Hannah Tanbonliong. J.C. 36/M December 24, 1975 Filipino Catholic Makati City Date of Admission: March 21, 2012.

Hannah Tanbonliong

• J.C.• 36/M• December 24, 1975• Filipino• Catholic• Makati City• Date of Admission: March 21, 2012

2 days PTA • Epigastric pain• Non-radiating• Crampy• HNBB no relief

1 day PTA

• Epigastric pain• Radiating to RLQ• Crampy• No N/V• No fever• No change in BM• Polymedic

Hospital WBC 15.35

A

• No DM, HTN, CA, PTB, cardiac, kidney, or lung diseases.

• No known allergies.• No previous surgeries or hospitalizations.

• + Stroke• No HTN, DM, CA, cardiac, kidney or lung diseases.

• 3rd year college• Call center agent• 10-pack-year smoker• 4-5 bottles of beer per week• No illicit drug use

• General: No changes in weight, change in appetite, easy fatigability, or fever.

• Skin: No rashes, lumps, sores, or itchiness.

• Head, Eyes, Ears, Nose, Throat (HEENT). No dizziness, hearing loss, diplopia or headaches.

• Neck: No enlarged lymph nodes. No swollen glands.

• Respiratory: No dyspnea or cough.

• Cardiovascular: No chest pain, palpitations, or syncope.

• Gastrointestinal: No nausea, diarrhea, constipation.

• Urinary: No dysuria, hematuria or flank pain.

• Musculoskeletal: No muscle pain, joint pain or swelling.

• Endocrine: No excessive thirst, heat intolerance, polyuria or cold intolerance.

Alert and coherent. GCS15.

Vital Signs:

•Height of 160cm

•Weight of 69.5kg

•BMI of 27.1 kg/m2 (overweight)

•BP 110/60

•HR 80 bpm and regular

•RR 23 breaths per minute

•Temp 36C

• Skin: Warm, normal skin color, no rashes or lesions.

• Head, Eyes, Ears, Nose, Throat (HEENT): Ancteric sclera, pink palpebral conjunctiva. EBRTL 2mm No tonsillo-pharyngeal congestion.

• Neck: Trachea is midline. No enlarged lymph nodes. No nuchal rigidity.

• Pulmonary: Normal shape of chest and movement. No scars, birthmarks, discolorations. Normal respiratory expansion/symmetric. No masses or tenderness. Clear breath sounds, no crackles or wheezing.

• Cardiac: Apex beat at the 5th left ICS, MCL. Distinct S1 and S2, no murmurs. Increased heart rate with normal rhythm. No heaves or thrills.

• Abdomen: Flat abdomen, no scars. Normoactive bowel sounds. Tympanitic on percussion of all quadrants. Liver span of 10 cm MCL. No hepatosplenomegaly. Soft. Tender on palpation of RLQ, no masses, liver edge is smooth. (-) Murphy's, (-) rebound tenderness, (+) Rovsing’s, (-) Obturator sign. No CVA tenderness.

• DRE: No skin tags, visible lesions. Good sphincter tone. No masses, fissures or impacted fecal matter. No blood on examining finger.

• Extremities: No lesions, edema, cyanosis or clubbing of finger nails. With good turgor. Full and equal pulses on all extremities.

• 36/M• Epigastric RLQ pain• + Direct Tenderness• + Rovsing’s Sign

• Acute Appendicitis

Rule InRule In Rule OutRule Out

AppendicitisAppendicitis

•Pain migrating to the RLQPain migrating to the RLQ•Sudden onsetSudden onset•(+) Rovsing’s Sign(+) Rovsing’s Sign•(+) Direct Tenderness(+) Direct Tenderness

Meckel’s Meckel’s DiverticulitisDiverticulitis

Same clinical picture as Same clinical picture as appendicitisappendicitis

Acute Acute Epididimytis/ Epididimytis/

Testicular Testicular TorsionTorsion

•MaleMale•Sudden onset of painSudden onset of pain

•(-) groin pain, inguinal (-) groin pain, inguinal painpain•(-) scrotal erythema/ (-) scrotal erythema/ warmth on touchwarmth on touch•* Cremasteric reflex* Cremasteric reflex

NephrolithiasisNephrolithiasisMidureteral calculi can cause Midureteral calculi can cause pain in the RLQ and mimic pain in the RLQ and mimic appendicitisappendicitis

•(-) urinary signs(-) urinary signs•(-) hematuria(-) hematuria•Pain migration (left to Pain migration (left to Right), peritoneal signsRight), peritoneal signs

• Acute inflammation of the appendix

• Common cause of acute abdomen at the 2nd to 4th decade of life (mean of 30 y.o.)

• Stages:

• Obstructive

• Suppurative

• Gangrenous

• Perforated

RLQ pain, maximal at McBurney’s pointPeritoneal signs:

Rebound tendernessRovsing’s signObturator’s signPsoas signDunphy’s signMarkle’s sign

Guarding

CBCWBC> 10,000 per mm3 seen in 80% of casesLow predictive value, low specificity

UrinalysisC-Reactive protein

new suggested laboratory parameterLevels > 0.9mg/dL

All laboratory tests together--”highly sensitive” (97-100% sensitivity)

UTZblind-ending, nonperistaltic bowel loop from the cecumPOSITIVE:

>6mm in anteroposterior directionIdentify appendicolithThickening of the wall with periappendiceal fluid

NEGATIVE: Non-compressible appendix, measuring <5mm

UTZSensitivity: 55-96%Specificity: 85-98%Can identify abscessFastNo contrast neededCan be used in children and pregnant women

UTZFalse-positive

Periappendicitis from surrounding inflammationOther structures mistaken as the appendix

User-dependentObese patients

CT ScanDilated appendix (diameter > 5mm)Thickened wallFecalith 92-97% sensitivity, 85-94% specificity75-95% PPV, 95-99% NPV

CT-ScanExpensiveRadiation exposureAllergy to IV contrastNot available in all institutions*

AppendectomyOpenLaparoscopic

Less painLess hospital stayShorter admission time

•7x2cm appendix, non-suppurative