1. What is happening to the patient? b.

PID
c. Twisted Ovarian Cysts
- Pt’s symptoms d. UTI

2. What is your Impression? 4. Review the anatomy of your Impression?

- Acute Appendicitis - Medially toward the ileocecal valve

- Variable length (2- 20cm)
3. What is your differential diagnosis? Children? Elderly? Male - Typical location: retrocecal-retrocolic, pelvic,
vs Female? subcecal, ileocecal(anterior to ileum) and
a. Acute Gastritis ileocecal(posterior to cecum)
b. Ectopic Pregnancy - Appendicular Artery
c. Twisted Ovarian Cysts -Which is the terminal branch of the
d. Indirect Inguinal Hernia ileocolic artery or ileal or colic
e. UTI
branch of the ileocolic ( branch of
Children superior mesenteric artery)

a. Intussusceptions 6. What are the causes of your impression?

b. Meckel’s Diverticulitis - Obstruction followed by infection.
c. Indirect Inguinal Hernia - The lumen of the appendix becomes obstructed by
hyperplasia of submucosal lymphoid follicles, a
Elderly fecalith, stricture, tumor

a. Colon CA 7. What are the stages of your impression?

b. Fecal CA - 1. Focal/Catharral
c. Indirect Inguinal Hernia - 2. Suppurative
- 3. Gangrenous
Male - 4. Ruptured/Perforated

a. Meckel’s Diverticulitis
b. Inguinal Hernia
c. Ureterolithiasis
d. UTI 8. What is the most important sign for your impression?
- McBurney sign
- Localized right lower quadrant pain or guarding on
palpation of the abdomen (the single most important
Female
sign)
a. Ectopic Pregnancy
9. what is McBurney’s point?
- Usual point of maximal tenderness in right lower
quadrant.
- the junction of the outer 1/3 and inner 2/3 of a line
joining the anterosuperior iliac spine and the
umbilicus.
10. what is the importance of those signs mentioned?
- Patients with appendicitis usually have accessory signs
that may be helpful for diagnosis . For example, the obturator sign is
present when the internal rotation of the thigh elicits pain (ie, pelvic
appendicitis), and the psoas sign is present when the extension of
the right thigh elicits pain (ie, retroperitoneal or retrocecal
appendicitis).
11. Do you have to elicit all those signs?
- No.
- The most specific physical findings in appendicitis
are rebound tenderness, pain on percussion, rigidity,
and guarding.
- However, their absence never should be used to rule
out appendiceal inflammation. The Rovsing sign
(RLQ pain with palpation of the LLQ) suggests
peritoneal irritation in the RLQ precipitated by
palpation at a remote location.
- The obturator sign (RLQ pain with internal and
external rotation of the flexed right hip) suggests that
the inflamed appendix is located deep in the right
hemipelvis.
- The psoas sign (RLQ pain with extension of the right
hip or with flexion of the right hip against resistance)
suggests that an inflamed appendix is located along
the course of the right psoas muscle.
- The Dunphy sign (sharp pain in the RLQ elicited by
a voluntary cough) may be helpful in making the
clinical diagnosis of localized peritonitis.
- The Markle sign, pain elicited in a certain area of the
abdomen when the standing patient drops from
standing on toes to the heels with a jarring landing,
was studied in 190 patients undergoing
appendectomy and found to have a sensitivity of
74%.
12. Do you have to do a rectal exam in this patient?
- There is no evidence in the medical literature that
the digital rectal examination (DRE) provides useful
information in the evaluation of patients with suspected
appendicitis; however, failure to perform a rectal examination
is frequently cited in successful malpractice claims.
13. Admitting orders :
• Diet: NPO strictly, resume diet slowly if without pain or
vomitting
• Status: Guarded
• Activity: CBR w/o TP
• IVF: D5NR 1L x 8hrs
• VS: Vital signs q 2 hours including progress of abdominal
pain
• Pls. insert NGT F 18 if with ileus or vomitting
• Pls. insert urinary foley bag catheter
• Monitor I & O q hourly
Diagnostics:
• CBC, platelet count, Na, K, Ca, Mg, BUN, CREA
• Crossmatching
 • U/A
• AXR, CXR, ECG
• CT scan of upper Abdomen
• Medications:
• Analgesic
Meperidine (Demerol), 25-100 mg IV q4-6h
• Stress ulcer prevention
Omeprazole (Lozec) 40 mg q 12-24h
• Antibiotics
Cefoxitin sodium (Mefoxin) 500 mg q 6h IV
• Surgical:
Schedule for appendectomy
14. Why do you request for a CBC? Urinalysis?
- The white blood cell (WBC) count is elevated (greater than
10,000 per mm3 [100 × 109 per L]) in 80 percent of all cases
of acute appendicitis.9 Unfortunately, the WBC is elevated in
up to 70 percent of patients with other causes of right lower
quadrant pain.10 Thus, an elevated WBC has a low predictive
value. Serial WBC measurements (over 4 to 8 hours) in
15. Can the diagnosis be based on history and PE only?
suspected cases may increase the specificity, as the WBC
count often increases in acute appendicitis (except in cases
of perforation, in which it may initially fall).
- In addition, 95 percent of patients have neutrophilia 1 and, in
the elderly, an elevated band count greater than 6 percent
has been shown to have a high predictive value for
appendicitis.9 In general, however, the WBC count and
differential are only moderately helpful in confirming the
diagnosis of appendicitis because of their low specificities.
- In a retrospective review of 32 consecutive patients (20
adults and 12 children) with acute appendicitis, we
correlated abnormal urinalysis with the operative findings.
Abnormal results on urinalysis were noted in 10 adults and 5
children. All urine specimens were collected by the clean-
catch method. Abnormal findings were found more frequently
in female patients. The majority of the patients with abnormal
urinalysis had a ruptured or inflamed appendix in proximity to
the urinary tract.
- Inflammation of appendicitis can spread to the urinary tract.
It may lead to abnormal urinalysis.
- Normal urinalysis in appendicitis suggests that inflammation
seems to be limited to the appendix, and no spread to the
urinary tract.
- Urinalysis is performed to exclude urinary tract infection and
renal calculi. A mild pyuria or hematuria is consistent with
appendicitis due to inflammation adjacent to the right ureter
- In women of reproductive age, a urine β-hcG is obtained to
exclude the possibility of ectopic pregnancy or alert the
surgeon for intrauterine pregnancy
- No, none of the 3--history, exam, or labs--is sufficiently
accurate to diagnose acute appendicitis (strength of
recommendation [SOR]: A, based on meta-analysis of high-
quality studies). When combined, the following tests are
helpful: an elevated C-reactive protein (CRP), elevated total
white blood cell (WBC) count, elevated percentage of
polymorphonuclear leukocyte (PMN) cells (left shift), and the
presence of guarding or rebound on physical examination.
The combination of any 2 of these tests yields a very high
positive likelihood ratio (LR ), but the absence of these does
not exclude appendicitis (SOR: A, based on meta-analysis of
high-quality studies).
16. What diagnostic modalities can you request? Disadvantages:

- Plain Film Radiograph : o Sensitivity very dependent on operator skill

o Not cost effective o Greater potential for false positives

o Not specific o Normal appendix must be visualized to rule out

appendicitis: Diagnosis limited by position of
o Can be misleading appendix

o Not recommended unless other pathology is Computed Tomography (CT)

suspected: eg. perforation, intestinal obstruction,
ureteral calculus Advantages:

- Ultrasonography o More Precise than US: less hospital to hospital

variation
Findings on US for appendicitis
o More accurately identifies pathology
o Non-compressible appendix
o Reveals normal appendix better than US
o Appendix >6mm diameter
Disadvantages:
o Signs of perforation
o Radiation and/or contrast exposure: increased risk
o Free fluid for peds and pregnant women

o Abscess o Cost: relatively expensive

Advantages: o Patient discomfort: children often unable to tolerate

without sedation
o Safe and Non-invasive: No ionizing radiation
MRI
o Cost-effective: cheap and can efficiently rule out
other abnormalities o Low risk, no ionizing radiation

o Very sensitive with a skilled technician: (71 to 97% o Relatively new modality: little data
accuracy)
o Expensive
 o Not widely used and unnecessary

17. What are the chances of perforation in this patient? If she is

younger or older?
20. What microorganisms are you dealing with?
- Acute Appendicitis in the Young (5-12 y.0. :<10% and a
perforated appendix rate of 20%)

- Acute Appendicitis in the Elderly (50 to 70% in the

elderly (perforation rate))

18. How do you prepare the patient for surgery?

- IV fluid replacement

- Nasogastric suction is helpful in patients with peritonitis and

profound ileus

- Reduce fever if BT > 39°C

- Cefoxitin to help control sepsis and reduce incidence of post-

op wound infection
21. What antibiotic will you give preoperatively? Why? What is the
19. If you are the anesthesiologist and patient took a meal 4 hours
cost of your preferred antibiotic?
prior to admission, what will you do?

- Give antiemetics - Preoperative antibiotic we give Broad spectrum antibiotic

such as CEFOXITIN to provide prophylaxis against
postoperative wound infection and intraabdominal abscess
because the principle organism seen in normal appendicitis
is Escherichia coli and Bacteroides fragilis but maybe
present of polymicrobial infection that broad spectrum
antibiotic are indecate .CEFOXITIN is Bacteriacidal that
highly susceptibility to E. coli, Klebsiella and Gram-negative
anaerobes except for Pseudomonas and There were no
subjective nor objective side effects related to CFX

22. What incision will you make? What is Mcburney’s incision?
- Mcburney incision or muscle-splitting incision its most
widely use in uncomplicated appendicitis .the skin incision
made through 1/3 of the way along a line from anterior
superior spine of ileum to umbilicus (Mcburney’s point) .the
incision made oblique .8-10 cm in length
23. What is gridiron incision? Rockey Davis incision?
- Gridiron incision is another name of Mcburney
incision or muscle-plitting incision its most widely use in
uncomplicated appendicitis .the skin incision made through
1/3 of the way along a line from anterior superior spine of
ileum to umbilicus .the incision made oblique .8-10 cm in
lenth
- Rocky Davis incision or transverse incision the incision
made transverse direction 1-3 cm below umbilicus and
center on midclavicular line abdominal wall split in direction
of their fiber
24. What are layers of the abdominal wall that you will traverse?
- 1.Skin 2.Superficial fascia(Camper’s and Scarpa’s) 3.
External Oblique muscle 4.Internal oblique muscle 5.
Transversus abdominis muscle 6. Transversalis fascia 7.
Preperitoneum fat 8.Peritoneum External
Oblique Aponeurosis is slitted along its fiber, and the internal
oblique muscle is split along its length
25. Upon opening the peritoneal cavity, you encounter turbid fluid,
What will you do?
- Bacterial cultures to guide post-op antibiotic coverage.
26. If you encounter an abscess around your impression, what will
you do?
- Drainage
27. Will you leave a drain? Why?
- Yes because….
28. If your impression turns out to be normal, what will you do?
29. After surgery, will you close the skin? What suture will you use?
Why?
- Yes, if non-perforated we use subcuticular absorbable suture
or staples coz it reduce scar formation but if rupture we use
staples or interrupted nonabsorbable placed 2-3 cm apart
alternating with gauze packing. If heavy fecal contamination
is present, the skin is often left open to close secondarily.
30. How do you give post-op care following surgery? If your
impression has ruptured?
- Fluid and Electrolytes support
 The drain remains till the pus or fluids stops draining.
IV antibiotics are given throughout the hospital stay.
After discharge oral antibiotics are given, and the patient is
instructed to take proper care of the drain and gauge pack.
It is important for the patient to note any increase in pus or
infection and report to the surgeon immediately.
Advice on Discharge is usually rest for a week or two with a
few pain killers and sometimes an extended course of
antibiotics.
31. What are the complications to watch out for after surgery?
- Postoperative Fever
The most common complication of appendectomy is
infection of the surgical wound.
- Intra-abdominal abscess (fluid), needing drainage.
- Paralytic ileus where the gut stops functioning. This usually
happens if the appendix ruptures and causes diffuse
inflammation.
32. If you are dealing with a child with a not so clear history, what
should you do?
33. How do you make progress notes of your patient?
- The SOAP note (an acronym
for subjective, objective, assessment, and plan) is a
method of documentation employed by health care providers
to write out notes in a patient's chart,
Subjective component
- Initially is the patient's Chief Complaint, or CC. This is a
very brief statement of the patient as to the purpose of the
office visit or hospitalization.
Objective component
The objective component includes:
- Vital signs
- Findings from physical examinations, such as posture,
bruising, and abnormalities
- Results from laboratory
- Measurements, such as age and weight of the patient.
Assessment
- Is a quick summary of the patient with main
symptoms/diagnosis including a differential diagnosis, a list
of other possible diagnoses usually in order of most likely to
least likely. When used in a Problem Oriented Medical
Record, relevant problem numbers or headings are included
as subheadings in the assessment.
Plan
- This is what the health care provider will do to treat the
patient's concerns - such as ordering labs, radiological work
up, referrals given, procedures performed, medications
given. This should address each item of the differential
diagnosis. A note of what was discussed or advised with the
patient as well as timings for further review or follow-up may
also be included.