Question 1

1. Appendicitis 2. Further history would include: When the pain started and whether it was sudden or insidious Precipitants to the pain such as trauma, heavy lifting, fasting Character of the pain (Dull, sharp or colicky; progression) Associated symptoms such as sweating, hotness of body, change in bowel and urinary habits Timing in relation to food intake or diurnal Relieving and aggravating factors such as movements or lying still, analgesics, food Patients view on the severity of the pain Current medications Chronic illnesses such as diabetes Family history of Acute Intermittent Porphyria (AIP), history of neuropathies Ingestion of any foreign materials Prior abdominal or pelvic surgery 3. Further examination: General exam: Observe posture Pulse rate Temperature readings Respiratory rate Blood pressure Lymphadenopathy Abdominal exam would try to elicit: Therapeutic scars (or absence thereof) Obvious swellings Movement with respiration Pointing sign (Ask patient to show you where the pain is) Masses on palpation Guarding at McBurney point Rebound tenderness and tenderness on vibration (Blumberg sign) Dunphys sign (Right iliac fossa pain on cough) Rovsings sign (Deep palpation of the left iliac fossa may cause pain in the right iliac fossa) Psoas sign (Right iliac fossa pain on extension of the right hip if appendix lies along psoas muscle) Obturator test (Hypogastric pain on flexion and internal rotation of right hip in a pelvic appendicitis) Markle sign (Right iliac fossa pain when standing patient drops from toes to heels)

H31/22852/2008 2 Surgery rotation assignment

4. Relevant investigations may reveal: FHG with WBC differentials Leucocytosis (mild suggestive of appendicitis; marked if complicated by perforation) usually >10,000 cells/mm3 Neutrophilia >75% Hb and platelet levels in view of surgery Liver Function Tests Normal bilirubin, ALP, GGT to rule out cholecystitis Normal amylase and lipase to rule out pancreatitis Urinalysis There may be pyuria. Done to exclude urinary tract disease; Diabetes mellitus Urea, Electrolytes and Creatinine Deranged electrolytes. C-reactive protein and Erythrocyte Sedimentation Rate: Elevation suggestive of acute inflammation Urinary porphobilinogen Normal values would rule out AIP Random Blood and urine glucose Normal values would rule out Diabetic Ketoacidosis Imaging options include: Abdominal CT scan with oral and IV contrast Reveals an enlarged appendix with thickened walls, which do not fill with colonic contrast agent Ultrasound Acutely inflamed appendix appearing as a tubular structure that is noncompressible, lacks peristalsis, and measures greater than 6 mm in diameter Abdominal X-ray Gas-filled appendix; radiopaque fecolith or ureteric calculi; deformed cecum; airfluid levels in a perforated appendix. Barium enema non-filling appendix; mass effect at the right lower quadrant Laparoscopy Diagnostic by direct visualisation; may be converted to a therapeutic procedure 5. Management: Alvarado score Supportive Fluid resuscitation with IV crystalloids Correct electrolyte imbalance Parenteral analgesics eg. IV diclofenac Definitive Nil per oral Nasogastric tube for evacuation Pre-op antibiotics Penicillin/Cephalosporin and Metronidazole

H31/22852/2008 3 Surgery rotation assignment Emergency appendectomy (open or laparoscopic)

Question 2
Management: In my Primary Survey, I would: Assess and establish patency of his Airway with the jaw thrust method removing any foreign objects and secretion. Consider endotracheal intubation if patency is difficult to maintain. Stabilize the cervical spine with a rigid cervical collar. Expose his chest and assess Breathing by inspection, palpation and auscultation. Administer oxygen at a high flow rate. If necessary, I would also: Drain a massive haemothorax with tube thoracostomy Decompress a tension pneumothorax with needle thoracostomy Administer analgesia for a flail chest Occlusive dressing for an open pneumothorax Assess the Circulatory status. Insert two wide bore IV catheters (taking samples for grouping and cross matching and other necessary tests) and begin immediate infusion of fluids beginning with a 1-2 L bolus of preheated crystalloids, totalling 3 times the estimated blood loss (2L*3). When blood is ready, transfuse. Apply pressure dressings to control any severe external haemorrhage. Grade the level of neurologic Disability according to the GCS. Re-evaluate the airway, breathing and circulation if he scores low. Expose him by removing his clothes and examine for other injuries then cover him with warm blankets as necessary. Monitor: Pulse oximetry Urine output (Avoid catheterisation in Respiratory rate urethral injury) Temperature Electrocardiography Arterial blood gases Central venous pressure if necessary Decompress stomach with a nasogastric tube In my Secondary survey, I would: Take a quick history laying emphasis on Allergies, Medications he uses, Past illnesses, Last meal, Events surrounding the injury. Perform a thorough physical exam on him from head to toe with emphasis on the chest exam for a haemothorax. Order a cervical spine x-ray, a chest X-ray, a pelvic x-ray, a CT scan in case of head injury and radiographs of limbs with suspected fractures. Splint any fractures discovered Re-evaluate his ABCDs assessing response to fluid therapy Consider definitive surgical intervention for treating continued haemorrhage + diagnosing internal haemorrhage