ADMITTING DIAGNOSIS: Acute abdomen, rule out perforated acute appendicitis.

FINAL DIAGNOSIS: Acute perforated appendicitis with peritonitis. OPERATION PERFORMED: Appendectomy. CLINICAL SUMMARY: This is a 51-year-old male admitted to the hospital with an approximate 30-hour history of increasing abdominal pain associated with nausea. He had some chills and sweats prior to coming to the emergency room in the early morning hours. PHYSICAL EXAMINATION: A physical examination in the emergency room revealed temperature of 101.8 degrees. His abdomen was moderately distended and generalized guarding, with maximum tenderness and guarding in the right lower quadrant where there was some rebound tenderness. RECTAL: Rectal examination revealed no mass, fluctuancy, or significant tenderness. LABORATORY DATA: White blood cell count was 18,600, 77 polymorphonuclear leukocytes (polys), 11 bands. Urinalysis was negative. HOSPTIAL COURSE: With a presumptive diagnosis of acute appendicitis, rule out perforation, the patient was started on intravenous antibiotics, in the form of Cefobid and Flagyl, and taken in an emergent basis to the operating suite. At exploration, his appendix was noted to be acutely inflamed and perforated. There was no abscess. There is no fecalith noted. He had a moderate amount of cloudy peritoneal fluid. Appendectomy was performed without incident. The peritoneal cavity was not drained. Cultures of peritoneal fluid revealed numerous organisms, including Bacteroides fragilis, pseudomonas, escherichia coli (E coli), and fecal streptococcus. He was continued on intravenous antibiotics. Postoperatively, he awakened from anesthesia with stable vital signs and his course was basically unremarkable. He remained febrile for approximately 4 days, however, there were no spikes on the temperature curve. His diet was begun on the 2nd postoperative day, and he tolerated this well with no abdominal distention, nausea, or vomiting. His abdomen remained soft. His incision remained clean. There was no evidence of any or local inflammation. Rectal examinations done periodically revealed no tenderness. There was no fluctuancy or masses felt. Subjectively, he remained fairly weak; however, he was noted to ambulate ad lib with minimal discomfort. Intravenous antibiotics were discontinued on the 5th postoperative day and Flagyl was continued by mouth because of the prolonged fever which he had as well as the amount of clinical sepsis present. His white blood cell count was noted to be slightly elevated at 12,000, 74 polys, 22 lymphocytes, (lymphs), and there were no bands. He was discharged home on the 7th postoperative day. He has been afebrile for 24 hours. His abdominal examination is benign. His lungs are clear. DISCHARGE MEDICATIONS: He is discharged home on Flagyl 250 mg t.i.d. and he will continue this for 7 more days. Prescription for Vicodin p.r.n is also given.