A 17 year old girl presents with history of generalised abdominal pain, fever, recurrent vomiting. On examination, she has a temperature of 103degF, Right Iliac fossa tenderness, and WBC are 19600/mm' ?

Ans. is 'a' i.e., Ruptured appendicular abscess Abdominal pain and vomiting suggest the most likely diagnosis of appendicitis. High temp (103degF) and high WBC count suggest appendiceal rupture. Schwaz writes - "Rupture should be suspected in the presence of fever greater than 39degC (102degF) and a WBC count greater than 18,000/mm3." Other options are less likely, as fever and vomiting is uncommon in them. Intussusception Is usually seen in children younger than 2 yrs of age Fever, leucocytosis is not seen. Ruptured ectopic pregnancy Schwaz writes - "Rupture of . tubal or ovarian pregnancies can mimic appendicitis. Patients usually give a history of abnormal menses; either missing one or two periods or noting only slight vaginal bleeding. The diagnosis of ruptured ectopic pregnancy should be relatively easy. The presence of a pelvic mass and elevated levels of chorionic gonadotropin are characteristic While the leukocyte count rises slightly (to approx. 14,000), the hematocrit level falls as a consequence of the intraabdominal haemorrhage. Vaginal examination reveals cervical motion and adenexal tenderness." Twisted ovarian cyst Shaw's writes - "A twisted ovarian cyst causes sudden pain in abdomen with occasional vomiting, but pyrexia is usually absent or very low. An abdominal lump is felt distinctly.