Beruflich Dokumente
Kultur Dokumente
Department of Surgery
2) Complications:
Nil
3) Associated Diseases:
Nil
PASSPORT DATA
SUBJECTIVE EXAMINATION
COMPLAINTS
The patient complains of pain at the right iliac region. It is felt as a stabbing pain. The
intensity of pain is severe. The pain increases while walking. It is relieved when the
patient is lying down.
He also complains of infrequent vomiting. It contains stomach contents.
Patient complains of fever.
He also complains of a poor appetite.
OBJECTIVE EXAMINATION
GENERAL INSPECTION
RESPIRATORY SYSTEM
The form of chest is barrel form. There is symmetry in both sides of the body. There is no
deformation. There are no changes in expansion of chest. State of intercostal region is
normal. He has abdominal type of breathing.
His respiration rate is about 18 breaths per minute.
He does not have any kinds of dyspnoea.
Palpation of the chest revealed normal conditions of the ribs, clavicles and intercostal
spaces. No pain was felt during palpation. The vocal fremitus was normal.
Comparative percussion showed resonant sound at the upper lobes but dull sound at the
lower lobes of both the lungs. The dull sound can be heard at the scapular line, at level of
the 9th intercostal spaces.
Topographic percussion:
Height (altitude) of apex pulmonaris:
i) 3 cm above clavicle
ii) 3 cm laterally to spinous process of 7th cervical vertebra.
Lower border of the lungs:
Percussion point
Right lung
Left lung
Parasternal line
5th intercostals space
th
Midclavicular line
6 rib
Anterior axillary line
7th rib
7th rib
Midaxillary line
8th rib
8th rib
th
Posterior axillary line
9 rib
9th rib
Scapular line
10th rib
10th rib
th
Paraspinal line
Spinous process of 11
Spinous process of 11th
thoracic vertebra
thoracic vertebra
Auscultation revealed normal breath sounds in the upper and lower lobes of the lungs.
There was an absence of any types of rales.
CARDIOVASCULAR SYSTEM
There was no cardiac humpback. The apex beat is strong. There were no abnormal
pulsations. There was no aortic arch pulsation, no carotid artery pulsation, and no
engorgement of jugular veins. There was also no undulation of neck veins. The trachea
was located at the midline. The peripheral arteries pulsation was also strong and quite
easy to find. There were no arrhythmic pulsations. There was no wriggleness of arteries
(worms sign). There was also no epigastric pulsation. Plesh sign was negative. Patient
did not have varicose veins.
Palpation of the apex beat showed the apex beat to be in the 5th intercostal space and was
located 2cm laterally from the midclavicular line, which is normal. The strength and
intensity of the apex beat was normal. There was no presence of thrills. The palpation of
aortic arch showed that the Oliver-Kardarelli symptom was absent. Palpation of the aorta
and pulmonary artery showed no changes. The radial artery pulsation was rhythmic.
There were no extrasystoles.
Percussion revealed normal configuration of the heart. The borders of the heart were
normal. The right border was at the 4th intercostal space, 1.5cm laterally from the
parasternal line. The left border was located at 5th intercostal space, 1.5cm medially from
midclavicular line. The upper border was at the lower border of the 3rd rib.
In auscultation, there were no changes in S1 and S2. Both sounds were perceived as
normal. The patients rhythm is rhythmic. There is an absence of murmurs and extra heart
sounds. Auscultation of vessels was normal.
Blood Pressure is 140/80
GASTROINTESTINAL SYSTEM
The oral cavity was normal. There was no abnormal odour. Inspection of teeth was
normal. Patient did not have any gold tooth. Colour of the gums was normal. There was
no bleeding, ulceration or suppuration. The mucous membrane of the oral cavity was
normal. There was no pigmentation, ulceration, cicatrices, cleft or palate.
The tongue size was normal. It is pink in colour. It is clean and not coated. The tongue is
moist. There was no papilla, ulceration, cracks or scars. The throat was normal. The
colour of the mucous membrane was normal. The tonsils were also normal.
The size of the abdomen was normal for the patients configuration. There was no
diverticulum and the belly was not retracted in the upper region of the abdomen. There
was no visible gastric or intestinal peristalsis. There was no stria and pigmentation. There
are no scars on his body. The umbilicus is normal.
There was tenderness and muscle guarding during surface palpation of the abdomen. The
Schetkin-Blumberg symptom was positive. There was tenderness in the McBurney point.
There were no tumours and no ascites.
The lower border of the stomach is normal, 2cm above the navel. Percussion of the
stomach did not present any pain. There was no succusion sound. Auscultation of the
stomach was normal.
The palpation of the intestine revealed no abnormalities. There was no tenderness and no
splashing sounds.
The percussion of the liver showed normal upper borders. At the right parasternal and
midclavicular line, liver dullness was heard at the 6th rib. It was at the 7th rib at the right
anterior axillary line. Palpation of the lower border of the liver was normal. The patient
did not feel any pain or tenderness.
Palpation of the gallbladder was normal. There was no pain.
Palpation of the spleen also revealed normal borders and was not painful.
Inspection of the lumbar area did not reveal any redness, swelling or oedema. There was
no pain during percussion.
The external examination of the genitals did not reveal any abnormalities.
PROVISIONAL DIAGNOSIS
Acute appendicitis.
PLAN OF TREATMENT
Operation: Emergency appendicectomy
LABORATORY TESTS
Urine Analysis
Colour: Yellow
Blood Analysis
19 nov 2014
RBC: 4.67
Hemoglobin: 152
Colour Index: 0.98
WBC: 14.4
Segmented: 74
Bent: 5
Basophiles: 1
Lymphocytes: 14
Monocytes: 2
ESR: 5
Blood Screening
Urea: 4.5
Creatinine: 405
Bilirubin:
General Protein:16.3
Glucose: 4.3
INSTRUMENTAL TESTS
Plain abdominal X-ray: absence of any mass in the intestine.
Abdominal ultrasound: NOT DONE
DIFFERENTIAL DIAGNOSIS
1. Right sided ureteric colic: hematuria, severe pain from loin to groin,
absence of cough
tenderness help in excluding acute appendicitis.
2. Amoebic typhilitis is associated with diarrhea, blood in the stools and
tenderness in
left iliac fossa (Manson Barrs amoebic point of tenderness)
3. Torsion of undescended testis: absence of testis in the scrotum clinches
the diagnosis.
4. Meckels diverticulitis.
2.
3.
4.
5.
It is common in white races more often than dark coloured persons. Young
males are affected more often.
It may be related to westernization of food a diet rich in meat precipitates
appendicitis and a diet rich in fibers (cellulose) protects the person from
appendicitis.
Familial susceptibility
It is related to having a long retrocaecal appendix in which case the blood
supply is diminished to the distal portion, which may precipitate appendicitis.
Socio-economic status
Appendicitis is common in middle class and rich people. The exact reasons
are not known.
Obstructive theory
Obstruction to the lumen of the appendix due to faecoliths, worms, ova, cysts
of entamoeba causes obstructive appendicitis.
Non-obstructive theory
It is due to bacteria like E.Coli, Enterococci, Proteus, Pseudomonas,
Klebsiella and anaerobes which produce diffuse inflammation of appendix and
cause appendicitis.
Pathogenesis
1. In non-obstructive cases (catarrhal appendicitis)
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.
Gangrene and perforation are rare.
2. In obstructive cases, symptoms are abrupt, vomiting, pain and tenderness are more.
It is a more dangerous variety. Due to obstruction, the contents get infected
fast and the tension increases. The appendix becomes a closed loop, which
results in septic thrombosis of vessels. Gangrene of appendix, perforation,
peritonitis, followed by a local abscess can occur.
In children, greater omentum is very thin. Hence, it cannot localize the
infection. In adults, omentum is like a fatty apron which localizes the
infection.
In aged patients, because of atherosclerosis, gangrene occurs very fast
resulting in peritonitis. Obstruction is caused by faecoliths, worms and bands
which cause tenting. Other causes are volvulus, carcinoma, hepatic flexture,
etc.
Common bacteria encountered in acute appendicitis are Bacteroides fragilis,
Escherichia coli, Cloustridium perfringens, Streptococcus faecalis,
Pseudomonas aeruginosa, etc.
DAILY EXAMINATION
The patient was not hospitalized before the operation; therefore there was no daily
examination of the patient.
PREOPERATIVE EPICRISIS
The operation was indicated because the patient came to the hospital within 24 to 48
hours of abdominal pain. There was pain and tenderness at the right iliac fossa. There was
tenderness and muscle guarding during surface palpation of the abdomen. The SchetkinBlumberg symptom was positive. There was tenderness in the McBurney point. The
presence or absence of a mass was detected with the help of the X-ray investigation.
There was no presence of mass.
OPERATION
An emergency appendicectomy was done on 5th September 2011.
Appendix is identified by tracing taenia coli which converges onto the base of the
appendix. Mesoappendix is divided in between ligatures. Purse-string suture is applied all
around the appendix in the cecum. The appendix is divided in between ligatures, the
stump is invaginated and the purse-string is tightened. Abdomen is closed in one layer.
Laparoscopic appendicectomy has become more popular nowadays.
After the operation, the patient feels better. He does not complain of anymore pain. He
was not allowed any food per os. Patient was administered glucose drips.