The clinical signs present in acute appendicitis are all except:
a. The classic right lower quadrant physical signs are present when the inflamed appendix lies in the anterior position.
b. Tenderness is often maximal at or near McBurney's point. Direct rebound tenderness is usually present.
c. Additionally, referred or indirect rebound tenderness is present. This referred tenderness is felt maximally in the right lower quadrant, indicating localized peritoneal irritation.
d. Rovsing's sign—pain in the right lower quadrant when palpatory pressure is exerted in the left lower quadrant—also indicates the site of peritoneal irritation.
e. Cutaneous hyperesthesia in the area supplied by the spinal nerves on the right at T10, T11, and T12 frequently accompanies acute appendicitis.
f. Hyperesthesia is elicited either by needle prick or by gently picking up the skin between the forefinger and thumb.
g. Pemberton's sign is the development of facial flushing,distended neck and head superficial veins, inspiratory stridor and elevation of the jugular venous pressure (JVP) upon raising of the patient's both arms above his/her head simultaneously, as high as possible (Pemberton's maneuver).
h. A positive Pemberton's sign is a sign of superior vena cava syndrome, possibly from a mass in the mediastinum, such as a tumor or goiter (thoracic inlet obstruction due to retrosternal goitre or mass).
i. Apical lung cancers often cause a positive Pemberton's sign and a high index of suspicion should be maintained in patients with symptoms of dyspnea and facial plethora with an extensive smoking history
j. If the appendix is in a high retrocecal position or is entirely within the true pelvis, point tenderness and muscle rigidity might not be elicited. In high retrocecal appendicitis, tenderness may occur over a large area, and there may be no signs of muscle rigidity.
k. In pelvic appendicitis, neither tenderness nor muscle guarding may be present. Both signs are often lacking or only minimally expressed in the aged population.