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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