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ACUTE APPENDICITISJI CLEOFE, MYANNE C
KO, 23/F Filipinosingleborn on 7-19-80 at Manila,
DOA: 7-6-10 Admitting impression: Acute AppendicitisAttending MD: Dr. PrevosaOperation done: AppendectomyDOD: 7-8-10
Cc: abdominal pain
1 day PTA patient +epigastric pain, tolerable, nonradiating.
+anorexia and nausea. - vomiting - fever . +Buscopan, Kremil S
and Diatabs no relief. - consult done.
Several hr PTC, patient noticed a shift of pain to her RLQ, tolerable and non radiating.
+4 episodes of vomiting of PIF.
+anorexia and nausea. - fever. + Consult + lab workups done. Patient was then referred to Valenzuela General Hospital and then later referred to our institution hence subsequently admitted.
Past Medical Hx: U/R Family history: U/R OBGYNE history: G0P0 Personal social history: U/R
: conscious coherent NICRD HR- 81 RR-18BP 110/80 T- 36.9 Anicteric sclera, pink palpebral conjuncitiva, no
cervicolymphadenopathy, no nasoaural discharge Symmetrical chest expansion, no retractions, clear
breath sounds Adynamic precordium, normal rate regular rhythm,
no murmur Flabby, NABS, rigid + direct and rebound
tenderness RLQ + psoas sign + obturator sign (-) rovsing sign
GNE, + FEP, no cyanosis, no edema DRE: no external lesions no skin tags with good
sphincter tone, no mass noted with fecal material on tactating finger no blood noted.
A> Acute Appendicitis P> A
Hgb hct WBC Segmenters Lymphocytes Monocytes126 0.40 11.6 0.81 0.16 0.03
CBC- 7-6-10 Valenzuela General Hospital
Urinalysis 7-6-10 Valenzuela General Hospital
RBC 0-2/hpf,WBC 1-4/hpfBacteria: occasional
Pt. Stayed for 2 hospital days. Upon admission, D- NPO I- D5 LR IL x 6hrs E- Cefuroxime 15 gm/IV then 750 mg
q12 T- Appendectomy
Postop hours are unremarkable. Was on pain control medications, Ketorolac 30mg q8 TIV x 3 days and Nubain 10 mg IV. Was then shifted from NPO to general liquid to soft diet. Day 1 post op, shifted to oral meds. Discontinued IVF. Day 2 post op, patient improved, discharged.
convergence of the 3 taenia coli at the junction of the cecum, tip can be found at either:
1. retrocecal- MC 2. pelvic 3. subcecal 4. preileal 5. right pericolic position Blood supply: Appendiceal artery An Immunologic organ.
>most common abdominal surgical emergency >It is initiated by obstruction of the appendix by a
fecalith, inflammation, foreign body, or neoplasm. Obstruction leads to increased intraluminal pressure, venous congestion, infection, and thrombosis of intramural vessels. If untreated, gangrene and perforation develop within 36 hours.
> disease of the young. 40% cases= 10-29yo patients Variations in the position of the appendix, age of the
patient, and degree of inflammation make the clinical presentation of appendicitis notoriously inconsistent
Early: periumbilical pain; later: right lower quadrant pain and tenderness.
Anorexia, nausea and vomiting, obstipation.
Tenderness or localized rigidity at McBurney point.
Low-grade fever and leukocytosis
> Abdominal pain (centered initially in the lower epigastrium or periumbilical area, later localizes at the RLQ)
> Anorexia >Vomiting > Mild temperature
elevation > RLQ tenderness/
Mcburney’s point >Rovsings sign > psoas sign >obturator sign
Will depend on: 1. anatomic location of the inflamed
appendix 2. the stage of the process (simple/
ruptured) 3. patient’s age 4. patient’s sex
CBC Mild leukocytosis (10,000- 18,000)
Urinalysis r/o UTI as focus of infection
IMAGING
Plain film abdomen + fecalith is suggestiveGraded compression sonography*accurate
+ appendicolith establishes diagnosis, + thickening of the appendiceal wall and periappendiceal fluid is highly suggestive
Transabd/ trans vaginal ultrasonography r/o gyne conditionsHigh resolution, computed tomography + dilated, thickened wall of the appendix,
+ arrowhead sign
Laparoscopy (dx & tx)
Characteristic Score
M = Migration of pain to the RLQ
1
A = Anorexia 1
N = Nausea and vomiting
1
T = Tenderness in RLQ
2
R = Rebound pain 1
E = Elevated temperature
1
L = Leukocytosis 2
S = Shift of WBC to the left
1
Total 10
•score of 3 or lower had a 3.6% incidence of appendicitis
•scores of 4-6 had a 32% incidence of appendicitis
•scores of 7-10 had a 78% incidence of appendicitis
ALVARADO’S SCORE
> ensure adequate hydration >correct electrolyte abnormalities > manage co-morbid illness > OPEN APPENDECTOMY > LAPAROSCOPIC APPENDECTOMY > INTERVAL APPENDECTOMY
Four possible incision sites: 1. Mcburney (oblique) 2. Rocky Davis (transverse) 3. R paramedian 4. Midline (ex lap)
Overall mortality rate in ruptured AP: 3%. Complications: wound infection, abscess.
Things You Don't Want To Hear During Surgery:
"Better save that. We'll need it for the autopsy."
"Someone call the janitor - we're going to need a mop."
"Accept this sacrifice, O Great Lord of Darkness"
"Bo! Bo! Come back with that! Bad Dog!"
"Wait a minute, if this is his spleen, then what's that?"
"Hand me that...uh...that uh.....thingie."
"Oh no! I just lost my Rolex."
"Oops! Hey, has anyone ever survived 500ml of this stuff before?"