceral afferent pain fibers. This produces the characteristic vague, periumbilical pain. As inflammation intensifies and extends transmurally to involve the parietal peritoneum, the pain localizes sharply to the right lower quadrant (RLQ) at McBurney's point. This point, located one-third of the distance from the anterior superior iliac spine to the umbilicus, becomes exquisitely tender.

The most characteristic assessment finding in this patient is rebound tenderness at McBurney's point. This sign, also known as Blumberg's sign, is a direct indicator of peritoneal irritation. The mechanism involves a sudden release of pressure applied to the abdominal wall, which causes a sharp, stabbing pain as the inflamed peritoneal layers snap back into place. The case report of appendicitis secondary to *T. saginata* infection corroborates this, describing a patient with migratory RLQ pain who demonstrated "positive peritoneal irritation signs" upon physical examination [1]. This underscores that regardless of the inciting cause—be it a common fecalith or an uncommon parasite—the clinical manifestation of peritoneal inflammation remains the diagnostic hallmark.

The other options are less specific or inconsistent with a typical early presentation. A high-grade fever above 102°F (38.9°C) is not an initial characteristic finding; low-grade fever is more common, and a sudden spike often suggests perforation. Projectile vomiting with bile is more indicative of a proximal small bowel obstruction rather than the anorexia, nausea, and non-bilious vomiting sequence typically seen with appendicitis. Cramping pain that comes and goes is characteristic of colicky pain from a hollow viscus obstruction, such as the ureter or intestine, and does not reflect the steady, progressive somatic pain of peritoneal irritation. The intraoperative finding of a "congested and edematous" appendix with its "tip wrapped by the greater omentum" [1] visually confirms the intense localized inflammation that gives rise to the reliable physical exam finding of focal rebound tenderness.

References (research sources)

- [1]Acute appendicitis caused by <i>Taenia saginata</i>: A case report.Case reportYang W, Yan Y, Liao H, Li Y. (2025) · DOI: 10.1016/j.idcr.2025.e02448

## 임상 시나리오

Assessing for Peritoneal Signs in AppendicitisIdentifying rebound tenderness at McBurney's point
The most characteristic finding is rebound tenderness at McBurney's point. To elicit this, apply deep palpation to the right lower quadrant and quickly release the pressure. A sharp, stabbing pain upon release (Blumberg's sign) indicates peritoneal irritation.

The classic pain progression starts with vague periumbilical pain (visceral) that migrates to the RLQ (parietal) as inflammation spreads. McBurney's point is located one-third of the distance from the anterior superior iliac spine to the umbilicus.

CautionA low-grade fever is typical early on. A sudden spike to >102°F (38.9°C) or temporary pain relief can signal perforation and requires urgent surgical evaluation.

## 핵심 개념

- **McBurney's Point** — Point of maximal tenderness in appendicitis, located one-third of the distance from the anterior superior iliac spine to the umbilicus.
- **Rebound Tenderness (Blumberg's Sign)** — Sharp pain upon sudden release of deep palpation pressure, indicating peritoneal inflammation.
- **Visceral Pain** — Dull, poorly localized pain arising from distension of a hollow organ, perceived in the periumbilical region in early appendicitis.
- **Parietal Pain** — Sharp, well-localized pain caused by inflammation of the parietal peritoneum, localizing to the right lower quadrant.
- **Fecalith** — A hard mass of feces that can obstruct the appendiceal lumen, the most common cause of appendicitis.

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