In a 12-year-old girl with suspected acute appendicitis after completing the abdominal examination, what is the next most appropriate examination to perform?

Next Examination After Abdominal Assessment in Suspected Pediatric Appendicitis

In a 12-year-old female with suspected acute appendicitis after completing the abdominal examination, perform a genital examination next (Answer B).

Rationale for Genital Examination

The genital examination is critical in adolescent females because gynecologic pathology accounts for approximately 21.6% of alternative diagnoses in patients presenting with right lower quadrant pain mimicking appendicitis. 1

Key Gynecologic Differentials to Exclude

• Ovarian torsion – a surgical emergency requiring immediate intervention 1
• Ectopic pregnancy – life-threatening if ruptured, must be considered in post-menarchal females 1
• Ovarian cyst rupture or hemorrhage – can present identically to appendicitis 1
• Pelvic inflammatory disease – causes peritoneal signs and right lower quadrant pain 1

Clinical Examination Sequence

The physical examination should systematically evaluate for:

• Cervical motion tenderness – suggests pelvic inflammatory disease
• Adnexal masses or tenderness – indicates ovarian pathology
• Vaginal discharge – points toward infectious etiology
• Pregnancy status assessment – essential in post-menarchal females 1

Why Not Hip or Lower Limb Examination First?

Hip Joint Examination (Answer A)

While the psoas sign (pain with hip extension) and obturator sign (pain with internal hip rotation) are reliable findings in pediatric appendicitis 2, these maneuvers are typically performed during or immediately after the abdominal examination as part of the peritoneal irritation assessment, not as a separate "hip joint examination."

Lower Limb Examination (Answer C)

Lower limb examination has no direct diagnostic value in suspected appendicitis and would unnecessarily delay critical diagnostic steps.

Subsequent Diagnostic Algorithm After Physical Examination

Once the complete physical examination (including genital assessment) is finished:

For Intermediate Clinical Risk Patients

• Ultrasound of the right lower quadrant is the initial imaging modality in children, avoiding radiation exposure 3
• If ultrasound is nondiagnostic or equivocal, proceed to CT abdomen/pelvis with IV contrast (sensitivity 85.7-100%, specificity 94.8-100%) 3
• The staged ultrasound-then-CT approach achieves 99% sensitivity and 91% specificity 1

For High Clinical Risk Patients

• Some centers proceed directly to CT with IV contrast or MRI without IV contrast when clinical suspicion is very high 3
• Others advocate for immediate surgical intervention without imaging based on validated clinical scoring systems 3

Critical Pitfalls to Avoid

• Never assume appendicitis based on abdominal findings alone – clinical assessment misdiagnoses appendicitis in 34-68% of cases 1
• Do not skip the pelvic examination in post-menarchal females – gynecologic pathology is found in approximately 22% of cases presenting with right lower quadrant pain 1
• Absence of fever does not exclude appendicitis – fever is absent in approximately 50% of appendicitis cases 1, 2
• Do not delay imaging if peritoneal signs are present – rebound tenderness, guarding, and rigidity warrant immediate diagnostic confirmation 1