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ADMISSION CONFERENCE 2010 ASMPH Clerkship – SURGERY ROTATION St. Martin de Porres Charity Hospital 02 August 2010 Admissions from August 2-August 8, 2010 # Patient ID Admitting Diagnosis Operation Done Final Diagnosis 1 RJ,23/M Ileocecal Tuberculosis, Ulcerohypertrophic type 2 JP,15/M Small Bowel Obstruction probably 2’ to Ruptured AP Ileocecal Tuberculosis, Ulcerohypertrop hic type “E” Small Bowel Exploratory Obstruction Laparotomy, probably 2’ to Appendectom Ruptured AP y 3 RM,42/M Cholelithiasis Lap Chole Cholelithiasis 4 MA,18/F Fistula in ano Fistulotomy Fistula in ano Admissions from August 2-August 8, 2010 # Patient ID Admitting Diagnosis 5 GV,45/F Calculous Cholecystitis Acute 6 EA,63/F Cholecystitis 7 NV,77/F Operation Done Final Diagnosis Lap Cholecystectomy Lap Cholecystectomy Calculous Cholecystitis Calculous Cholecystitis Femoral Partial Hip neck replacement fracture Garden Type IV 8 MM,25/M Acute “E” Appendicitis Appendectomy Femoral neck fracture Garden Type IV Ruptured Appendicitis General Data • RJ, 23/M • CC: RLQ pain HPI 7 mos PTA (+) intermittent epigastric pain. Stabbing character. Aggravated by oral intake. Alleviated when eats less, passing flatus, and belching. Associated with bloating and vomiting. No radiations. 5/10 severity. -Pt sought consult with local doctor treated as dyspepsia, given meds w/c provided no relief. Subjective Findings • 3 mos PTA - Persistence of epigastric pain. Pt’s relatives noted gradual weight loss. Undocumented fever. Persistence of pain prompted consult with another doctor. - EGD procedure was done with negative results. Subjective Findings • 2 mos PTA - Pain localized to RLQ area. Colicky character. Aggravated by oral intake. Associated with bloating, vomiting, bulge in RLQ, 28% wt loss, and alternating diarrhea (2-5x/day) with constipation (2-3days). Alleviated when eats less, passing flatus, belching, and massaging RLQ. No radiations. 8-9/10 severity. Subjective Findings • 2 mos PTA -CT scan and colonscopy was done at De Los Santos Medical Center. - CT scan revealed ileitis with mild colitis of the cecum. Associated few ileocecal regional mesenteric lymphadenopathies. Subjective Findings • 2 mos PTA - Colonoscopy revealed inflammatory bowel disease. - Biopsy revealed chronic iliocolitis with ulcer, granulation tissue, benign lymphoid aggregate and reactive epithelial change. - Prednisone was given w/c afforded temporary relief. Subjective Findings • 1 mo PTA - Repeat colonoscopy was done, ileocecal TB was considered. - Surgery was recommended due to obstructive symptoms hence admission. ADMISSION Subjective Findings • ROS: General: (+) Fever, weight loss, weakness Musculo/Skin: (–) Rashes, joint pains, jaundice, muscle pains HEENT: (–) Headache, tinnitus, deafness cough, colds, enlarged LN Resp: (–) Dyspnea, hemoptysis, wheeze Cardio: (–) Palpitations, chest pains, syncope GI: (–) Inguinal lymphadenopathies Genitourinary: (–) Nocturia (–) Dysuria, hematuria Endocrine: (–) Excessive sweat, heat intolerance, cold intolerance Subjective Findings • Past Medical History: – (+) Mumps, 13 y/o – (–) Allergies to food or medicines – (+) BCG – (–) TB Subjective Findings • Family history: – (+) Diabetes, – (+) Hypertension • Social history: Smoker; 1.6 pack years, occasional alcoholic beverage drinker Objective Findings • • • • • • • Height: 165cm Weight: 42kg BMI: 15 BP: 100 / 70 Temp: 36.7°C HR: 106 RR: 22 Objective Findings • Gen: Alert, Coherent, Not in Resp. distress • HEENT: Anicteric sclera, pink palpebral conjunctiva, (–) CLAD, (–) TPC, Dry tongue and buccal mucosa, Flat neck veins • Cardio: Adynamic precordium, Apex beat 5th LICS MCL, Normal rate, Regular rhythm, (–) Murmur • Pulmo: SCE, Resonant lung fields, Clear breath sounds, (–) Crackles and wheezes Objective Findings • GI: Scaphoid, hypoactive bowel sounds, tympanitic, soft, (+) Direct tenderness on deep palpation of RLQ, (–) Rebound, (–) Masses organomegaly, surgical scar • Extremities: Pulses full and equal, (–) edema, cyanosis, good turgor • DRE: (–) skin tags, (–) perianal masses or tenderness, Good sphincter tone, (–) Pararectal tenderness or masses, Empty rectal vault, feces on tactating finger Salient Features • 23/M • Colicky RLQ pain. • Associated with bloating, vomiting, bulge in RLQ, 28% wt loss, fever, and alternating diarrhea (25x/day) with constipation (2-3days). • Aggravated by oral intake. • Alleviated when eats less, passing flatus, belching, and massaging RLQ. • No radiations. • 8-9/10 severity. Salient Features • GI PE: Scaphoid, hypoactive bowel sounds, tympanitic, soft, (+) Direct tenderness on deep palpation of RLQ, (–) Rebound, (–) Masses organomegaly, surgical scar • DRE: (–) perianal masses or tenderness, Good sphincter tone, (–) Pararectal tenderness or masses, Empty rectal vault, feces on tactating finger Dx Labs: Salient Features • (–) EGD • CT revealed ileitis and mild colitis of the cecum. Regional mesenteric lymphadenopathes. • Colonscopy revealed chronic ileocolonic inflammation, T/C ileocecal TB. • Biopsy of ileocecal area revealed chronic ileocolitis with ulcer, granulation tissue, benign lymphoid aggregates, reactive epithelial change. No granuloma or dysplasia. Assessment • Primary Impression: Ileocecal Tuberculosis, Ulcerohypertrophic type • Differentials: – Chronic Inflammatory Bowel Disease: Chron’s – Lymphoma – Colon Cancer Plan • Diagnostic Plan: – CBC – ESR – PPD – CXR – CT abdomen – AFB of biopsy – PCR of biopsy – Culture of biopsy Plan • Anti- TB Medications (WHO Tx of TB Guidelines, 2009) – Anti-TB Drugs: Pulmonary and extrapulmonary disease should be treated with the same regimens. (Strong/High grade of Evidence) • Surgery for late complications Text here Right hemi? colectomy and anastomosis RETURN TO TABLE Identifying Data • JP, 15/M • Date of birth: August 9, 1995 • Currently resides in Bonifacio Exit, Bagong Silangan QC • Date of admission: August 3, 2010. 9:45 am • CC: Abdominal Pain and Distention Subjective Findings: HPI • 5 days PTA • • • • • Persistent hypogastric pain Pain scale of 7/10 No radiation On and off fever Sough consult in a local health center – diagnosed with UTI – Given Co-Amoxiclav and Domperidone – Treatment offered partial temporary relief Subjective Findings: HPI • 3 days PTA • Hypogastric pain localized to the LLQ • 7 episodes of vomiting of previously ingested food • 7 episodes of diarrhea – Stools described as wet and yellow Subjective Findings: HPI • 2 days PTA • Abdominal distention noted to be relieved by vomiting • Persistence and development of new symptoms led to admission in East Avenue – – – – Treated as AGE Unrecalled IV medication Placed on NPO NGT inserted Subjective Findings: HPI • 1 day PTA • Allowed to eat • Abdominal distention worsened with each meal • Abdominal pain now described as diffuse accompanied by abdominal rigidity • Persistence of diarrhea and ADMISSION vomiting Subjective Findings: ROS • ROS – – General • (-) changes in weight, (-) fatigue, (-) weakness – HEENT • (-) headache, (-) colds, (-) enlarged lymph nodes – Respiratory • (-) cough, (-)dyspnea, (-) wheezing – Cardiovascular • (-) orthopnea, (-)palpitations, (-) chest pain – Gastrointestinal • (-)heartburn, (-)rectal bleeding, (-)jaundice – Genitourinary • (-)frequency, (-) hematuria, (-) nocturia Subjective Findings: PMHx • Past Medical History – No previous surgeries – Admitted at 1 y/o at Mary Johnson for amoebiasis – Treated for Primary complex for 9 months – No known co-morbids – No known food or drug allergies Subjective Findings • Family history: – Asthma • Social history: – Student – (-) Smoker – (-) Alcohol drinker – (-) Illicit drug user Objective Findings: Vital Signs • • • • • • • • Height: 160 cm Weight: 40.5 kg BMI: 15.8 - Underweight BP: 120/80 Temp: 37.5°C HR: 121 – tachycardic RR: 28 – tachypneic Abdominal Girth: 70 cm Objective Findings: PE • • • • Patient was alert, coherent but in severe pain Anicteric sclera, pink palpebral conjunctiva (-) TPC, (-) CLAD, (-) NVE Symmetric chest expansion, (-) chest retractions, (-) chest lag, bilaterally resonant with clear breath sounds, (-) adventitious breath sounds Objective Findings: PE • Adynamic precordium, PMI at 5th LICS MCL, tachycardic, Regular rhythm, (-) murmurs • Protruberant and distented, (-) surgical scars, hypoactive bowel sounds, direct and rebound tenderness on all quadrants • DRE: Not done as per patient request. • Full and equal pulses on all extremities, (-) edema, (-) cyanosis, CRT of 2 seconds Objective Findings: Labs Value Normal Remarks Hemoglobin 132 140-170 Low Hematocrit 0.36 0.40-0.50 Low WBC 8 4.5-10 Normal Neutrophil 0.60 0.56-0.66 Normal Lymphocyte 0.31 0.22-0.40 Normal Eosinophil 0.02 0.01-0.04 Normal Mean corpuscular Hgb 30.6 27-31 Normal Mean corpuscular Hgb concentration 365 320-360 High Mean cell volume 83.8 80-96 Normal RDW 12.2 11.5-14.4 Normal Platelet 405 150-350 High Objective Findings: Labs URINALYSIS Dark amber, slightly turbid pH alkaline specific gravity 1.015 RBC 2-3 per hpf WBC 4-5 per hpf Epithelium Many Mucus threads Abundant Amorphous Phosphates Moderate Albumin (+) Sugar (-) Objective Findings Labs Value Normal Remarks Bleeding time 3 mins 5 secs 2-4 mins Normal Clotting Time 3 mins 15 secs 2-4 mins Normal Prothrombin Time 12.9 10-13 Normal PT control 12 INR 1.08 % Activity 89.6 PTT 30 PTT Control 30 Creatinine Normal 29-34 Normal 63.10 44.16-150.16 Normal Na 132 138-146 Low K 3.8 3.6-5.0 Normal Objective Findings • CXR – Clear lung fields – Bony thorax intact – Heart magnified Objective Findings Objective Findings Objective Findings Salient Features • • • • • • 14 year old male Persistent pain on hypogastrum with localization to LLQ On and off fever Diarrhea and vomiting Dysuria Abdominal Distention worsened by eating and relieved by vomiting • Direct and Rebound Tenderness on all quadrants • Rigidity • X-ray Findings Assessment • Clinical Impression: Small Bowel Obstruction probably secondary to Ruptured Appendicitis • Differentials : – Peptic Ulcer Disease – Ileus – Meckel’s Diverticulum Plan • Diagnostic Plan: – CBC – Urinalysis – Electrolytes – Fecalysis – Abdominal X-ray – CXR – Ultrasound – CT-Scan Plan • Treatment Plan – Emergency Lapparatomy Appendectomy – Hydration – Antibiotics – Analgesics for pain – NPO RETURN TO TABLE Subjective Findings • MA, 18 F • CC: anal discharge Subjective Findings 4 Years PTA Noted a rectal mass, R perianal area (+)Tender (-) tenesmus (-)pain on defecation (-) fecal retension (-) soiling of underwear (-) no discharge (-) change in bowel movements (-) itch/rashes (-) blood in stools Consult was done at another hospital Incision and drainage Condition resolved Subjective Findings 1 year PTA Pain on defecation (+)Soiling of underwear (+) Purulent discharge (+) yellowish discharge (-) anal mass (-) tenesmus (-) tenderness (-) blood in stools Subjective Findings 1 week PTA Increasing pain on defecation Brownish discharge Palpated right perianal mass larger than the previous (-) tenesmus (-) fecal retension (+) soiling of underwear (-) change in bowel movements (-) perianal itch/rashes (-) blood in stools Subjective Findings (+) undocumented fever Persistence of symptoms prompted consult 1 day PTA August 2, 2010, 4:30 Subjective Findings • PMHx – s/p I & D 2006 – No known medical illness – No known allergy to food and drugs • FHx – (+) HPN – Heart disease • P/S Hx – student – Non-smoker – Non-alcoholic beverage drinker Sexual Hx - denies sexual contact LMP: July 4, 2010 Objective Findings Physical Exam • BP: 110/70 • Temp: 37.1 C • HR: 98 • RR: 15 • Pain Severity: 0/10 Objective Findings • Gen: Alert, Coherent, not in cardiorespiratory distress • HEENT: Anicteric sclera, pink palpebral conjunctiva, neck veins not engorged • Pulmo: Symmetric chest , clear breath sounds, (-) Crackles and wheezing • Caridio: Adynamic Precordium, Normal rate, Regular rhythm, (-) Murmur, good S1, S2 Objective Findings • Abdomen – Flat, soft abdomen – Normoactive bowel sounds – tympanitic – No palpable mass, No tenderness • Extremities • full and equal Objective Findings • Digital Rectal Exam – External opening 3 cm from anal verge. R posterior (7 o clock) – (+) yellowish pus discharge – Good external sphincter tone – (-) blood in examining fingers – (-) masses – (-) induration Assessment Fistula - in – ano Differentials 1. anal abscess 2. anal fissure Plan • • • • • • Fistulotomy Curretage Healing by secondary intension Sitz bath Biopsy of tract Possible use of drains/seton RETURN TO TABLE Subjective Findings • GV, 45/F • Residence: Taytay, Rizal • CC: recurrent RUQ abdominal pain for 11 years Subjective Findings • 11 years PTA • Colicky RUQ pain radiating to the back (after eating a heavy meal) • UTZ: cholelithiasis • Meds: Buscopan Plus 500mg OD • 2 weeks PTA • Same Sx + Abdominal fullness Subjective Findings • 8 hours PTA • After a heavy fatty meal: – RUQ pain radiating to the back – Severity score of 9/10 – No relief: Buscopan Plus Admitted August 2, 2010; 4pm Subjective Findings • ROS: – (-) weight gain, fever, jaundice, change in bowel/micturition habits, changes in sensorium • Current Medications: – NO maintenance medications – Vitamins: • Myra-E OD • Vit B Subjective Findings • Past Medical History: – No previous hospitalizations – No allergies: food and medicines – Surgeries: • s/p Appendectomy: 1970’s • s/p TAHBSO: stage II CA 2003 • Family History: – Hypertension: mother – Gallstones: 3 brothers – VACCINATION: (+) flu vaccine 8 mos ago Subjective Findings • • • • • Accountant Non-smoker Non-alcohol beverage drinker No exercise Diet: – Sweet – Fatty – Salty Objective Findings • • • • • • • Height 149cm Weight 52.6kg BMI 23.69 normal BP 110/80 HR 80 RR 18 Temp 36.9 degrees Celsius Objective Findings • HEENT: anicteric sclera, pink palpebral conjunctivae, no TPC, no CLAD, no neck masses • Chest: symmetrical chest expansion, resonant on percussion, clear breath sounds, no visible and palpable pulsations, distinct S1/S2, no murmurs Objective findings • Abdomen: no rigidity, no visible pulsations, surgical scars visible (8-9cm RLQ scar from a previous appendectomy procedure, 20-22cm horizontal scar from a previous TAHBSO procedure 10cm from the umbilicus), tympanitic on percussion, liver span 9cm at the MCL, no voluntary and involuntary guarding, smooth liver border, no palpable masses, (+) Murphy’s sign Assessment • Recurrent Calculous Cholecystitis • Differentials: – Peptic Ulcer Disease – Viral Hepatitis Plan • Surgical: Lap cholecystectomy (Dr. Cenon Alfonso) • Non-surgical Management: – Antibiotics – Analgesics – Watch out for 5 W’s • Advise on: – Food: fatty RETURN TO TABLE General Data • EA, 63/F • CC: RUQ pain HPI 1 Year PTA (+) intermittent epigastric and RUQ pain. Lasts for a few minutes. Associated with bloating. Alleviated by burping, flatus, massage of epigastrium. Aggravated with food intake. No radiations. Severity 1-2/10. -UTZ was done which revealed cholelithiasis. Subjective Findings • 1 year PTA -Dx and Tx as peptic ulcer disease, was given unrecalled medicines w/c afforded temporary relief. - Persistence and progression of symptoms prompted consult and subsequent admission. • Few weeks PTA ADMISSION Subjective Findings • ROS: General: (+) Weakness, loss of appetite (-) Fever Musculo/Skin: (-) Rashes, joint pains, muscle pain HEENT: (+) Sinusitis, dizziness (-) Headache, blurring of vision, tinnitus, cough, colds, enlarged LN Resp: (-) Dyspnea, hemoptysis, wheeze Cardio: (+) Palpitations (-) Chest pains GI: (+) Heart burn, (-) Nausea, vomiting , change in bowel movements, rectal bleeding Genitourinary: (-) Nocturia,Dysuria, hematuria Endocrine: (-) Excessive sweat, heat intolerance, cold intolerance Subjective Findings • Past Medical History: – (+) Hypertension, controlled ~ 10 years • Maintained on Losartan 50mg OD, Clonidine 75mg PRN. Normal BP: 130/80 – (+) Asthma, controlled ~ 40 years, • Maintained on Salbutamol and Fluticasone/Salmeterol – (+) Anxiety DO, ~25 years • Maintained on Alprazolam 500 mcg PRN – (+) Dyspepsia, 1 year • Maintained on antacids Subjective Findings • Past Medical History: – (–) Allergies to foods or medications – No recent vaccinations • Past Hospitalizations: – 2003 - R forearm fracture closed reduction – 1971 - H. mole D&C – 1970 – PID 2° IUD D&C – 17 y/o, Asthma in Acute Exacerbation Subjective Findings • Family history: – (+) Gall stone - Daughter • Social history: Non-smoker, non-alcoholic beverage drinker Objective Findings • • • • • BP: 140 / 80 Temp: 36.8°C HR: 78 RR: 20 Pain Severity: 0/10 Objective Findings • Gen: Alert, coherent, afebrile, not in cardioresp distress • HEENT: Anicteric sclera, pink palpebral conjunctiva, (–) TPC, (–) CLAD, flat neck veins • Caridio: Adynamic precordium, Apex beat 5th LICS, MCL, Normal rate, Regular rhythm, (–) Murmur • Pulmo: Symmetric chest expansion, Resonant lung fields, Clear breath sounds, (-) Crackles and wheezes Objective Findings • AB: Protuberant abdomen, NABS, tympanitic, soft, (–) Tenderness, Murphy’s sign, organomegaly, masses, surgical scars • Extremities: Full and equal pulses, (–) edema, cyanosis, good turgor • Skin: (–) Rashes, clean nails, dry hair Salient Features • • • • • 63/F Colicky RUQ pain Associated with bloating. Aggravated with food intake Alleviated by burping, flatus, massage of epigastrium. • No radiations. • Severity 1-2/10. • UTZ revealed cholelith in gallbladder. Assessment • Clinical Impression: Calculous Cholecystitis • Differentials : – Peptic Ulcer Disease – Cholangitis – Hepatitis – Acute Coronary Syndrome Plan • Diagnostic Plan: – Abdominal Ultrasound – CBC – Hepatitis Serology – ECG Plan • Treatment Plan – Cholecystectomy – IV Fluids – IV Antibiotics – IV Analgesics Numerous pigmented stones, ranging from ~1x1cm RETURN TO TABLE Subjective Findings • NV, 77/F • CC: hip pain Subjective Findings • • • • NOI: Fall POI: Paranaque City DOI: 8/1/10 TOI: 7 pm Subjective Findings • 2 hours PTA • (+) sharp pain on movement • Inability to ambulate • (+) numbness • (-) swelling, pallor, paresthesia, discoloration, crepitus • Xray done • Pain meds, referred for surgery Subjective Findings • ROS • • • • • (+) weight loss (-) fatigue, weakness, joint pains (-) tingling sensation (-) loss of consciousness (-) difficulty breathing, tachypnea, cyanosis, chest pain Subjective Findings • ROS • • • • • • (-) fever (-) edema (-) skin changes, jaundice (-) palpitations (-) chest pain (-) dysuria, hematuria, freq Subjective Findings • PMH/PSH • Cervical spondylosis, OA (1993) – Naproxen sodium – Almitrine/ raubasine (30/10mg) • HPN (1995) – Amlodipine 5mg OD • Patellar Fracture (2004) Subjective Findings • Obstetric history • P/SH • • • • Post-menopausal Not on HRT Non-smoker Non-alcoholic beverage drinker Objective Findings • VS • • • • RR: 18 HR: 86 T: 36.0 BP: 150/80 Objective Findings • Primary Survey – A: (-) signs of airway obstruction, (-) cervical spine injury – B: RR 18, (-) use of accessory muscles, SCE, patient is able to talk, lungs resonant, (-) cyanosis, (-) jugular venous distention, trachea midline Objective Findings Primary Survey – C: BP 150/80, pulses full and equal, (-) cyanosis, T: 36.0 – D: awake, alert, coherent. GCS 15, (-) motor, sensory deficits, (-) changes in mental status Objective Findings • HEENT • Pulmonary • Anicteric sclerae, pale palpebral conjunctivae, (-) TPC, (-) CLAD, flat neck veins • Symmetric chest expansion, equal tactile fremiti, lungs resonant, minimal bilateral bibasal crackles Objective Findings • Cardiovascular • Abdomen Adynamic precordium, Apex beat: 6th ICS MCL, distinct S1 and S2, (-) murmurs Flabby, (-) surgical scars, (-) masses, NABS, (-) bruits, tympanitic, (-) tenderness, (-) organomegaly, (-) CVA tenderness Objective Findings • DRE Did not consent Objective Findings • Extremities • L leg shorter and externally rotated • (+) L hip tenderness • (+) LOM in affected limb • (-) neurologic deficits • (-) loss of pulse Objective Findings • Xray • Complete fracture with total displacement of fracture fragment Assessment Femoral neck fracture Garden Type IV Garden Classification Plan: Treatment • Preoperative management – Preoperative traction – Pressure-reducing mattresses – Surgery performed once patient is medically stable (within 24 hours if possible) Plan: Treatment • Perioperative management – Operative tx is better than conservative tx – Surgical technique • Non displaced: screws better than pins • Displaced: hemiarthroplasty or total hip arthroplasty • Cemented arthroplasties superior to noncemented arthroplasties Plan: Treatment • Perioperative management – Regional anesthesia (reduces morbidity and mortality) – DVT prophylaxis for 10 days postoperatively – Antibiotics preop: wound, urinary, respiratory Plan: Treatment • Early post-operative mgt (7-10 days) – Nutrition, protein supplementation for malnourished patients – Initiate transition to rehabilitation – Prevent complications: DVT, PE, bedsores, pneumonia Plan: Treatment • Rehabilitation/ discharge planning – Exercise programs improve function, length of stay, institutionalization, activity of daily living mobility, and ambulation Prevention • • • • • • Prevent falls Increase physical activity External hip protectors Combination of folate and mecobalamin(B12) Vitamin D, calcium, and bisphosphonates HRT Screening • Bone density scan (DEXA) for osteoporosis RETURN TO TABLE 1 Subjective Findings • M.M. 25M • CC: abdominal pain 1 Subjective Findings HPI 1 day PTC 1 day history of periumbilical pain Localized to RLQ after few hours Persistent 8/10 Not aggravated/relieved by eating No radiation (+) vomiting (+) anorexia (-) fever (-) change in bowel movement Persistence of pain prompted consult Admission 1 Subjective Findings • ROS – No weight loss – No cough/colds – No dyspnea – No chest pain • Past Medical s/p CS 2007 Preeclampsia (+)Asthma FH • HPN • Asthma • PTB • PS Non-smoker Non-alcoholic beverage drinker • Obstetrics/gyne • LMP: July 21 • G1P1 (1001) • S/P CS 1 Objective Findings • On PE: – Vitals Temp: 37.6 C,HR: 86 RR: 19 – HEENT: • anicteric sclera, pink palpebral conjunctivae, moist tongue and buccal mucosa, – Cardiopulmonary • • • • Equal chest expansion Clear breath sounds Normal rate and rhythm Good S1, S2, no murmurs 1 Objective Findings Abdomen: • I: flat, (+) infraumbilical scar midline (from previous CS) A: normoactive bowel sounds • P: soft, (-) guarding, (+)RLQ pain direct and rebound, (-) Rovsing’s (+) Psoas and obturator sign, (-) cutaneous hyperesthesia, (-) Murphy’s sign , (-) Dunphy’s sign (+) CVA tenderness (R) Extremities – Full and equal pulses, no edema, no cyanosis DRE: patient refused DRE 1 Assessment • Impression: Acute Appendicitis • Differentials – UTI – Ureteral stones 1 Plan • Diagnostic Plan • Labs – Pregnancy test – Urinalysis – CBC • Imaging – Abdominal Ultrasound – CT scan of the abdomen 1 Plan • Treatment Plan – Emergency Appendectomy • Final dx: Suppurative appendicitis – Post op: antibiotics, pain relievers RETURN TO TABLE 1 Subjective Findings • M.M. 25M • CC: abdominal pain 1 Subjective Findings HPI 1 day PTC 1 day history of periumbilical pain Localized to RLQ after few hours Persistent 8/10 Not aggravated/relieved by eating No radiation (+) vomiting (+) anorexia (-) fever (-) change in bowel movement Persistence of pain prompted consult Admission 1 Subjective Findings • ROS – No weight loss – No cough/colds – No dyspnea – No chest pain • Past Medical s/p CS 2007 Preeclampsia (+)Asthma FH • HPN • Asthma • PTB • PS Non-smoker Non-alcoholic beverage drinker • Obstetrics/gyne • LMP: July 21 • G1P1 (1001) • S/P CS 1 Objective Findings • On PE: – Vitals Temp: 37.6 C,HR: 86 RR: 19 – HEENT: • anicteric sclera, pink palpebral conjunctivae, moist tongue and buccal mucosa, – Cardiopulmonary • • • • Equal chest expansion Clear breath sounds Normal rate and rhythm Good S1, S2, no murmurs 1 Objective Findings Abdomen: • I: flat, (+) infraumbilical scar midline (from previous CS) A: normoactive bowel sounds • P: soft, (-) guarding, (+)RLQ pain direct and rebound, (-) Rovsing’s (+) Psoas and obturator sign, (-) cutaneous hyperesthesia, (-) Murphy’s sign , (-) Dunphy’s sign (+) CVA tenderness (R) Extremities – Full and equal pulses, no edema, no cyanosis DRE: patient refused DRE 1 Assessment • Impression: Acute Appendicitis • Differentials – UTI – Ureteral stones 1 Plan • Diagnostic Plan • Labs – Pregnancy test – Urinalysis – CBC • Imaging – Abdominal Ultrasound – CT scan of the abdomen 1 Plan • Treatment Plan – Emergency Appendectomy • Final dx: Suppurative appendicitis – Post op: antibiotics, pain relievers RETURN TO TABLE