TEXILA AMERICAN UNIVERSITY

COLLEGE OF MEDICINE

CLINICAL CASE PRESENTATION

COMPILATION

NAME: Pavithra Muruganathan

REG.NO: 2014010072
DATE OF SUBMISSION: 9-12-2019
 GENERAL SURGERY CLINICAL CASE
MANAGEMENT OF ACUTE APPENDICITIS

HOSPITAL: - GPHC

ATTENDING PHYSICIAN: - Dr. Sheik Amir

OUTLINE:
 Introduction
 Abstract
o Background
o Keywords
o Objective
 History of Present Illness
 Discussion
o Case Report
o Treatment
o Prevention
o Risk factor
 Summary
 Reference

INTRODUCTION:
Appendicitis is a medical emergency that almost always requires prompt surgery to
remove the appendix. Left untreated, an inflamed appendix will eventually burst, or
perforate, spilling infectious materials into the abdominal cavity. This can lead to
peritonitis, a serious inflammation of the abdominal cavity's lining (the peritoneum) that
can be fatal unless it is treated quickly with strong antibiotics.

ABSTRACT:
This article seeks to discuss the management of Appendicitis patient and review the
recent discoveries in the management of Appendicitis.

KEY: appendicitis, epigastric pain, inflammation, antibiotics

NOTE: Presently Appendicitis treatment usually involves surgery to remove the
inflamed appendix. Before surgery you may be given a dose of antibiotics to prevent
infection.

OBJECTIVE: The objective of this case is to show the importance of Appendicitis.

HISTORY OF PRESENT ILLNESS:
JJ is a 22-year old male patient who lives in spring lands, New Amsterdam, with no
past medical history. Patient present to our A&E Department referring that, he started
with pain in lower right quadrant of abdomen when lying down on last night; at the same
time, he vomits 12 episodes throughout by nausea. The pain continued to intensity
throughout the night which he describes as a beating sensation, so around 4 AM this
morning he decided to visit Skeldon hospital, when he was given buscopen and fluids,
then transferred to our institution, after he had an abdomen ultrasound done which
concluded Acute Appendicitis. presently he refers that the pain subsided about 2 hours
ago after he received pain medication at A&E., HE denies fever and refers one painful
motion this morning.

CASE DISCUSSION:
CASE REPORT:
CHIEF COMPLAINT: Belly pain and vomiting.
PAST SURGICAL HISTORY: NIL.
PAST MEDICAL HISTORY: NIL
PAST DRUGS HISTORY: NIL
SOCIAL HISTORY: Nil
ALLERGIES: Nil

REVIEW OF SYSTEMS:

Constitutional - NAD, has been generally feeling well the last couple of weeks
Eyes - no changes in vision, double vision, blurry vision, wears glasses, PERRLA X 2
ENT - No congestion, changes in hearing, does not wear hearing aids
Cardiovascular - No SOB, chest pain, heart palpitations
Pulmonary -no dyspnea, BLAE, no rales, no cough
Endocrine - No changes in appetite
Gastro Intestinal - No n/v/d or constipation. Has not eaten because can't swallow solid
foods.
Genito Urinary - No increased frequency or pain on urination.
Musculoskeletal - no changes in strengths, no joint tenderness or swelling
Neurologic - No changes in memory
Psychology - No changes in mood
Heme/Lymph - Denies easy bruising

Physical Examination
GENERAL APPEARANCE: Patient appears ill, tired and sleepy.
VITALS:
Temp: 98.2 °f
Pulse: 96 bpm
Resp: 16
Bp: 130/90 mmHg

Head: normocephalic, no scars are seen

Anterior fontanelle: closed, normotensive, no retraction
Eyes: PERRL, EOMI. Fundi normal, vision is grossly intact
Ears: External auditory canals and tympanic membranes clear, hearing grossly intact.
Nose: No nasal discharge
Throat: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions.
Teeth and gingiva in good general condition.
Neck: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly.
Cardiac: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no
peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary
refill is less than 2 seconds. No carotid bruits.
Lungs: Clear to auscultation and percussion without rales, rhonchi, wheezing or
diminished breath sounds.
Abdomen Positive bowel sounds. Soft, nondistended, nontender. No guarding or
rebound. No masses.
Musculoskeletal: Adequately aligned spine. ROM intact spine and extremities. No joint
erythema or tenderness. Normal muscular development. Normal gait.
Extremities: All the four extremities normal with normal range of motion. No edema or
tenderness.
CNS Alert, oriented and conscious
INVESTIGATIONS:
HEMATOLOGY:

NO TEST RESULT NORMAL RANGES

1 Haemoglobin 15.5 g/dl 12-17

2 WBC 14400 MM3 ↑ 4000-10000

3 Differential:
Polys. 73 % ↑ 50-70

Lymph. 22% 25-40

Eosin. 03% 1-5

Baso. 01% 1-2

Mono. 01% 0-10

4 Platelet 403000 150000-450000

5 Blood group

URINE ANALYSIS:
1.CHEMISTRY REPORT:
UROBINOGEN- NEGATIVE KETONES- NEGATIVE
GLUCOSE- NEGATIVE PROTIEN- NEGATIVE
BLOOD- NEGATIVE LEUKOCYTES- NEGATIVE
NITRITE- NEGATIVE HCG- NEGATIVE
BILIRUBIN - NEGATIVE

2.MICROSCOPIC REPORT:
EITHELIAL CELLS: +
WBC: +
BATERIA: +
 PRIMARY IMPRESSION: Belly pain and vomiting
FINAL DIAGNOSIS: Acute appendicitis

MANAGEMENT:
 Admit
 Vital every 9 hrs, NPO
 IV- RL 1-litre
 INJ- Rocephin 1mg IV STAT
 INJ- flagyl 500mg IV STAT
 Prepare for operation theatre
 Cap, gown (for surgery)
Open appendectomy done.
 Post op orders
 Transferred to ward 8 when fully conscious
 Vitals every 8 hours
 Diet as tolerated
 IVF- RL 1 litre BID
 INJ- Rocephin 1mg IV BID
 INJ- flagyl 500mg IV BID
 INJ- diclofenac 75 mg IM INJECTION BID
 TABLET-Panadol 1mg PO QID
 In observe for 2 days
 No negative changes or post op infection observed
 Discharged
 Return to clinic after 6 weeks

TREATMENT OF ACUTE APPENDICITIS:

Specific treatment for appendicitis will be determined by the doctor based on:
 age, overall health, and medical history
 Extent of the condition
 tolerance of specific medicines, procedures, or therapies
 Expectations for the course of the condition
 opinion or preference
Because of the likelihood of the appendix rupturing and causing a severe, life-
threatening infection, doctors will recommend that the appendix be removed with an
operation.

The appendix may be removed in two ways:

 Open method. Under anaesthesia, an incision is made in the lower right-hand side of
the abdomen. The surgeon finds the appendix and removes it. If the appendix has
ruptured, a small drainage tube may be placed to allow pus and other fluids that are in
the abdomen to drain out. The tube will be removed in a few days, when the surgeon
feels the abdominal infection has subsided.
 Laparoscopic method. This procedure uses several small incisions and a camera
called a laparoscope to look inside the abdomen during the operation. Under
anaesthesia, the instruments the surgeon uses to remove the appendix are placed
through several small incisions, and the laparoscope is placed through another incision.
This method is not usually performed if the appendix has ruptured.
Generally, without a rupture, recovery after an appendectomy is just a few days. If the
appendix has ruptured, recovery is longer and antibiotics are necessary.
People can live a normal life without their appendix. Changes in diet, exercise, or other
lifestyle modifications are usually not necessary.

PREVENTION OF APPENDICITIS:
There is no way to prevent appendicitis. However, appendicitis may be less common in
people who eat foods high in fibre, such as fresh fruits and vegetables

SUMMARY:
Complicated appendicitis may occur more in patients with atypical symptoms (epigastric
pain, diarrhea, malaise, lack of anorexia, and history of chronic RLQ pain), those who
are older, married, without higher education or with a longer interval from the onset of
symptoms to admission. Patients with these factors and suspicion for appendicitis
should be evaluated, advised and followed-up in a vigorous way not to be overlooked.
Furthermore, “bedside evaluation” is a useful, cheap, quick and readily available
method for identifying those at risk for developing complicated acute appendicitis.
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