ADMISSION CONFERENCE 2010

ASMPH Clerkship – SURGERY ROTATIONSt. Martin de Porres Charity Hospital

02 August 2010

Admissions from August 2-August 8, 2010# Patient ID Admitting Diagnosis Operation

Done Final Diagnosis

1 RJ,23/M Ileocecal Tuberculosis, Ulcerohypertrophic type

Ileocecal Tuberculosis, Ulcerohypertrophic type

2 JP,15/M Small Bowel Obstruction probably 2’ to Ruptured AP

“E” Exploratory Laparotomy, Appendectomy

Small Bowel Obstruction probably 2’ to Ruptured AP

3 RM,42/M Cholelithiasis Lap Chole Cholelithiasis

4 MA,18/F Fistula in ano Fistulotomy Fistula in ano

Admissions from August 2-August 8, 2010# Patient ID Admitting

Diagnosis Operation Done Final Diagnosis

5 GV,45/F Calculous Cholecystitis

Lap Cholecystectomy

Calculous Cholecystitis

6 EA,63/F Acute Cholecystitis

Lap Cholecystectomy

Calculous Cholecystitis

7 NV,77/F Femoral neck fractureGarden Type IV

Partial Hip replacement

Femoral neck fractureGarden Type IV

8 MM,25/M Acute Appendicitis

“E” Appendectomy

Ruptured Appendicitis

General Data

• RJ, 23/M • CC: RLQ pain

HPI

7 mos PTA (+) intermittent epigastric pain. Stabbing character. Aggravated by oral intake. Alleviated when eats less, passing flatus, and belching. Associated with bloating and vomiting. No radiations. 5/10 severity.

-Pt sought consult with local doctor treated as dyspepsia, given meds w/c provided no relief.

Subjective Findings

• 3 mos PTA - Persistence of epigastric pain. Pt’s relatives noted gradual weight loss. Undocumented fever. Persistence of pain prompted consult with another doctor.

- EGD procedure was done with negative results.

Subjective Findings

• 2 mos PTA - Pain localized to RLQ area. Colicky character. Aggravated by oral intake. Associated with bloating, vomiting, bulge in RLQ, 28% wt loss, and alternating diarrhea (2-5x/day) with constipation (2-3days). Alleviated when eats less, passing flatus, belching, and massaging RLQ. No radiations. 8-9/10 severity.

Subjective Findings

• 2 mos PTA -CT scan and colonscopy was done at De Los Santos Medical Center.

- CT scan revealed ileitis with mild colitis of the cecum. Associated few ileocecal regional mesenteric lymphadenopathies.

Subjective Findings

• 2 mos PTA - Colonoscopy revealed inflammatory bowel disease.

- Biopsy revealed chronic iliocolitis with ulcer, granulation tissue, benign lymphoid aggregate and reactive epithelial change.

- Prednisone was given w/c afforded temporary relief.

Subjective Findings

• 1 mo PTA - Repeat colonoscopy was done, ileocecal TB was considered.

- Surgery was recommended due to obstructive symptoms hence admission.

ADMISSION

Subjective Findings • ROS:General: (+) Fever, weight loss, weaknessMusculo/Skin: (–) Rashes, joint pains, jaundice, muscle painsHEENT: (–) Headache, tinnitus, deafness cough, colds, enlarged

LNResp: (–) Dyspnea, hemoptysis, wheezeCardio: (–) Palpitations, chest pains, syncopeGI: (–) Inguinal lymphadenopathiesGenitourinary: (–) Nocturia (–) Dysuria, hematuriaEndocrine: (–) Excessive sweat, heat intolerance, cold

intolerance

Subjective Findings

• Past Medical History: – (+) Mumps, 13 y/o– (–) Allergies to food or medicines– (+) BCG– (–) TB

Subjective Findings

• Family history: – (+) Diabetes, – (+) Hypertension

• Social history: Smoker; 1.6 pack years, occasional alcoholic beverage drinker

Objective Findings

• Height: 165cm• Weight: 42kg• BMI: 15• BP: 100 / 70• Temp: 36.7°C• HR: 106• RR: 22

Objective Findings

• Gen: Alert, Coherent, Not in Resp. distress• HEENT: Anicteric sclera, pink palpebral

conjunctiva, (–) CLAD, (–) TPC, Dry tongue and buccal mucosa, Flat neck veins

• Cardio: Adynamic precordium, Apex beat 5th LICS MCL, Normal rate, Regular rhythm, (–) Murmur

• Pulmo: SCE, Resonant lung fields, Clear breath sounds, (–) Crackles and wheezes

Objective Findings

• GI: Scaphoid, hypoactive bowel sounds, tympanitic, soft, (+) Direct tenderness on deep palpation of RLQ, (–) Rebound, (–) Masses organomegaly, surgical scar

• Extremities: Pulses full and equal, (–) edema, cyanosis, good turgor

• DRE: (–) skin tags, (–) perianal masses or tenderness, Good sphincter tone, (–) Pararectal tenderness or masses, Empty rectal vault, feces on tactating finger

Salient Features

• 23/M• Colicky RLQ pain. • Associated with bloating, vomiting, bulge in RLQ, 28%

wt loss, fever, and alternating diarrhea (2-5x/day) with constipation (2-3days).

• Aggravated by oral intake. • Alleviated when eats less, passing flatus, belching, and

massaging RLQ. • No radiations. • 8-9/10 severity.

Salient Features

• GI PE: Scaphoid, hypoactive bowel sounds, tympanitic, soft, (+) Direct tenderness on deep palpation of RLQ, (–) Rebound, (–) Masses organomegaly, surgical scar

• DRE: (–) perianal masses or tenderness, Good sphincter tone, (–) Pararectal tenderness or masses, Empty rectal vault, feces on tactating finger

Salient Features• (–) EGD• CT revealed ileitis and mild colitis of the cecum.

Regional mesenteric lymphadenopathes.• Colonscopy revealed chronic ileocolonic

inflammation, T/C ileocecal TB.• Biopsy of ileocecal area revealed chronic

ileocolitis with ulcer, granulation tissue, benign lymphoid aggregates, reactive epithelial change. No granuloma or dysplasia.

Dx Labs:

Assessment

• Primary Impression: Ileocecal Tuberculosis, Ulcerohypertrophic type

• Differentials:– Chronic Inflammatory Bowel Disease: Chron’s– Lymphoma– Colon Cancer

Plan

• Diagnostic Plan:– CBC – ESR– PPD – CXR– CT abdomen – AFB of biopsy– PCR of biopsy– Culture of biopsy

Plan• Anti- TB Medications (WHO Tx of TB Guidelines,

2009)– Anti-TB Drugs: Pulmonary and extrapulmonary disease

should be treated with the same regimens. (Strong/High grade of Evidence)

• Surgery for late complications

Text here

Right hemi? colectomy and anastomosis

RETURN TO TABLE

Identifying Data

• JP, 15/M• Date of birth: August 9, 1995• Currently resides in Bonifacio Exit, Bagong

Silangan QC• Date of admission: August 3, 2010. 9:45 am• CC: Abdominal Pain and Distention

Subjective Findings: HPI

• 5 days PTA • Persistent hypogastric pain• Pain scale of 7/10• No radiation• On and off fever• Sough consult in a local

health center – diagnosed with UTI– Given Co-Amoxiclav and

Domperidone– Treatment offered partial

temporary relief

Subjective Findings: HPI

• 3 days PTA • Hypogastric pain localized to the LLQ

• 7 episodes of vomiting of previously ingested food

• 7 episodes of diarrhea – Stools described as wet and

yellow

Subjective Findings: HPI

• 2 days PTA • Abdominal distention noted to be relieved by vomiting

• Persistence and development of new symptoms led to admission in East Avenue– Treated as AGE– Unrecalled IV medication– Placed on NPO– NGT inserted

Subjective Findings: HPI

• 1 day PTA • Allowed to eat• Abdominal distention

worsened with each meal• Abdominal pain now

described as diffuse accompanied by abdominal rigidity

• Persistence of diarrhea and vomitingADMISSION

Subjective Findings: ROS

• ROS – – General

• (-) changes in weight, (-) fatigue, (-) weakness

– HEENT• (-) headache, (-) colds, (-) enlarged lymph nodes

– Respiratory• (-) cough, (-)dyspnea, (-) wheezing

– Cardiovascular• (-) orthopnea, (-)palpitations, (-) chest pain

– Gastrointestinal• (-)heartburn, (-)rectal bleeding, (-)jaundice

– Genitourinary • (-)frequency, (-) hematuria, (-) nocturia

Subjective Findings: PMHx

• Past Medical History– No previous surgeries – Admitted at 1 y/o at Mary Johnson for amoebiasis– Treated for Primary complex for 9 months– No known co-morbids– No known food or drug allergies

Subjective Findings

• Family history:– Asthma

• Social history: – Student– (-) Smoker– (-) Alcohol drinker– (-) Illicit drug user

Objective Findings: Vital Signs

• Height: 160 cm• Weight: 40.5 kg• BMI: 15.8 - Underweight• BP: 120/80• Temp: 37.5°C• HR: 121 – tachycardic • RR: 28 – tachypneic • Abdominal Girth: 70 cm

Objective Findings: PE

• Patient was alert, coherent but in severe pain• Anicteric sclera, pink palpebral conjunctiva• (-) TPC, (-) CLAD, (-) NVE• Symmetric chest expansion, (-) chest

retractions, (-) chest lag, bilaterally resonant with clear breath sounds, (-) adventitious breath sounds

Objective Findings: PE

• Adynamic precordium, PMI at 5th LICS MCL, tachycardic, Regular rhythm, (-) murmurs

• Protruberant and distented, (-) surgical scars, hypoactive bowel sounds, direct and rebound tenderness on all quadrants

• DRE: Not done as per patient request. • Full and equal pulses on all extremities, (-)

edema, (-) cyanosis, CRT of 2 seconds

Objective Findings: LabsValue Normal Remarks

Hemoglobin 132 140-170 Low

Hematocrit 0.36 0.40-0.50 Low

WBC 8 4.5-10 Normal

Neutrophil 0.60 0.56-0.66 Normal

Lymphocyte 0.31 0.22-0.40 Normal

Eosinophil 0.02 0.01-0.04 Normal

Mean corpuscular Hgb

30.6 27-31 Normal

Mean corpuscular Hgb concentration

365 320-360 HighMean cell volume 83.8 80-96 Normal

RDW 12.2 11.5-14.4 Normal

Platelet 405 150-350 High

Objective Findings: LabsURINALYSIS

Dark amber, slightly turbid

pH alkaline

specific gravity 1.015

RBC 2-3 per hpf

WBC 4-5 per hpf

Epithelium Many

Mucus threads Abundant

Amorphous Phosphates Moderate

Albumin (+)

Sugar (-)

Objective Findings Labs

Value Normal Remarks

Bleeding time 3 mins 5 secs 2-4 mins Normal

Clotting Time 3 mins 15 secs 2-4 mins Normal

Prothrombin Time 12.9 10-13 Normal

PT control 12

INR 1.08 Normal

% Activity 89.6

PTT 30 29-34 Normal

PTT Control 30

Creatinine 63.10 44.16-150.16 Normal

Na 132 138-146 Low

K 3.8 3.6-5.0 Normal

Objective Findings

• CXR – Clear lung fields– Bony thorax intact– Heart magnified

Objective Findings

Objective Findings

Objective Findings

Salient Features

• 14 year old male• Persistent pain on hypogastrum with localization to LLQ• On and off fever• Diarrhea and vomiting• Dysuria• Abdominal Distention worsened by eating and relieved

by vomiting• Direct and Rebound Tenderness on all quadrants• Rigidity• X-ray Findings

Assessment

• Clinical Impression: Small Bowel Obstruction probably secondary to Ruptured Appendicitis

• Differentials :– Peptic Ulcer Disease– Ileus– Meckel’s Diverticulum

Plan

• Diagnostic Plan:– CBC– Urinalysis– Electrolytes– Fecalysis– Abdominal X-ray– CXR– Ultrasound– CT-Scan

Plan

• Treatment Plan– Emergency Lapparatomy Appendectomy– Hydration– Antibiotics– Analgesics for pain– NPO

RETURN TO TABLE

Subjective Findings

• MA, 18 F• CC: anal discharge

Subjective Findings

4 Years PTA

Noted a rectal mass, R perianal area(+)Tender(-) tenesmus(-)pain on defecation(-) fecal retension(-) soiling of underwear(-) no discharge(-) change in bowel movements(-) itch/rashes(-) blood in stoolsConsult was done at another hospitalIncision and drainageCondition resolved

Subjective Findings

1 year PTA Pain on defecation(+)Soiling of underwear(+) Purulent discharge(+) yellowish discharge(-) anal mass(-) tenesmus(-) tenderness(-) blood in stools

Subjective Findings

1 week PTA Increasing pain on defecationBrownish dischargePalpated right perianal mass

larger than the previous(-) tenesmus(-) fecal retension(+) soiling of underwear(-) change in bowel

movements(-) perianal itch/rashes(-) blood in stools

Subjective Findings

1 day PTA (+) undocumented feverPersistence of symptoms

prompted consult

August 2, 2010, 4:30

Subjective Findings

• PMHx– s/p I & D 2006– No known medical

illness– No known allergy to

food and drugs

• FHx– (+) HPN– Heart disease

• P/S Hx– student– Non-smoker– Non-alcoholic beverage

drinker

Sexual Hx- denies sexual contact

LMP: July 4, 2010

Objective Findings

Physical Exam• BP: 110/70• Temp: 37.1 C• HR: 98• RR: 15• Pain Severity: 0/10

Objective Findings

• Gen: Alert, Coherent, not in cardiorespiratory distress

• HEENT: Anicteric sclera, pink palpebral conjunctiva, neck veins not engorged

• Pulmo: Symmetric chest , clear breath sounds, (-) Crackles and wheezing

• Caridio: Adynamic Precordium, Normal rate, Regular rhythm, (-) Murmur, good S1, S2

Objective Findings

• Abdomen– Flat, soft abdomen– Normoactive bowel sounds– tympanitic– No palpable mass, No tenderness

• Extremities• full and equal

Objective Findings

• Digital Rectal Exam– External opening 3 cm from anal verge. R

posterior (7 o clock)– (+) yellowish pus discharge– Good external sphincter tone– (-) blood in examining fingers– (-) masses– (-) induration

Assessment

Fistula - in – ano

Differentials1. anal abscess

2. anal fissure

Plan

• Fistulotomy• Curretage• Healing by secondary intension• Sitz bath• Biopsy of tract• Possible use of drains/seton

RETURN TO TABLE

Subjective Findings

• GV, 45/F• Residence: Taytay, Rizal• CC: recurrent RUQ abdominal pain for 11

years

Subjective Findings

• 11 years PTA

• 2 weeks PTA

• Colicky RUQ pain radiating to the back (after eating a heavy meal)

• UTZ: cholelithiasis• Meds: Buscopan Plus

500mg OD

• Same Sx + Abdominal fullness

Subjective Findings

• 8 hours PTA • After a heavy fatty meal:– RUQ pain radiating to

the back– Severity score of 9/10– No relief: Buscopan Plus

Admitted August 2, 2010; 4pm

Subjective Findings

• ROS: – (-) weight gain, fever,

jaundice, change in bowel/micturition habits, changes in sensorium

• Current Medications:– NO maintenance

medications– Vitamins: • Myra-E OD• Vit B

Subjective Findings

• Past Medical History:– No previous

hospitalizations– No allergies: food and

medicines– Surgeries:• s/p Appendectomy:

1970’s• s/p TAHBSO: stage II

CA 2003

• Family History:– Hypertension:

mother– Gallstones: 3

brothers

– VACCINATION: (+) flu vaccine 8 mos ago

Subjective Findings

• Accountant• Non-smoker• Non-alcohol beverage drinker• No exercise• Diet: – Sweet– Fatty– Salty

Objective Findings

• Height 149cm• Weight 52.6kg• BMI 23.69 normal• BP 110/80• HR 80• RR 18• Temp 36.9 degrees Celsius

Objective Findings

• HEENT: anicteric sclera, pink palpebral conjunctivae, no TPC, no CLAD, no neck masses

• Chest: symmetrical chest expansion, resonant on percussion, clear breath sounds, no visible and palpable pulsations, distinct S1/S2, no murmurs

Objective findings

• Abdomen: no rigidity, no visible pulsations, surgical scars visible (8-9cm RLQ scar from a previous appendectomy procedure, 20-22cm horizontal scar from a previous TAHBSO procedure 10cm from the umbilicus), tympanitic on percussion, liver span 9cm at the MCL, no voluntary and involuntary guarding, smooth liver border, no palpable masses, (+) Murphy’s sign

Assessment

• Recurrent Calculous Cholecystitis• Differentials:– Peptic Ulcer Disease– Viral Hepatitis

Plan

• Surgical: Lap cholecystectomy (Dr. Cenon Alfonso)

• Non-surgical Management:– Antibiotics– Analgesics– Watch out for 5 W’s

• Advise on:– Food: fatty

RETURN TO TABLE

General Data

• EA, 63/F • CC: RUQ pain

HPI1 Year PTA (+) intermittent epigastric

and RUQ pain. Lasts for a few minutes. Associated with bloating. Alleviated by burping, flatus, massage of epigastrium. Aggravated with food intake. No radiations. Severity 1-2/10.

-UTZ was done which revealed cholelithiasis.

Subjective Findings

• 1 year PTA -Dx and Tx as peptic ulcer disease, was given unrecalled medicines w/c afforded temporary relief.

- Persistence and progression of symptoms prompted consult and subsequent admission.

ADMISSION

• Few weeks PTA

Subjective Findings • ROS:General: (+) Weakness, loss of appetite (-) FeverMusculo/Skin: (-) Rashes, joint pains, muscle painHEENT: (+) Sinusitis, dizziness (-) Headache, blurring of vision,

tinnitus, cough, colds, enlarged LNResp: (-) Dyspnea, hemoptysis, wheezeCardio: (+) Palpitations (-) Chest painsGI: (+) Heart burn, (-) Nausea, vomiting , change in bowel

movements, rectal bleedingGenitourinary: (-) Nocturia,Dysuria, hematuriaEndocrine: (-) Excessive sweat, heat intolerance, cold intolerance

Subjective Findings

• Past Medical History: – (+) Hypertension, controlled ~ 10 years• Maintained on Losartan 50mg OD, Clonidine 75mg PRN.

Normal BP: 130/80

– (+) Asthma, controlled ~ 40 years, • Maintained on Salbutamol and Fluticasone/Salmeterol

– (+) Anxiety DO, ~25 years• Maintained on Alprazolam 500 mcg PRN

– (+) Dyspepsia, 1 year• Maintained on antacids

Subjective Findings

• Past Medical History:– (–) Allergies to foods or medications– No recent vaccinations

• Past Hospitalizations:– 2003 - R forearm fracture closed reduction– 1971 - H. mole D&C– 1970 – PID 2° IUD D&C– 17 y/o, Asthma in Acute Exacerbation

Subjective Findings

• Family history: – (+) Gall stone - Daughter

• Social history: Non-smoker, non-alcoholic beverage drinker

Objective Findings

• BP: 140 / 80• Temp: 36.8°C• HR: 78• RR: 20• Pain Severity: 0/10

Objective Findings

• Gen: Alert, coherent, afebrile, not in cardioresp distress

• HEENT: Anicteric sclera, pink palpebral conjunctiva, (–) TPC, (–) CLAD, flat neck veins

• Caridio: Adynamic precordium, Apex beat 5th LICS, MCL, Normal rate, Regular rhythm, (–) Murmur

• Pulmo: Symmetric chest expansion, Resonant lung fields, Clear breath sounds, (-) Crackles and wheezes

Objective Findings

• AB: Protuberant abdomen, NABS, tympanitic, soft, (–) Tenderness, Murphy’s sign, organomegaly, masses, surgical scars

• Extremities: Full and equal pulses, (–) edema, cyanosis, good turgor

• Skin: (–) Rashes, clean nails, dry hair

Salient Features

• 63/F• Colicky RUQ pain• Associated with bloating.• Aggravated with food intake• Alleviated by burping, flatus, massage of

epigastrium. • No radiations. • Severity 1-2/10.• UTZ revealed cholelith in gallbladder.

Assessment

• Clinical Impression: Calculous Cholecystitis• Differentials :– Peptic Ulcer Disease– Cholangitis– Hepatitis– Acute Coronary Syndrome

Plan

• Diagnostic Plan:– Abdominal Ultrasound– CBC– Hepatitis Serology– ECG

Plan• Treatment Plan– Cholecystectomy– IV Fluids– IV Antibiotics– IV Analgesics

Numerous pigmented stones, ranging from ~1x1cm

RETURN TO TABLE

Subjective Findings

• NV, 77/F• CC: hip pain

Subjective Findings

• NOI: Fall• POI: Paranaque City• DOI: 8/1/10• TOI: 7 pm

Subjective Findings

• 2 hours PTA • (+) sharp pain on movement

• Inability to ambulate• (+) numbness• (-) swelling, pallor,

paresthesia, discoloration, crepitus

• Xray done• Pain meds, referred for

surgery

Subjective Findings

• ROS • (+) weight loss• (-) fatigue, weakness, joint pains• (-) tingling sensation• (-) loss of consciousness• (-) difficulty breathing,

tachypnea, cyanosis, chest pain

Subjective Findings

• ROS • (-) fever• (-) edema• (-) skin changes, jaundice• (-) palpitations• (-) chest pain• (-) dysuria, hematuria, freq

Subjective Findings

• PMH/PSH • Cervical spondylosis, OA (1993)– Naproxen sodium– Almitrine/ raubasine

(30/10mg)

• HPN (1995)– Amlodipine 5mg OD

• Patellar Fracture (2004)

Subjective Findings

• Obstetric history

• P/SH

• Post-menopausal• Not on HRT• Non-smoker• Non-alcoholic beverage

drinker

Objective Findings

• VS • RR: 18• HR: 86• T: 36.0• BP: 150/80

Objective Findings

• Primary Survey– A: (-) signs of airway obstruction, (-) cervical spine

injury– B: RR 18, (-) use of accessory muscles, SCE, patient

is able to talk, lungs resonant, (-) cyanosis, (-) jugular venous distention, trachea midline

Objective Findings

Primary Survey– C: BP 150/80, pulses full and equal, (-) cyanosis, T:

36.0– D: awake, alert, coherent. GCS 15, (-) motor,

sensory deficits, (-) changes in mental status

Objective Findings

• HEENT

• Pulmonary

• Anicteric sclerae, pale palpebral conjunctivae, (-) TPC, (-) CLAD, flat neck veins

• Symmetric chest expansion, equal tactile fremiti, lungs resonant, minimal bilateral bibasal crackles

Objective Findings

• Cardiovascular

• Abdomen

Adynamic precordium, Apex beat: 6th ICS MCL, distinct S1 and S2, (-) murmurs

Flabby, (-) surgical scars, (-) masses, NABS, (-) bruits, tympanitic, (-) tenderness, (-) organomegaly, (-) CVA tenderness

Objective Findings

• DRE Did not consent

Objective Findings

• Extremities • L leg shorter and externally rotated

• (+) L hip tenderness • (+) LOM in affected limb• (-) neurologic deficits• (-) loss of pulse

Objective Findings

• Xray • Complete fracture with total displacement of fracture fragment

Assessment

Femoral neck fractureGarden Type IV

Garden Classification

Plan: Treatment

• Preoperative management– Preoperative traction – Pressure-reducing mattresses– Surgery performed once patient is medically stable

(within 24 hours if possible)

Plan: Treatment

• Perioperative management– Operative tx is better than conservative tx– Surgical technique• Non displaced: screws better than pins• Displaced: hemiarthroplasty or total hip arthroplasty• Cemented arthroplasties superior to noncemented

arthroplasties

Plan: Treatment

• Perioperative management– Regional anesthesia (reduces morbidity and

mortality)– DVT prophylaxis for 10 days postoperatively– Antibiotics preop: wound, urinary, respiratory

Plan: Treatment

• Early post-operative mgt (7-10 days)– Nutrition, protein supplementation for

malnourished patients– Initiate transition to rehabilitation– Prevent complications: DVT, PE, bedsores,

pneumonia

Plan: Treatment

• Rehabilitation/ discharge planning– Exercise programs improve function, length of

stay, institutionalization, activity of daily living mobility, and ambulation

Prevention

• Prevent falls• Increase physical activity• External hip protectors• Combination of folate and mecobalamin(B12)• Vitamin D, calcium, and bisphosphonates• HRT

Screening

• Bone density scan (DEXA) for osteoporosis

RETURN TO TABLE

Subjective Findings

• M.M. 25M• CC: abdominal pain

1

Subjective Findings

HPI1 day PTC

1 day history of periumbilical painLocalized to RLQ after few hoursPersistent8/10Not aggravated/relieved by eatingNo radiation(+) vomiting(+) anorexia(-) fever(-) change in bowel movement

Persistence of pain prompted consult

1

Admission

Subjective Findings

• ROS– No weight loss– No cough/colds– No dyspnea– No chest pain

• Past Medicals/p CS 2007Preeclampsia(+)Asthma

FH• HPN• Asthma• PTB

• PSNon-smokerNon-alcoholic beverage

drinker• Obstetrics/gyne• LMP: July 21• G1P1 (1001)• S/P CS

1

Objective Findings

• On PE:– Vitals Temp: 37.6 C,HR: 86 RR: 19– HEENT: • anicteric sclera, pink palpebral conjunctivae, moist

tongue and buccal mucosa,

– Cardiopulmonary• Equal chest expansion• Clear breath sounds• Normal rate and rhythm• Good S1, S2, no murmurs

1

Objective Findings

Abdomen: • I: flat, (+) infraumbilical scar midline (from previous CS)

A: normoactive bowel sounds• P: soft, (-) guarding, (+)RLQ pain direct and rebound, (-)

Rovsing’s (+) Psoas and obturator sign, (-) cutaneous hyperesthesia, (-) Murphy’s sign , (-) Dunphy’s sign(+) CVA tenderness (R)

Extremities – Full and equal pulses, no edema, no cyanosisDRE: patient refused DRE

1

Assessment

• Impression: Acute Appendicitis• Differentials – UTI– Ureteral stones

1

Plan

• Diagnostic Plan• Labs – Pregnancy test– Urinalysis– CBC

• Imaging– Abdominal Ultrasound– CT scan of the abdomen

1

Plan

• Treatment Plan– Emergency Appendectomy• Final dx: Suppurative appendicitis

– Post op: antibiotics, pain relievers

1

RETURN TO TABLE

Subjective Findings

• M.M. 25M• CC: abdominal pain

1

Subjective Findings

HPI1 day PTC

1 day history of periumbilical painLocalized to RLQ after few hoursPersistent8/10Not aggravated/relieved by eatingNo radiation(+) vomiting(+) anorexia(-) fever(-) change in bowel movement

Persistence of pain prompted consult

1

Admission

Subjective Findings

• ROS– No weight loss– No cough/colds– No dyspnea– No chest pain

• Past Medicals/p CS 2007Preeclampsia(+)Asthma

FH• HPN• Asthma• PTB

• PSNon-smokerNon-alcoholic beverage

drinker• Obstetrics/gyne• LMP: July 21• G1P1 (1001)• S/P CS

1

Objective Findings

• On PE:– Vitals Temp: 37.6 C,HR: 86 RR: 19– HEENT: • anicteric sclera, pink palpebral conjunctivae, moist

tongue and buccal mucosa,

– Cardiopulmonary• Equal chest expansion• Clear breath sounds• Normal rate and rhythm• Good S1, S2, no murmurs

1

Objective Findings

Abdomen: • I: flat, (+) infraumbilical scar midline (from previous CS)

A: normoactive bowel sounds• P: soft, (-) guarding, (+)RLQ pain direct and rebound, (-)

Rovsing’s (+) Psoas and obturator sign, (-) cutaneous hyperesthesia, (-) Murphy’s sign , (-) Dunphy’s sign(+) CVA tenderness (R)

Extremities – Full and equal pulses, no edema, no cyanosisDRE: patient refused DRE

1

Assessment

• Impression: Acute Appendicitis• Differentials – UTI– Ureteral stones

1

Plan

• Diagnostic Plan• Labs – Pregnancy test– Urinalysis– CBC

• Imaging– Abdominal Ultrasound– CT scan of the abdomen

1

Plan

• Treatment Plan– Emergency Appendectomy• Final dx: Suppurative appendicitis

– Post op: antibiotics, pain relievers

1

RETURN TO TABLE