SURGICAL POSTING

CASE WRITE-UP 2

ACUTE APPENDICITIS

AHMAD FAIZ BIN MOHD EZANEE

1061048
GROUP B3

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Patient Data

Name: Noorini Bt Noordin

Age: 31 year-old
Sex: Female
Race: Malay
Registration Number: AM 00118220
Occupation: Housewife
Marital Status: Married with 2 children
Address: Cheras, Kuala Lumpur
Date of Admission: 14/07/2009
Date of Clerking: 14/07/2009
She was admitted on July 14th 2009 at 1.40pm. History was taken on July 14 th 2009 at
3.15pm.

Presenting Complaint

She complained of right iliac fossa region for 2 days prior to admission.

History of Presenting Complaint

Patient was apparently well until 2 days ago where she had sudden pain on the
right iliac fossa region. She started experiencing right iliac fossa pain at 8.15a.m. (12 th
July 2009) after taking her breakfast. It was described as sudden in onset, colicky in
nature, and came on and off. The pain was moderate in intensity and aggravated by
movement. Nothing relieved the pain except lying on the left side of the body on the day
of admission. Otherwise, the pain did not radiate elsewhere. The severity was described
as 6 out of 10. However, the pain was reduced on the next day in which was 2 out of 10.

The pain was associated with vomiting on the day second, where she was
vomiting for 2 times in one day. She vomited soon after meals and it contains food
particles in which yellowish in colour. On the first episode, the amount of vomitus was
minimal. However, on the second episode of vomiting the amount was a cup. The vomit
was not forcefully ejected which was non-projectile vomiting. She also had no nausea
and no fever. No haematemesis reported. She claimed that she lost her appetite after the
episodes of vomiting. She claimed that she always enjoy eating spicy food. Micturation
and defeacation was good. Patient complained of no difficulty in passing urine and stool.
She also not had any episode of dysuria, hematuria, urgency, frequency and diarrhea.

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However, she claimed that the urine was dirty. Otherwise, no per vaginal bleed noted by
the patient. Patient then soughed treatment at clinic and was given tablet of Buscopan and
of Ponstan. She claimed that the pain was relieved but she still felt uncomfortable.

Review of Systems

Respiratory system
No cough, sputum, dypsnoea, wheezing, shortness of breath (SOB) and chest
pain. No upper respiratory tract infection (URTI) symptoms. Otherwise, respiratory
system was normal.

Cardiovascular system (CVS)

No dyspnoea and orthopnea. No murmur sound and signs of heart failure.
Otherwise, CVS was normal.

Gastrointestinal System and Abdomen

No diarrhea or constipation. No dysphagia. No altered bowel habit. But there are
right iliac fossa abdominal pain, loss of appetite and vomiting.

Genitourinary System
No dysuria, heamaturia, and nocturia.

Musculoskeletal System
No myalgia, arthralgia or weakness. She was able to move all four limbs and able
to use all her five sense.

Central Nervous System (CNS)

No syncope or fits. CNS was intact.

Past Medical History

No known of medical history of diabetes mellitus (DM), hypertension (HPT),

ischemic heart disease (IHD), and asthma.

Past Surgical History

No known of surgical history.

Drug History

No known drug history. No known drug allergies too.

Family History

No known family history of any diseases.

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Social History

She was married; lived with her husband and has two children of aged 6 and 3
years old. Both child delivered by normal delivery. She did not work but she stayed at
home as housewife. She did not smoke and did not consume alcohol.

Reproductive History

She had her menarche when she was 15 years old. Last menstrual period was on
June 29th 2009. She has regular menstrual cycle with 5 to 6 days of menses of 30 days
cycle. She had completed her abortion 2 times in year 2000 and 2001.

General Examination

Patient was conscious, alert and uncomfortable. She was lying on her left side of
her body. She had an IV branula attached on the dorsum of her left hand in which was
connected to IV Metronidazole.

She had slight pallor on examination of her conjunctiva of the eyes and her palm.
Hydration was fair. No palmar erythema, Dupuytren’s contracture, visible muscle
wasting, cyanosis, pallor, clubbing of the fingers, and lymphadenopathy.

Her vitals upon admission are:

 Pulse rate: 97 beats per minute
 Respiratory rate: 20 breaths per minute
 Blood pressure: 140/78 mmHg
 SpO2: 97 % on air
 Temperature: 37.3oC

Hand
Hands were a bit sweaty but not warm. However, there was slight pallor of the
palm. No finger clubbing, peripheral cyanosis, palmar erythema or Dupuytren’s
contracture. Flapping tremor could not be elicited. Capillary refill time is less than 2
seconds. Pulse is regular in rhythm and the volume is good. No radioradial or
radiofemoral delay. No flapping tremors.

Arm
No bruising, scratch marks and spider naevi was found on the arms. There was no
loss of axillary hair. No collapsing pulse and trochlea nodes.

Face
Corneal arcus was present. Conjunctiva was slight pallor but no jaundice on the
sclera of both eyes. Oral hygiene and hydration status were fair. No fetor hepaticus. No
central cyanosis. No visible parotid swelling.

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Neck
Trachea was not deviated and lymph nodes were not visible.

Chest
On inspection, spider naevi was not present. There was no sign of breast diseases.

Leg
No oedema, loss of hairs, dries of skin or calf tenderness.

Systemic Examination

Gastrointestinal System and Abdomen

Inspection: Abdomen was scaphoid in shape. Abdomen was not distended. Abdomen
moves equally with respiration. No scar and no dilated vein or any visible pulsation and
peristaltic movement detected. Umbilicus was centrally located and inverted. No
discharge and nodule surrounding the umbilicus. There was no abnormality of the groin
and genitalia. There was no visible cough impulse in both inguinal hernia orifices.

Palpation: On palpation, abdomen was soft and tender at right iliac fossa region.
Temperature was normal. However, rebound tenderness and Rovsing’s sign were
positive. Otherwise, no guarding or rigidity elicited. No hepatomegaly and the liver
measured about 7 cm in which was normal. There was also no splenomegaly. The kidneys
were not ballot able. Renal punch was negative.

Percussion: On percussion, right iliac fossa region was resonance. No

hepatosplenomegaly. Shifting dullness and fluid thrill were negatives.

Auscultation: Bowel sounds were present and normal in which were 4 per minute.

Abdomen examination was end up with hernia orifices examination and per rectal (PR)
examination but patient refused, and both exams were not done.

Other Systemic Examination

Cardiovascular System
Inspection: No chest deformities, sternotomy or valvulotomy scars, dilated veins, spider
naevi or visible apex beat.

Palpation: Apex beat is felt at 5th intercostals space 1cm medial to the midclavicular line.
No parasternal heave, palpable P2 or thrills palpable.
Auscultation: S1 and S2 are heard at the mitral, tricuspid, pulmonic and aortic areas.
There was no murmur. No abnormalities detected.

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Respiratory System
Chest expansion was normal. Percussion was resonant. Tactile fremitus and vocal
resonance were normal. Lungs were clear to auscultation.

CNS & PNS

Examinations were not performed but both systems were grossly intact.

Summary

Noorini Bt Noordin, a 31-year-old Malay female, no known case of disease,

complained of pain in the right iliac fossa region for 2 days associated with 2 episodes
of vomiting for one day prior to admission. On examination, there were no abnormalities
detected but there was tenderness and positive rebound tenderness on the right iliac fossa
region. Rovsing’s sign was also positive.

Provisional Diagnosis

Acute Appendicitis
 Reasons for:
o Right iliac fossa pain
o Positive Rovsing’s sign
o Vomiting soon after eating
o Tenderness on right iliac fossa region
o Positive rebound tenderness
o Leucocytosis
 Reasons against:
o No periumbilical pain at first pain
o No constipation or diarrhea

Differential diagnosis

1.Urinary tract infections (UTIs)

 Reasons for:
o Slight pyrexia on admission
o Pain started at right iliac fossa region
 Reasons against:
o No history of dysuria, frequency, or urgency
o No loin tenderness
o No foul smelling urine

2. Meckle’s Diverticulitis
 Reason for:
o Low grade fever
o Leucocytosis

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 o Vomiting

 Reason against:
o No altered bowel habit
o No per rectal bleeding

Investigations
1. Full blood count (FBC)
Red Blood Cell 4.90 ( 4.20- 6.30)
Haemoglobin 12.0 g/dL ( 12.0- 18.0)
Haematocrit 39.3 % ( 37.0- 51.0)
Mean Cell Volume 80.2 fL ( 76.0- 96.0)
Mean Cell Haemoglobin 24.5 pg Abnormal ( 27.0- 32.0)
Mean Cell Haemoglobin Concentration 30.6 g/dL ( 30.0- 35.0)
Red Cell Distribution Width 12.3 % ( 11.6- 15.0)
Platelet 329 K/uL (140-440)
Mean Platelet Volume 8.4 fL ( 6.3- 10.2)
White Blood Cells 11.2 K/uL ABNORMAL ( 4.0- 11.0)
Percentage Of Neutrophil 75.4 % ABNORMAL ( 40.0- 75.0)
Absolute Neutrophil 8.4 ABNORMAL ( 2.0- 7.5)
Percentage of Lymphocyte 19.7 % Abnormal ( 20.0- 45.0)
Absolute Lymphocyte 2.2 ( 1.5- 4.0)
Percentage Of Monocyte 4.3 % ( 2.0- 10.0)
Absolute Monocyte 0.4 ( 0.2- 0.8)
Percentage Of Eosinophil 0.1 % Abnormal ( 1.0- 6.0)
Absolute Eosinophil 0.0 ( 0.0- 0.4)
Percentage of Basophil 0.4 % Abnormal ( 0.9- 2.0)
Absolute Basophil 0.0 ( 0.0- 0.1)

2. Abdominal X-ray (AXR)

3. Abdominal Ultrasound
Discussion

Acute appendicitis is a condition characterized by inflammation of the appendix.

Peak incidence is in the second and third decades of life. It is very uncommon before the
age of 2 years. Acute appendicitis is the common cause of acute abdominal pain and is an
emergency case with significant morbidity and mortality.
Pathologically, acute appendicitis can be due to obstruction or non-obstruction
cause of the appendix. In obstructive appendicitis, symptoms are abrupt, vomiting is
more, and tenderness is more. This type of appendicitis is dangerous. This is due to
obstruction that causes the contents inside the appendix like faecolith, worms, ova, or
cysts of entamoeba get infected fast and the tension increase. The appendix then becomes
a closed loop, which results in septic thrombosis of vessels. Gangrene of the appendix,
perforation, peritonitis, followed by a local abscess, can occur. In non-obstructive

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appendicitis, the process of inflammation is slow and gradual. A mild attack may
completely resolve or mucosal and sub-mucosal oedema can occur. Ulceration of the
appendix results in slow bacterial invasion of lymphoid tissue. Bacteria like E.coli,
Enterococci, Proteus, Pseudomonas, Klebsiella and anaerobes may produce inflammation
of the appendix and cause appendicitis.
My patient in this case, had a sudden onset of pain and colicky in nature, and the
pain was intermittent. The pain was moderate in intensity and aggravated by movement.
Nothing relieved the pain except lying on the left side of the body on the day of
admission. Otherwise, the pain did not radiate elsewhere. The pain also associated with
vomiting for 1 day in which she had 2 episodes of vomiting after meals and slight
pyrexia. These symptoms suggest a gastrointestinal pathology.
On examination, no abnormality was detected on her abdomen. However, the
right iliac fossa was tender on palpation. Rebound tenderness and Rovsing’s sign were
positive which indicates inflammation in the parietal peritoneum. However, no guarding
or rigidity elicited.
Investigation wise, only full blood count (FBC) was done. Total white blood cell
was elevated which was 11.2 x 109/L. This indicates that there was inflammation occur in
the body. Neutrophil was slightly elevated which indicates bacterial infection. Other
investigations that should be done are abdominal X-ray and abdominal ultrasound.
Abdominal X-ray is taken in erect position to rule out perforation of the appendix.
Abdominal ultrasound is done to rule out other causes including gynaecological causes.
Management of the patient should start with antibiotics to reduce the infections.
Antibiotics like metronidazole and cefuroxime can be given. Prompt appendicectomy
must be done then. Confirmation of appendicitis can be made after the operation. The
operation can not be delayed as complication such as perforation, appendix mass and
appendix abscess may occur.

References
1. Browse’s introduction to the symptoms and signs of surgical disease, 4 th edition,
Norman L.Browse, John Black, Kevin G. Burnand, William E.G. Thomas
2. http://en.wikipedia.org
3. Aids to clinical surgery, Mr Mohd Zamrin Dimon
4. Manipal manual of surgery, 2nd edition, K.Rajagopal Shenoy.