J.C. 36/M December 24, 1975 Filipino Catholic Makati City Date of Admission: March 21, 2012
2 days PTA Epigastric pain Non-radiating Crampy HNBB no relief
1 day PTA Epigastric pain Radiating to RLQ Crampy No N/V No fever No change in BM Polymedic Hospital WBC 15.35 A
No DM, HTN, CA, PTB, cardiac, kidney, or lung diseases. No known allergies. No previous surgeries or hospitalizations.
+ Stroke No HTN, DM, CA, cardiac, kidney or lung diseases.
3 rd year college Call center agent 10-pack-year smoker 4-5 bottles of beer per week No illicit drug use
General: No changes in weight, change in appetite, easy fatigability, or fever. Skin: No rashes, lumps, sores, or itchiness. Head, Eyes, Ears, Nose, Throat (HEENT). No dizziness, hearing loss, diplopia or headaches. Neck: No enlarged lymph nodes. No swollen glands. Respiratory: No dyspnea or cough.
Cardiovascular: No chest pain, palpitations, or syncope. Gastrointestinal: No nausea, diarrhea, constipation. Urinary: No dysuria, hematuria or flank pain. Musculoskeletal: No muscle pain, joint pain or swelling. Endocrine: No excessive thirst, heat intolerance, polyuria or cold intolerance.
Alert and coherent. GCS15. Vital Signs: Height of 160cm Weight of 69.5kg BMI of 27.1 kg/m2 (overweight) BP 110/60 HR 80 bpm and regular RR 23 breaths per minute Temp 36C
Skin: Warm, normal skin color, no rashes or lesions. Head, Eyes, Ears, Nose, Throat (HEENT): Ancteric sclera, pink palpebral conjunctiva. EBRTL 2mm No tonsillo-pharyngeal congestion. Neck: Trachea is midline. No enlarged lymph nodes. No nuchal rigidity.
Pulmonary: Normal shape of chest and movement. No scars, birthmarks, discolorations. Normal respiratory expansion/symmetric. No masses or tenderness. Clear breath sounds, no crackles or wheezing. Cardiac: Apex beat at the 5 th left ICS, MCL. Distinct S1 and S2, no murmurs. Increased heart rate with normal rhythm. No heaves or thrills.
Abdomen: Flat abdomen, no scars. Normoactive bowel sounds. Tympanitic on percussion of all quadrants. Liver span of 10 cm MCL. No hepatosplenomegaly. Soft. Tender on palpation of RLQ, no masses, liver edge is smooth. (-) Murphy's, (-) rebound tenderness, (+) Rovsing’s, (-) Obturator sign. No CVA tenderness.
DRE: No skin tags, visible lesions. Good sphincter tone. No masses, fissures or impacted fecal matter. No blood on examining finger. Extremities: No lesions, edema, cyanosis or clubbing of finger nails. With good turgor. Full and equal pulses on all extremities.
Rule In Rule Out Appendicitis Pain migrating to the RLQPain migrating to the RLQ Sudden onsetSudden onset (+) Rovsing’s Sign(+) Rovsing’s Sign (+) Direct Tenderness(+) Direct Tenderness Meckel’s Diverticulitis Same clinical picture as appendicitis Acute Epididimytis/ Testicular Torsion MaleMale Sudden onset of painSudden onset of pain (-) groin pain, inguinal pain(-) groin pain, inguinal pain (-) scrotal erythema/ warmth on touch(-) scrotal erythema/ warmth on touch * Cremasteric reflex* Cremasteric reflex Nephrolithiasis Midureteral calculi can cause pain in the RLQ and mimic appendicitis (-) urinary signs(-) urinary signs (-) hematuria(-) hematuria Pain migration (left to Right), peritoneal signsPain migration (left to Right), peritoneal signs
CBC WBC> 10,000 per mm 3 seen in 80% of cases Low predictive value, low specificity Urinalysis C-Reactive protein new suggested laboratory parameter Levels > 0.9mg/dL All laboratory tests together--”highly sensitive” (97-100% sensitivity)
UTZ blind-ending, nonperistaltic bowel loop from the cecum POSITIVE: >6mm in anteroposterior direction Identify appendicolith Thickening of the wall with periappendiceal fluid NEGATIVE: Non-compressible appendix, measuring <5mm
UTZ Sensitivity: 55-96% Specificity: 85-98% Can identify abscess Fast No contrast needed Can be used in children and pregnant women
UTZ False-positive Periappendicitis from surrounding inflammation Other structures mistaken as the appendix User-dependent Obese patients