This document presents a case report of a 28-year old male presenting with abdominal pain. A clerk presents the case to discuss appendicitis. The patient reports sudden onset of severe abdominal pain localized to the right lower quadrant. Physical exam reveals tenderness and rebound tenderness in the right lower quadrant. Intraoperative findings show gangrenous appendicitis. The clerk then reviews anatomy of the appendix, pathophysiology of appendicitis, signs and symptoms, and management of acute appendicitis.
This document presents a case report of a 28-year old male presenting with abdominal pain. A clerk presents the case to discuss appendicitis. The patient reports sudden onset of severe abdominal pain localized to the right lower quadrant. Physical exam reveals tenderness and rebound tenderness in the right lower quadrant. Intraoperative findings show gangrenous appendicitis. The clerk then reviews anatomy of the appendix, pathophysiology of appendicitis, signs and symptoms, and management of acute appendicitis.
This document presents a case report of a 28-year old male presenting with abdominal pain. A clerk presents the case to discuss appendicitis. The patient reports sudden onset of severe abdominal pain localized to the right lower quadrant. Physical exam reveals tenderness and rebound tenderness in the right lower quadrant. Intraoperative findings show gangrenous appendicitis. The clerk then reviews anatomy of the appendix, pathophysiology of appendicitis, signs and symptoms, and management of acute appendicitis.
This document presents a case report of a 28-year old male presenting with abdominal pain. A clerk presents the case to discuss appendicitis. The patient reports sudden onset of severe abdominal pain localized to the right lower quadrant. Physical exam reveals tenderness and rebound tenderness in the right lower quadrant. Intraoperative findings show gangrenous appendicitis. The clerk then reviews anatomy of the appendix, pathophysiology of appendicitis, signs and symptoms, and management of acute appendicitis.
Download as PPTX, PDF, TXT or read online from Scribd
Download as pptx, pdf, or txt
You are on page 1of 52
At a glance
Powered by AI
The case presentation is about a 28-year-old male presenting with abdominal pain. The presentation discusses the patient's history, physical examination, and diagnosis of appendicitis.
The case presentation is about a 28-year-old male presenting with abdominal pain. It discusses the patient's history, physical examination, and diagnosis of appendicitis.
The symptoms of appendicitis discussed are abdominal pain localized to the right lower quadrant, anorexia, nausea, and vomiting.
DEPARTMENT OF SURGERY
NORTHERN MINDANAO MEDICAL CENTER
Towards Excellence in Patient Care and Safety
Clerks Presentation
SC Ian Christian A. Gonzales XU JPRSM DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
GENERAL OBJECTIVE: To present a case of a 28 year old male presenting with abdominal pain
SPECIFIC OBJECTIVES: to present the history and physical examination to discuss anatomy, functions, incidence, pathogenesis, and management of the diagnosis M.E. 28 year old male Filipino Roman Catholic Manticao, Misamis Oriental March 2, 2014. General Data DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Abdominal pain Chief Complaint DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Morning PTA Sudden abdominal pain in the epigastric area, persistent, diffuse in quality, non- radiating, with a pain score of 8/10 aggravated by physical activity and unrelieved by rest History of Present Illness DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Associated anorexia and nausea (-) fever, change in BM, dysuria, flank pain History of Present Illness DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
12 hours PTA Abdominal pain now localized to the right lower quadrant with a pain score of 10/10. History of Present Illness DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Past Medical History DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
hypertension on the paternal side
Family History Personal/Social History laborer high school graduate non smoker, non alcoholic
DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Physical Examination awake, coherent, afebrile, not in respiratory distress
General Survey Vital Signs BP: 100/70 mmHg Wt: 50kg HR: 82 bpm BMI: 20kg/m2 RR: 20 cpm Temp: 36.9 C
DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
acyanotic (-) jaundice (-) pallor warm good turgor Skin DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
anicteric sclerae pinkish palpebral conjunctivae (-) alar flaring moist lips, tongue, and oral mucosae (-) oropharyngeal lesions HEENT DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
trachea in midline non palpable thyroid gland (-) cervical lymphadenopathy
Neck DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Chest and Lungs DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
normal rate regular rhythm (-) heaves/thrills (-) murmur
Cardiovascular System DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
flat normoactive bowel sounds soft (+) direct tenderness, RLQ (+) rebound tenderness, RLQ (+) Rovsings sign Abdomen DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Extremities DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
(-) perianal lesions good sphincter tone (-) rectal mass non palpable prostate gland (+) greenish fecal mater examining finger (-) pararectal tenderness (-) blood on examining finger Rectal Exam DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Salient Features sudden, severe abdominal pain of localizing RLQ area anorexia nausea History DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Physical Examination (+) RLQ tenderness (+) RLQ rebound tenderness (+) rovsing sign DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Impression Differentials Rule In Rule Out Urinary tract infection - sudden onset abdominal pain -nausea - vomiting - No dysuria - No urinary frequency - No hematuria Acute gastroenteritis -abdominal pain - No episodes of loose watery stool Mesenteric adenitis -right lower quadrant pain -nausea - No history upper respiratory infection s Course in the Ward At the wards... admitted at surgical ward NPO plan: For E Appendectomy Cefoxitin 1gm IVTT DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Labs: CBC Hb 13.5 g/dL Hct 41% WBC 9,500/uL Neutrophils 79% Plt 312,000 DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Labs: UA Yellow Clear SpGrav 1.020 pH 6.5 (-) sugar, (-) protein WBC 0-1, RBC 0-1, Epith rare DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Labs: Chemistry Na 144.30 mEq/L K 4.5 mEq/L DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Intraop findings: Gangrenous appendicitis
DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Case Discussion first becomes visible in the eighth week of embryologic development displaced medially toward the ileocecal valve (growth rate of the cecum exceeds that of the appendix) Relationship of base is relatively fixed Tips may be variable (retrocecal, pelvic, subcecal, preileal, or right pericolic) Anatomy DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
taeniae coli converge important landmark to identify the appendix Length varies from length <1 cm to >30 cm (Average: 6 to 9 cm) Blood supply: appendiceal artery ileocolic artery superior mesenteric artery DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Lymphoid tissue first appears in the appendix approximately 2 weeks after birth immunologic organ secretes immunoglobulins (IgA) Appendectomy may have a protective role against IBD (mechanism unclear) Functions DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
second through fourth decades of life mean age of 31.3 years median age of 22 years male:female predominance (1.2 to 1.3:1) rate of misdiagnosis (15.3%) lifetime rate of appendectomy is 12% for men and 25% for women
Incidence DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Obstruction of the lumen Fecaliths hypertrophy of lymphoid tissue inspissated barium from previous x-ray studies tumors vegetable and fruit seeds intestinal parasites
Etiology DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Pathogenesis proximal obstruction of the appendiceal lumen closed-loop obstruction continuous normal secretion by the appendiceal mucosa lumen distension Stimulation of the nerve endings of visceral afferent stretch fibers vague, dull, diffuse pain in the midabdomen or lower epigastrium peristalsis cramping continuous normal secretion by the appendiceal mucosa Increased magnitude of lumen distension continued mucosal secretion & rapid multiplication bacteria Venous pressure is exceeded more severe diffuse visceral pain Reflex nausea and vomiting Occlusion of capillaries and venules; arteriolar inflow continues Inflammation of the appendiceal serosa Compromise of arteriolar outflow Peritoneal irritation with shift of pain in the region of inflammation engorgement and vascular congestion Progressive distension ellipsoidal infarcts @ antimesenteric border Perforation Escherichia coli Bacteroides fragilis
principal organisms seen in the normal appendix, in acute appendicitis, and in perforated appendicitis Bacteriology DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Abdominal pain Epigastric then localizing to the RLQ within 1-12 hours Variations: Retrocecal flank/back pain Pelvic suprapubic pain Retroileal testicular pain Symptoms DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Anorexia nearly always accompanies appendicitis vomiting occurs in nearly 75% of patients (neural or ileus) Usual sequence : Anorexia abdominal pain vomiting DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
RLQ tenderness RLQ rebound tenderness Rovsings sign Psoas sign Obturator sign Signs DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
CBC (WBC count): 10,000 to 18,000 cells/mm3 (acute, uncomplicated appendicitis) >18,000 cells/mm3 (complicated appendicitis., possible perforated appendix +/- abscess)
Laboratory Findings DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
designed to improve the diagnosis of appendicitis and was devised by giving relative weight to specific clinical manifestation Alvarados Scoring importance of early operative intervention (appendectomy) should not be minimized Adequate hydration Correct electrolyte abnormalities Stabilize comorbidities
Management DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
Antibiotics simple acute appendicitis no need to extend coverage beyond 24 - 48 hours (single-agent therapy with cefoxitin, cefotetan, or ticarcillin-clavulanic acid) DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
perforated or gangrenous appendicitis continued until afebrile or has decreasing white count , 7-10 days (single-agent therapy with carbapenems or combination therapy with a third-generation cephalosporin, monobactam, or aminoglycoside plus anaerobic coverage with clindamycin or metronidazole)
DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety
DEPARTMENT OF SURGERY NORTHERN MINDANAO MEDICAL CENTER Towards Excellence in Patient Care and Safety