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ADMISSION CONFERENCE 2010 ASMPH Clerkship – SURGERY ROTATION St. Martin de Porres Charity Hospital 02 August 2010.

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Presentation on theme: "ADMISSION CONFERENCE 2010 ASMPH Clerkship – SURGERY ROTATION St. Martin de Porres Charity Hospital 02 August 2010."— Presentation transcript:

1 ADMISSION CONFERENCE 2010 ASMPH Clerkship – SURGERY ROTATION St. Martin de Porres Charity Hospital 02 August 2010

2 Admissions from August 2-August 8, 2010 # Patient ID Admitting Diagnosis Operation Done Final Diagnosis 1RJ,23/M Ileocecal Tuberculosis, Ulcerohypertrophic type 2JP,15/M Small Bowel Obstruction probably 2 to Ruptured AP E Exploratory Laparotomy, Appendectom y Small Bowel Obstruction probably 2 to Ruptured AP 3RM,42/MCholelithiasisLap CholeCholelithiasis 4MA,18/FFistula in anoFistulotomyFistula in ano

3 Admissions from August 2-August 8, 2010 # Patient ID Admitting Diagnosis Operation Done Final Diagnosis 5GV,45/F Calculous Cholecystitis Lap Cholecystectomy Calculous Cholecystitis 6 EA,63/FAcute Cholecystitis Lap Cholecystectomy Calculous Cholecystitis 7NV,77/F Femoral neck fracture Garden Type IV Partial Hip replacement Femoral neck fracture Garden Type IV 8MM,25/MAcute Appendicitis E Appendectomy Ruptured Appendicitis

4 General Data RJ, 23/M CC: RLQ pain

5 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.

6 Subjective Findings 3 mos PTA-Persistence of epigastric pain. Pts relatives noted gradual weight loss. Undocumented fever. Persistence of pain prompted consult with another doctor. -EGD procedure was done with negative results.

7 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.

8 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.

9 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.

10 Subjective Findings 1 mo PTA-Repeat colonoscopy was done, ileocecal TB was considered. -Surgery was recommended due to obstructive symptoms hence admission. ADMISSION

11 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

12 Subjective Findings Past Medical History: – (+) Mumps, 13 y/o – (–) Allergies to food or medicines – (+) BCG – (–) TB

13 Subjective Findings Family history: – (+) Diabetes, – (+) Hypertension Social history: Smoker; 1.6 pack years, occasional alcoholic beverage drinker

14 Objective Findings Height: 165cm Weight: 42kg BMI: 15 BP: 100 / 70 Temp: 36.7°C HR: 106 RR: 22

15 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 5 th LICS MCL, Normal rate, Regular rhythm, (–) Murmur Pulmo: SCE, Resonant lung fields, Clear breath sounds, (–) Crackles and wheezes

16 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

17 Salient Features 23/M Colicky RLQ pain. Associated with bloating, vomiting, bulge in RLQ, 28% wt loss, fever, and alternating diarrhea (2- 5x/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.

18 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

19 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. Dx Labs:

20 Assessment Primary Impression: Ileocecal Tuberculosis, Ulcerohypertrophic type Differentials: – Chronic Inflammatory Bowel Disease: Chrons – Lymphoma – Colon Cancer

21 Plan Diagnostic Plan: – CBC – ESR – PPD – CXR – CT abdomen – AFB of biopsy – PCR of biopsy – Culture of biopsy

22 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

23

24 Text here

25 Right hemi? colectomy and anastomosis

26 RETURN TO TABLETABLE

27 Identifying Data JP, 15/M Date of birth: August 9, 1995 Currently resides in Bonifacio Exit, Bagong Silangan QC Date of admission: August 3, :45 am CC: Abdominal Pain and Distention

28 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

29 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

30 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

31 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 vomiting ADMISSION

32 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

33 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

34 Subjective Findings Family history: – Asthma Social history: – Student – (-) Smoker – (-) Alcohol drinker – (-) Illicit drug user

35 Objective Findings: Vital Signs Height: 160 cm Weight: 40.5 kg BMI: Underweight BP: 120/80 Temp: 37.5°C HR: 121 – tachycardic RR: 28 – tachypneic Abdominal Girth: 70 cm

36 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

37 Objective Findings: PE Adynamic precordium, PMI at 5 th 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

38 Objective Findings: Labs ValueNormalRemarks Hemoglobin Low Hematocrit Low WBC Normal Neutrophil Normal Lymphocyte Normal Eosinophil Normal Mean corpuscular Hgb Normal Mean corpuscular Hgb concentration High Mean cell volume Normal RDW Normal Platelet High

39 Objective Findings: Labs URINALYSIS Dark amber, slightly turbid pHalkaline specific gravity1.015 RBC2-3 per hpf WBC4-5 per hpf EpitheliumMany Mucus threadsAbundant Amorphous PhosphatesModerate Albumin(+) Sugar(-)

40 Objective Findings Labs ValueNormalRemarks Bleeding time3 mins 5 secs2-4 minsNormal Clotting Time3 mins 15 secs2-4 minsNormal Prothrombin Time Normal PT control12 INR1.08Normal % Activity89.6 PTT Normal PTT Control30 Creatinine Normal Na Low K Normal

41 Objective Findings CXR – Clear lung fields – Bony thorax intact – Heart magnified

42 Objective Findings

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44

45 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

46 Assessment Clinical Impression: Small Bowel Obstruction probably secondary to Ruptured Appendicitis Differentials : – Peptic Ulcer Disease – Ileus – Meckels Diverticulum

47 Plan Diagnostic Plan: – CBC – Urinalysis – Electrolytes – Fecalysis – Abdominal X-ray – CXR – Ultrasound – CT-Scan

48 Plan Treatment Plan – Emergency Lapparatomy Appendectomy – Hydration – Antibiotics – Analgesics for pain – NPO

49

50 RETURN TO TABLETABLE

51 Subjective Findings MA, 18 F CC: anal discharge

52 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

53 Subjective Findings 1 year PTA Pain on defecation (+)Soiling of underwear (+) Purulent discharge (+) yellowish discharge (-) anal mass (-) tenesmus (-) tenderness (-) blood in stools

54 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

55 Subjective Findings 1 day PTA (+) undocumented fever Persistence of symptoms prompted consult August 2, 2010, 4:30

56 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

57 Objective Findings Physical Exam BP: 110/70 Temp: 37.1 C HR: 98 RR: 15 Pain Severity: 0/10

58 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

59 Objective Findings Abdomen – Flat, soft abdomen – Normoactive bowel sounds – tympanitic – No palpable mass, No tenderness Extremities full and equal

60 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

61 Assessment Fistula - in – ano Differentials 1. anal abscess 2. anal fissure

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66 Plan Fistulotomy Curretage Healing by secondary intension Sitz bath Biopsy of tract Possible use of drains/seton

67

68

69 RETURN TO TABLETABLE

70 Subjective Findings GV, 45/F Residence: Taytay, Rizal CC: recurrent RUQ abdominal pain for 11 years

71 Subjective Findings 11 years PTA 2 weeks PTA Colicky RUQ pain radiating to the back (after eating a heavy meal) UTZ: cholelithiasis Meds: Buscopan Plus 500mg OD Same Sx + Abdominal fullness

72 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

73 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

74 Subjective Findings Past Medical History: – No previous hospitalizations – No allergies: food and medicines – Surgeries: s/p Appendectomy: 1970s s/p TAHBSO: stage II CA 2003 Family History: – Hypertension: mother – Gallstones: 3 brothers – VACCINATION: (+) flu vaccine 8 mos ago

75 Subjective Findings Accountant Non-smoker Non-alcohol beverage drinker No exercise Diet: – Sweet – Fatty – Salty

76 Objective Findings Height 149cm Weight 52.6kg BMI normal BP 110/80 HR 80 RR 18 Temp 36.9 degrees Celsius

77 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

78 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, (+) Murphys sign

79 Assessment Recurrent Calculous Cholecystitis Differentials: – Peptic Ulcer Disease – Viral Hepatitis

80 Plan Surgical: Lap cholecystectomy (Dr. Cenon Alfonso) Non-surgical Management: – Antibiotics – Analgesics – Watch out for 5 Ws Advise on: – Food: fatty

81 RETURN TO TABLETABLE

82 General Data EA, 63/F CC: RUQ pain

83 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.

84 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. ADMISSION Few weeks PTA

85 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

86 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

87 Subjective Findings Past Medical History: – (–) Allergies to foods or medications – No recent vaccinations Past Hospitalizations: – R forearm fracture closed reduction – H. mole D&C – 1970 – PID 2° IUD D&C – 17 y/o, Asthma in Acute Exacerbation

88 Subjective Findings Family history: – (+) Gall stone - Daughter Social history: Non-smoker, non-alcoholic beverage drinker

89 Objective Findings BP: 140 / 80 Temp: 36.8°C HR: 78 RR: 20 Pain Severity: 0/10

90 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 5 th LICS, MCL, Normal rate, Regular rhythm, (–) Murmur Pulmo: Symmetric chest expansion, Resonant lung fields, Clear breath sounds, (-) Crackles and wheezes

91 Objective Findings AB: Protuberant abdomen, NABS, tympanitic, soft, (–) Tenderness, Murphys sign, organomegaly, masses, surgical scars Extremities: Full and equal pulses, (–) edema, cyanosis, good turgor Skin: (–) Rashes, clean nails, dry hair

92 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.

93 Assessment Clinical Impression: Calculous Cholecystitis Differentials : – Peptic Ulcer Disease – Cholangitis – Hepatitis – Acute Coronary Syndrome

94 Plan Diagnostic Plan: – Abdominal Ultrasound – CBC – Hepatitis Serology – ECG

95 Plan Treatment Plan – Cholecystectomy – IV Fluids – IV Antibiotics – IV Analgesics

96 Numerous pigmented stones, ranging from ~1x1cm

97 RETURN TO TABLETABLE

98 Subjective Findings NV, 77/F CC: hip pain

99 Subjective Findings NOI: Fall POI: Paranaque City DOI: 8/1/10 TOI: 7 pm

100 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

101 Subjective Findings ROS (+) weight loss (-) fatigue, weakness, joint pains (-) tingling sensation (-) loss of consciousness (-) difficulty breathing, tachypnea, cyanosis, chest pain

102 Subjective Findings ROS (-) fever (-) edema (-) skin changes, jaundice (-) palpitations (-) chest pain (-) dysuria, hematuria, freq

103 Subjective Findings PMH/PSH Cervical spondylosis, OA (1993) – Naproxen sodium – Almitrine/ raubasine (30/10mg) HPN (1995) – Amlodipine 5mg OD Patellar Fracture (2004)

104 Subjective Findings Obstetric history P/SH Post-menopausal Not on HRT Non-smoker Non-alcoholic beverage drinker

105 Objective Findings VS RR: 18 HR: 86 T: 36.0 BP: 150/80

106 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

107 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

108 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

109 Objective Findings Cardiovascular Abdomen Adynamic precordium, Apex beat: 6 th ICS MCL, distinct S1 and S2, (-) murmurs Flabby, (-) surgical scars, (-) masses, NABS, (-) bruits, tympanitic, (-) tenderness, (-) organomegaly, (-) CVA tenderness

110 Objective Findings DREDid not consent

111 Objective Findings Extremities L leg shorter and externally rotated (+) L hip tenderness (+) LOM in affected limb (-) neurologic deficits (-) loss of pulse

112 Objective Findings Xray Complete fracture with total displacement of fracture fragment

113 Assessment Femoral neck fracture Garden Type IV

114 Garden Classification

115 Plan: Treatment Preoperative management – Preoperative traction – Pressure-reducing mattresses – Surgery performed once patient is medically stable (within 24 hours if possible)

116 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

117 Plan: Treatment Perioperative management – Regional anesthesia (reduces morbidity and mortality) – DVT prophylaxis for 10 days postoperatively – Antibiotics preop: wound, urinary, respiratory

118 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

119 Plan: Treatment Rehabilitation/ discharge planning – Exercise programs improve function, length of stay, institutionalization, activity of daily living mobility, and ambulation

120 Prevention Prevent falls Increase physical activity External hip protectors Combination of folate and mecobalamin(B12) Vitamin D, calcium, and bisphosphonates HRT

121 Screening Bone density scan (DEXA) for osteoporosis

122 RETURN TO TABLETABLE

123 Subjective Findings M.M. 25M CC: abdominal pain 1

124 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 1 Admission

125 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

126 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

127 Objective Findings Abdomen: I: flat, (+) infraumbilical scar midline (from previous CS) A: normoactive bowel sounds P: soft, (-) guarding, (+)RLQ pain direct and rebound, (-) Rovsings (+) Psoas and obturator sign, (-) cutaneous hyperesthesia, (-) Murphys sign, (-) Dunphys sign (+) CVA tenderness (R) Extremities – Full and equal pulses, no edema, no cyanosis DRE: patient refused DRE 1

128 Assessment Impression: Acute Appendicitis Differentials – UTI – Ureteral stones 1

129

130 Plan Diagnostic Plan Labs – Pregnancy test – Urinalysis – CBC Imaging – Abdominal Ultrasound – CT scan of the abdomen 1

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132 Plan Treatment Plan – Emergency Appendectomy Final dx: Suppurative appendicitis – Post op: antibiotics, pain relievers 1

133 RETURN TO TABLETABLE

134 Subjective Findings M.M. 25M CC: abdominal pain 1

135 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 1 Admission

136 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

137 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

138 Objective Findings Abdomen: I: flat, (+) infraumbilical scar midline (from previous CS) A: normoactive bowel sounds P: soft, (-) guarding, (+)RLQ pain direct and rebound, (-) Rovsings (+) Psoas and obturator sign, (-) cutaneous hyperesthesia, (-) Murphys sign, (-) Dunphys sign (+) CVA tenderness (R) Extremities – Full and equal pulses, no edema, no cyanosis DRE: patient refused DRE 1

139 Assessment Impression: Acute Appendicitis Differentials – UTI – Ureteral stones 1

140

141 Plan Diagnostic Plan Labs – Pregnancy test – Urinalysis – CBC Imaging – Abdominal Ultrasound – CT scan of the abdomen 1

142

143 Plan Treatment Plan – Emergency Appendectomy Final dx: Suppurative appendicitis – Post op: antibiotics, pain relievers 1

144 RETURN TO TABLETABLE


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