The stem
A 19-year-old man has had pain for 12 hours that began around the umbilicus and moved to the right iliac fossa. He has no appetite and has vomited twice. Temperature 37.6 °C. He is tender in the right iliac fossa with rebound tenderness. White cell count 13.2 ×109/L with 82% neutrophils.
Alvarado score
| Feature | Points |
|---|---|
| Migration of pain to the right iliac fossa | 1 |
| Anorexia | 1 |
| Nausea or vomiting | 1 |
| Tenderness in the right iliac fossa | 2 |
| Rebound tenderness | 1 |
| Elevated temperature, 37.3 °C or more | 1 |
| Leucocytosis, white cells above 10 ×109/L | 2 |
| Shift to the left, neutrophils above 75% | 1 |
| Maximum | 10 |
Score as described by Alvarado, 1986.
The examiner’s questions
Question 1Calculate his Alvarado score.Show the model answer
10 out of 10: migration 1, anorexia 1, vomiting 1, right iliac fossa tenderness 2, rebound 1, temperature 1, leucocytosis 2, neutrophilia 1.
Question 2How is the score interpreted?Show the model answer
1 to 4: appendicitis unlikely. 5 to 6: possible, so observe or image. 7 to 10: probable, so refer for surgery.
Question 3What are its limitations?Show the model answer
It is less accurate in women of reproductive age, children and the elderly, and it does not replace clinical judgement. Other scores, such as the Appendicitis Inflammatory Response score, are also used.
Question 4What is your management?Show the model answer
Nil by mouth, intravenous fluids, analgesia and antibiotics, and laparoscopic appendicectomy. In a young man with a score of 10, imaging is not essential, though local practice varies.
After you answerThe teaching pointShow
The two features worth two points each, tenderness in the right iliac fossa and a raised white cell count, carry the most weight. Learn the mnemonic MANTRELS.
The patients are written for teaching and are not real.