Abdominal Pain Case Presentation

DEPARTMENT OF SURGERY
NORTHERN MINDANAO MEDICAL CENTER

Towards Excellence in Patient Care and Safety

Clerks Presentation

SC Ian Christian A. Gonzales
XU JPRSM

GENERAL OBJECTIVE:
To present a case of a 28 year old male
presenting with abdominal pain

SPECIFIC OBJECTIVES:
to present the history and physical examination
to discuss anatomy, functions, incidence,
pathogenesis, and management of the
diagnosis
M.E.
28 year old male
Filipino
Roman Catholic
Manticao, Misamis Oriental
March 2, 2014.
General Data

Abdominal pain
Chief Complaint

Morning PTA
Sudden abdominal pain in the epigastric
area, persistent, diffuse in quality, non-
radiating, with a pain score of 8/10
aggravated by physical activity and
unrelieved by rest
History of Present Illness

Associated anorexia and nausea
(-) fever, change in BM, dysuria, flank pain

12 hours PTA
Abdominal pain now localized to the
right lower quadrant with a pain score
of 10/10.

(-) hypertension
(-) diabetes
(-) bronchial asthma
(-) previous hospitalization
(-) previous surgery

Past Medical History

hypertension on the paternal side

Family History
Personal/Social History
laborer
high school graduate
non smoker, non alcoholic


Physical
Examination
awake, coherent, afebrile, not in
respiratory distress

General Survey
Vital Signs
BP: 100/70 mmHg Wt: 50kg
HR: 82 bpm BMI: 20kg/m2
RR: 20 cpm
Temp: 36.9 C


acyanotic
(-) jaundice
(-) pallor
warm
good turgor
Skin

anicteric sclerae
pinkish palpebral conjunctivae
(-) alar flaring
moist lips, tongue, and oral mucosae
(-) oropharyngeal lesions
HEENT

trachea in midline
non palpable thyroid gland
(-) cervical lymphadenopathy

Neck

symmetric chest expansion
(-) retractions
clear breath sounds

Chest and Lungs

normal rate
regular rhythm
(-) heaves/thrills
(-) murmur

Cardiovascular System

flat
normoactive bowel sounds
soft
(+) direct tenderness, RLQ
(+) rebound tenderness, RLQ
(+) Rovsings sign
Abdomen

(-) costovertebral angle tenderness

Genitourinary System
symmetric, brisk pulses
(-) edema
CRT < 2 sec

Extremities

(-) perianal lesions
good sphincter tone
(-) rectal mass
non palpable prostate gland
(+) greenish fecal mater examining
finger
(-) pararectal tenderness
(-) blood on examining finger
Rectal Exam

Salient Features
sudden, severe abdominal pain of
localizing RLQ area
anorexia
nausea
History

Physical Examination
(+) RLQ tenderness
(+) RLQ rebound tenderness
(+) rovsing sign

Impression
Differentials
Rule In Rule Out
Urinary tract
infection
- sudden onset
abdominal pain
-nausea
- vomiting
- No dysuria
- No urinary
frequency
- No hematuria
Acute
gastroenteritis
-abdominal pain - No episodes of
loose watery stool
Mesenteric
adenitis
-right lower
quadrant pain
-nausea
- No history upper
respiratory
infection
s
Course in the Ward
At the wards...
admitted at surgical ward
NPO
plan:
For E Appendectomy
Cefoxitin 1gm IVTT

Labs:
CBC
Hb 13.5 g/dL
Hct 41%
WBC 9,500/uL
Neutrophils 79%
Plt 312,000

Labs:
UA
Yellow
Clear
SpGrav 1.020
pH 6.5
(-) sugar, (-) protein
WBC 0-1, RBC 0-1, Epith rare

Labs:
Chemistry
Na 144.30 mEq/L
K 4.5 mEq/L

Intraop findings:
Gangrenous appendicitis


Case Discussion
first becomes visible in the eighth week of
embryologic development
displaced medially toward the ileocecal
valve (growth rate of the cecum exceeds
that of the appendix)
Relationship of base is relatively fixed
Tips may be variable (retrocecal, pelvic,
subcecal, preileal, or right pericolic)
Anatomy

taeniae coli converge important
landmark to identify the appendix
Length varies from length <1 cm to
>30 cm (Average: 6 to 9 cm)
Blood supply: appendiceal artery
ileocolic artery superior
mesenteric artery

Lymphoid tissue first appears in the
appendix approximately 2 weeks after
birth
immunologic organ secretes
immunoglobulins (IgA)
Appendectomy may have a protective
role against IBD (mechanism unclear)
Functions

second through fourth decades of life
mean age of 31.3 years
median age of 22 years
male:female predominance (1.2 to 1.3:1)
rate of misdiagnosis (15.3%)
lifetime rate of appendectomy is 12%
for men and 25% for women

Incidence

Obstruction of the lumen
Fecaliths
hypertrophy of lymphoid tissue
inspissated barium from previous
x-ray studies
tumors
vegetable and fruit seeds
intestinal parasites

Etiology

Pathogenesis
proximal obstruction of the
appendiceal lumen
closed-loop obstruction
continuous normal secretion
by the appendiceal mucosa
lumen distension
Stimulation of the nerve
endings of visceral afferent
stretch fibers
vague, dull, diffuse pain in
the midabdomen or lower
epigastrium
peristalsis
cramping
continuous normal secretion
by the appendiceal mucosa
Increased magnitude of
lumen distension
continued mucosal secretion
& rapid multiplication
bacteria
Venous pressure is exceeded
more severe
diffuse visceral
pain
Reflex nausea and vomiting
Occlusion of capillaries and venules; arteriolar
inflow continues
Inflammation of the
appendiceal serosa
Compromise of
arteriolar outflow
Peritoneal irritation with
shift of pain in the
region of inflammation
engorgement and vascular congestion
Progressive distension
ellipsoidal infarcts @
antimesenteric border
Perforation
Escherichia coli
Bacteroides fragilis

principal organisms seen in the
normal appendix, in acute
appendicitis, and in perforated
appendicitis
Bacteriology


Abdominal pain
Epigastric then localizing to the
RLQ within 1-12 hours
Variations:
Retrocecal flank/back pain
Pelvic suprapubic pain
Retroileal testicular pain
Symptoms

Anorexia nearly always accompanies
appendicitis
vomiting occurs in nearly 75% of
patients (neural or ileus)
Usual sequence :
Anorexia abdominal pain
vomiting

RLQ tenderness
RLQ rebound tenderness
Rovsings sign
Psoas sign
Obturator sign
Signs

CBC (WBC count):
10,000 to 18,000 cells/mm3 (acute,
uncomplicated appendicitis)
>18,000 cells/mm3 (complicated
appendicitis., possible perforated
appendix +/- abscess)

Laboratory Findings

designed to
improve the
diagnosis of
appendicitis and
was devised by
giving relative
weight to
specific clinical
manifestation
Alvarados Scoring
importance of early operative intervention
(appendectomy) should not be minimized
Adequate hydration
Correct electrolyte abnormalities
Stabilize comorbidities

Management

Antibiotics
simple acute appendicitis no need to
extend coverage beyond 24 - 48 hours
(single-agent therapy with cefoxitin,
cefotetan, or ticarcillin-clavulanic acid)

perforated or gangrenous appendicitis
continued until afebrile or has decreasing
white count , 7-10 days (single-agent
therapy with carbapenems or combination
therapy with a third-generation
cephalosporin, monobactam, or
aminoglycoside plus anaerobic coverage
with clindamycin or metronidazole)



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DEPARTMENT OF SURGERY

NORTHERN MINDANAO MEDICAL CENTER

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