NAME : NUR AYUNI BINTI MOHD SALLEH

MATRICS NO : MEM 140082

STREAM :5

POSTING :E

BATCH : 2014/2015

SUPERVISOR : A/PROF KALAI ARASU

TITLE : ACUTE APPENDICITIS

NAME : Aakash Bhajan

R.N : 34163842

AGE : 22 YEARS OLD

GENDER : MALE

ETHNICITY : Nepalese

D.O.A : 14/05/2017

Chief Complaint

A 22 years old Nepalese man, previously well, presented with acute onset of periumbilical
abdominal pain.

History of Presenting Illness

The sharp pain started 10 hours prior to admission, which started at the periumbilical region and
radiates to the right iliac fossa, progressively worsening, associated with nausea, vomiting for 3
times prior to admission, containing food particles, non-billous, no hematemesis. Patient has
reduced oral intake on the day of admission. Pain score during admission was 7/10. Reliever
medication presumably painkiller was given at a GP clinic and patient was transferred to UMMC.

Patients last meal was 5 hours prior to onset of pain, which was provided by the caterer at work
place. Other workers ate similar food, without having any symtoms.

Systemic Review

Patient denies fever, nor altered bowel habits.

No urinary symptoms, upper respiratory tract infection, night sweats, bone pain, bleeding
tendencies, apparent weight loss.

No history of sick contact with people of similar illness.

No neurological symptoms such as weakness or loss of consciousness.

Past Medical History

Nil of significance

Past Surgical History

Nil of significance

Drugs & Allergy

No known allergy.

Not taking medications, prescribed/over-the-counter

Family History

Mother died of diabetes complication at 44.

4th in a family of four siblings.

Siblings has no known medical illness, currently living in Nepal.

Social History

Single man

Came to Malaysia 1 year 7 months ago.

Works handling papers, at recycling company at PJ Tower.

Lives in a hostel- with 8 other workers, sectioned according to nationalities.

Denies smoking, drinking alcohol, taking recreational drugs, sexual promiscuity.

Summary

Patient is a young Nepalese man, previously well, presented to the hospital with acute onset
periumbilical pain progressively worsening, radiating to right iliac fossa associated with nausea and
vomiting. Patient denies altered bowel habit or past similar illness.

Provisional Diagnosis

Acute Appendicitis

Differential Diagnosis

Urinary tract infection (Cystitis)

Acute Gastroenteritis

Mesenteric Adenitis

Right Inguinal/Femoral Hernia Incarceration

Physical Examination

Post-op day 1

VITAL SIGNS

Blood Pressure : 118/75 mmHg

Respiratory rate : 14 bpm

Heart Rate : 80 bpm

Oxygen Saturation : 100% on room air

Temperature : 37.9 Celcius

GENERAL EXAMINATION

Patient was lying flat in bed, appeared well, oriented to person, time and place, verbally coherent,
not in respiratory distressed, well nourished.

ABDOMINAL EXAMINATION

Patient does not present with peripheral stigmata of gastrointestinal disease including nail changes
such as finger clubbing, leukonychia, koilonychia, palmar erythema, asterixis, flapping tremor,
scratch marks. No scleral jaundice, conjunctival pallor, buccal mucosa is moist, with average dental
hygiene.

On inspection, abdomen has 3 square bandages on each laparoscopic incision sites, bandages not
soaked. Abdomen is not distended, no mass seen.

On palpation, abdomen is guarded, tender on deep palpation and percussion on right iliac fossa &
periumbilical region. No mass felt. No peritoneal signs, nor hepatomegaly. Kidneys not ballotable.

On auscultation, normal bowel sound is heard.

CARDIOVASCULAR SYSTEM

On inspection of the chest, the chest move symmetrically with respiration. There was no chest
deformity, no surgical scar, no dilated superficial vein, no visible pulsation and no skin
discolouration.

On palpation, the apex beat was located at 6th intercostals space within the left midclavicular line.
No heave or thrill noted.

On percussion revealed normal cardiac dullness.

On auscultation, normal first & second heart sound was heard. There was no murmur.

All the peripheral pulses were palpable, good rhythm, normal volume and the jugular venous
pressure (JVP) was not raise.
RESPIRATORY SYSTEM

On inspection of the chest, the chest moves symmetrically with respiration, there was no
chest deformity, no use of respiratory accessory muscle, no surgical scar, no dilated vein, and no
intercostals, subcostals and suprasternal recession.

On palpation, the trachea was centrally located, normal chest expansion, and normal vocal
fremitus at both upper, middle and lower zone. Apex beat was palpable at the 6th intercostals space
at the left midclavicular line.

On percussion, there was normal resonance anterior and posteriorly and normal cardiac and
liver dullness were noted

On auscultation, vesicular breath sound was heard with normal air entry and normal vocal
resonance of both sides. No crepitation and rhonchi noted.

CENTRAL NERVOUS SYSTEM

Mental status Patient was alert, conscious and oriented to time, place and person.

Cranial nerve All cranial nerves were intact.

Muscle tone There were no muscle wasting, abnormal movement and fasciculation of her
upper and lower limb. Normal muscle tone of both upper and lower limbs.

Muscle power Normal muscle power of both upper and lower limbs (5/5)

Reflexes All tendon reflexes were normal

Reflexes Left Right

Biceps ++ ++

Supinator ++ ++

Knee ++ ++

Ankle ++ ++

Plantar Down going Down going

Cerebellar Signs There was no cerebellar sign present and his gait was normal

On sensory examination, there was no impaired sensation.

Provisional Diagnosis

Acute Appendicitis

Points for Points against

Age : Young adult (22)
History : Pain that begins at the centre
of the abdomen then shifts to right iliac
fossa.

Differential Diagnosis

Urinary Tract Infection

Points for Points against

Lower tract infections such as cystitis No urinary signs or symptoms such as
may also present with lower abdominal dysuria, haematuria, incontinence.
pain.

Acute Gastroenteritis

Points for Points against

Presents with abdominal pain with No altered bowel habits (diarrhoea)
acute onset
Associated with nausea & vomiting

Mesenteric Adenitis

Points for Points againts

Pain and tenderness are often centered
in the RLQ, but they may be more
diffuse than in appendicitis.
Leukocytosis is common.
The site of tenderness may
shift when the patients position
changes, whereas the site of
the tenderness tends to remain
localized with appendicitis.
No prior history of viral upper
respiratory tract
infection/lymphadenopathy.

Meckels Diverticulitis

Points for Points againts

Produces symptoms and signs Although, pain is generally felt more
indistinguishable from those of acute towards the centre of the abdomen
appendicitis. and does not shift.

Right Inguinal/Femoral hernia

Points for Points againts

 An incarcerated right inguinal or There was no irreducible swelling over
femoral hernia may present as RIF pain. the hernial orifice, and symptoms and
signs of bowel obstruction (other than
nausea and vomiting)

Investigations

The ones I would like to order:

Blood test. This allows to check for a high white blood cell count, which may

indicate an infection.

Urine test. To make sure that a urinary tract infection or a kidney stone isn't causing

your pain.

Stool Culture, Ova and Parasite exam. This will give a high index of suspicion for acute
gastroenteritis if result is positive.

Imaging Considerations

KUB: Simple abdominal x-ray showing kidneys, ureters, and bladder on one film. Search for
appendicolith in RLQ as well as for kidney and gallstones.

Pelvic ultrasonography: Usually performed through a full urinary bladder although transvaginal
sonography is faster. Sonography is particularly useful if GYN disorder is a key consideration.
Sonography for appendicitis is practical in the paediatric age group but has many false

negatives.

CT of abdomen and pelvis with oral/IV contrast:

Imaging modality of choice for appendicitis. Requires oral contrast which may take a significant
amount of time to opacify the terminal ileum and cecum (an hour or more) due to slow peristalsis in
ill patient. Very valuable for preoperative planning when appendix is in unsuspected location
(retrocecal) or appendicitis is complicated by abscess/rupture.

Investigations done on this patient :

Complete Blood Count

HB g/L 120.0-150.0 139

HCT L/L 0.36-0.46 0.40
RBC 10^12/L 3.80-4.80 4.5
MCV Fl 77-97 86
MCH Pg 27-32 27.9
MCHC g/L 315-345 326
RDW % 11.6-14.0 12.7
WBC 10^9/L 4.0-10.0 H 15.0 Leukocytosis reflects an
ongoing infection.
PLATELET 10^9/L 150-400 360
 Differential Count
% Neutrophil % 88.7
# 10^9/L 2.00-7.00 H 10.55 Neutrophilia is a sign of
Neutrophile bacterial infection.
% % 8
Lymphocyte
# 10^9/L 1.00-3.00 1.48
Lymphocyte
% Monocyte % 2.9
# Monocyte 10^9/L 0.20-1.00 0.54
% Eosinophil % 0.1
# Eosinophil 10^9/L 0.02-0.50 H 1.68 Patient has eosinophilia.
% Basophil % 0.3
# Basophil 10^9/L 0.02-0.10 0.06
% Imm. % 1
Granulocyte

RFT
*To detect any signs of renal injury/ electrolyte imbalance.
Interpretation : Normal kidney function.
Sodium mmol/L 136-145 141
(Serum)
Potassium mmol/L 3.6-5.2 3.6
(Serum)
Chloride mmol/L 99-109 102
(Serum)
Total CO2
(Serum)
Anion Gap mmol/L 10-20 15
(Serum)
Urea (Serum) mmol/L 3.2-8.2 4.4
Creatinine umol/L 44-71 64
(Serum)
eGFR >90 >90
ml/min/1.73m^2

Urine FEME :

Biochemistry

pH : 6 (5.5-7.0)

Specific Gravity : 1.017 (1.015-1.060)

Leukocyte Esterase I : Negative

Protein (I) : Negative

Urobilinogen (I) : Negative

Bilirubin (I) : Negative

Hemoglobin : Negative

Microscopy

Nil

*Urinalysis shows no signs of urinary tract infection.

Imaging

Chest XRay : Clear

Management

Surgery : The newer method to treat appendicitis is the laparoscopic surgery. This surgical procedure
consists of making three to four incisions in the abdomen, each 0.25 to 0.5 inches (6.4 to 12.7 mm)
long. This type of appendectomy is made by inserting a special surgical tool called laparoscope into
one of the incisions. The laparoscope is connected to a monitor outside the person's body and it is
designed to help the surgeon to inspect the infected area in the abdomen. The other two incisions
are made for the specific removal of the appendix by using surgical instruments. Laparoscopic
surgery also requires general anesthesia and it can last up to two hoursPatient undergone
laparoscopic appendicectomy successfully, without complications.

Pain : Pain medications (such as morphine) do not appear to affect the accuracy of the clinical
diagnosis of appendicitis and therefore should be given early in the person's care. Historically there
were concerns among some general surgeons that analgesics would affect the clinical exam in
children and thus some recommended that they not be given until the surgeon in question was able
to examine the person for themselves.

Final Diagnosis

Acute Appendicitis

Outcome

Post-op Day 1

Patient was generally well, pain is tolerated. He was discharged the next day.
Discussion

Appendicitis by definition is the inflammation of the appendix. Acute appendicitis is known to be one
of the commonest cause of abdominal pain. Although the cause has remained unknown up to this
day, there are a few causes that could play a part, including obstruction of lumen by faecolith,
swollen Payers Patch, a stricture, carcinoid tumour at the base and threadworms.

History-wise, most often appendicitis involves people of younger age. This matches with patients
background as he is in his early twenties. The symptoms typically present as a vague, often colicky
pain that begins in the centre of the abdomen and later on shifts to the right iliac fossa, becoming
more severe. This typical history is almost diagnostic of acute appendicitis as described as the
patient during history taking as acute appendicitis is a clinical diagnosis.

At the other end of the spectrum, there are patients who come with atypical presentations such as
pain at both sides simultaneously or no pain at all. The pathophysiology behind the pain can be
explained through the process behind referred pain. The central pain that the patient felt is a
referred pain. The normal visceral innervation of the appendix comes from the tenth thoracic spinal
segment. The corresponding somatic dermatome encircles the abdomen at the level of the
umbilicus.

A loss of appetite usually precedes the onset of pain by a few hours, and most patient feels slightly
nauseated. Many patient vomit once or twice, as experienced by Aakash, the patient.

On examination, typical general presentation would be a low-grade pyrexia, and an elevated pulse
rate as the infection spreads. If lymphadenopathy is found on head and neck examination, patient
may have mesenteric adenitis instead of appendicitis but they are cases where acute appendicitis
follows a viral investigation

On abdomen, there are a few sings that point out towards appendicitis such as :

Dunphy's sign: Increased pain in the right lower quadrant with coughing.

Kocher's (Kosher's) sign: From the person's medical history, the start of pain in the umbilical region
with a subsequent shift to the right iliac region.

Obturator sign: The person being evaluated lies on her/his back with the hip and knee both flexed at
ninety degrees. The examiner holds the person's ankle with one hand and knee with the other hand.
The examiner rotates the hip by moving the person's ankle away from the his/her body while
allowing the knee to move only inward. A positive test is pain with internal rotation of the hip.

Psoas sign: Also known as the "Obraztsova's sign" is right lower-quadrant pain that is produced with
either the passive extension of the right hip or by the active flexion of the person's right hip while
supine. The pain that is elicited is due to inflammation of the peritoneum overlying the iliopsoas
muscles and inflammation of the psoas muscles themselves. Straightening out the leg causes pain
because it stretches these muscles, while flexing the hip activates the iliopsoas and therefore also
causes pain.

Rovsing's sign: Pain in the lower right abdominal quadrant with continuous deep palpation starting
from the left iliac fossa upwards (counter-clockwise along the colon). The thought is there will be
increased pressure around the appendix by pushing bowel contents and air towards the ileocaecal
valve provoking right sided abdominal pain.

Patient elicited positive findings on signs with green fonts.

Investigation-wise, patient with acute appendicitis often presents with leucocytosis. Nevertheless,
blood investigation is not a diagnostic tool for acute appendicitis. Apart from the routine
investigations, ultrasound and CT scanning and laparoscopy are all useful in diagnosis and
management.

Laparoscopy is most valuable in diagnosis. In ultrasound, the finding of an enlarged appendix is

highly suggestive of appendicitis but a negative ultrasound does not exclude appendicitis because
ultrasound is a user-dependent modality. Ct scanning is increasingly used in diagnosis of appendicitis
in elderly patients with high operative risk.

Management is started immediately after diagnosis, which is appendicectomy, now usually done
laparoscopically although it may also be done through a small transverse incision in right iliac fossa.
Prophylactic antibiotic therapy reduces the incidence of wound infection.

Conclusion

Acute appendicitis is generally a spot diagnosis as it comes with typical presentation, most of the
time. The management is definitive, that is appendicectomy and is usually done in an emergency
setting. There are alternatives to treatment if patient is not keen on undergoing surgery. Antibiotics
and pain killers can e prescribed but the risk of perforation and peritonitis is high. Elective
appendicectomy is a choice after successful non-surgical management of appendiceal mass/
recurrent appendicitis but this is rare.

Reference

Browse, N. L. (2015). An introduction to the symptoms and signs of surgical disease (5th ed.).
Florida: CRC Press.
Henry, M. M., & Thompson, J. N. (2012). Clinical surgery. Edinburgh: Saunders Elsevier.
Nalliah, D. S., D. S., Sinniah, D. D., & Nagandla, D. K. (2012). Excellence In Clinical Case
Presentation In Surgery and Paediatrics (1st ed.). Melaka, Malaysia: Colour Box Publishing
House.