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Name : Muhammad Asyraf Age : 17 years old Chief Complaint - Pain at right lower abdomen since three days ago History of Presenting Illness - Pain started after taking dinner at college canteen three days ago - No rebound tenderness - Came to Hospital on 26/1/2015 and took medicine to ease the pain and allowed to go back - Pain again and got admitted on 27/1/2015 SOCRATES: Site: Right Iliac Fossa Onset: Pain comes and goes. Increases gradually Character: Sharp pain Radiation: No Alleviating factors: No Time course: Normally lasts 10-15 minutes Exacerbating factors: It comes any time Severity: 6/10 Associated symptoms: No fever, vomiting, constipation or dysuria Past medical history - No any past medical history Past surgery history - No any past surgery history Family history - Both parents healthy - Patient is 3 rd child of 6 childrens.

Appendicitis Case Write Up

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clinical case write upof appendicitis. clerked at muar gh

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Name : Muhammad AsyrafAge : 17 years old

Chief Complaint Pain at right lower abdomen since three days ago

History of Presenting Illness Pain started after taking dinner at college canteen three days ago No rebound tenderness Came to Hospital on 26/1/2015 and took medicine to ease the pain and allowed to go back Pain again and got admitted on 27/1/2015 SOCRATES: Site: Right Iliac Fossa Onset: Pain comes and goes. Increases gradually Character: Sharp pain Radiation: No Alleviating factors: No Time course: Normally lasts 10-15 minutes Exacerbating factors: It comes any time Severity: 6/10 Associated symptoms: No fever, vomiting, constipation or dysuriaPast medical history No any past medical historyPast surgery history No any past surgery historyFamily history Both parents healthy Patient is 3rd child of 6 childrens.Social history / Personal history No smoking No alcohol Residence : Kulai Occupation : StudentDrug history No past drug history or allergy

Diagnosis Physical exam to assess your pain Aure-Rozanova sign: Increased pain on palpation with finger in rightPetit triangle(can be a positive Shchetkin-Bloomberg's) Bartomier-Michelson's sign: Increased pain on palpation at the right iliac region as the person being examined lies on his/her left side compared to when he/she lies on his/her back. Dunphy's sign: Increased pain in the right lower quadrant with coughing. Kocher's (Kosher's) sign: From the person's medical history, the start of pain in the umbilical region with a subsequent shift to the right iliac region. Massouh sign: Developed in and popular in southwest England, the examiner performs a firm swish with his/her index and middle finger across the abdomen from theXiphoid processto the left and the right iliac fossa. A positive Massouh sign is a grimace of the person being examined upon a right sided (and not left) sweep. Obturator sign: The person being evaluated lies on her/his back with the hip and knee both flexed at ninety degrees. The examiner holds the person's ankle with one hand and knee with the other hand. The examiner rotates the hip by moving the person's ankle away from the his/her body while allowing the knee to move only inward. A positive test is pain with internal rotation of the hip. Psoas sign: Also known as the "Obraztsova's sign" is right lower-quadrant pain that is produced with either the passive extension of the right hip or by the active flexion of the person's right hip while supine. The pain that is elicited is due to inflammation of the peritoneum overlying the iliopsoas muscles and inflammation of the psoas muscles themselves. Straightening out the leg causes pain because it stretches these muscles, while flexing the hip activates the iliopsoas and therefore also causes pain. Rovsing's sign: Pain in the lower right abdominal quadrant with continuous deep palpation starting from the leftiliac fossaupwards (counterclockwise along the colon). The thought is there will be increased pressure around the appendix by pushing bowel contents and air towards theileocaecal valveprovoking right sided abdominal pain. Sitkovskiy (Rosenstein)'s sign: Increased pain in the right iliac region as the person is being examined lies on his/her left side.

Blood test.This allows to check for a high white blood cell count, which may indicate an infection. Urine test. To make sure that a urinary tract infection or a kidney stone isn't causing your pain. Imaging tests.Abdominal X-ray, an abdominal ultrasound or a computerized tomography (CT) scan to help confirm appendicitis or find other causes for your pain.Scoring systems Alvarado score -> A score below 5 is strongly against a diagnosis of appendicitis, while a score of 7 or more is strongly predictive of acute appendicitis. In a person with an equivocal score of 5 or 6, a CT scan is used to reduce the rate of negative appendicectomy.

Differential diagnosis Children:Gastroenteritis,mesenteric adenitis,Meckel's diverticulitis,intussusception,Henoch-Schnlein purpura, lobarpneumonia,urinary tract infection(abdominal pain in the absence of other symptoms can occur in children with UTI), new-onsetCrohn's diseaseorulcerative colitis,pancreatitis, and abdominal trauma fromchild abuse;distal intestinal obstruction syndromein children with cystic fibrosis; typhlitisin children with leukemia. Men:testicular torsion; Adults: new-onsetCrohn's disease,ulcerative colitis, regional enteritis,renal colic, perforatedpeptic ulcer,pancreatitis,rectus sheath hematoma; Elderly:diverticulitis, intestinal obstruction,colonic carcinoma,mesenteric ischemia, leakingaortic aneurysm.

Management Surgery : The newer method to treat appendicitis is thelaparoscopic surgery. This surgical procedure consists of making three to four incisions in the abdomen, each 0.25 to 0.5 inches (6.4 to 12.7mm) long. This type of appendectomy is made by inserting a special surgical tool called laparoscope into one of the incisions. The laparoscope is connected to a monitor outside the person's body and it is designed to help the surgeon to inspect the infected area in the abdomen. The other two incisions are made for the specific removal of the appendix by usingsurgical instruments. Laparoscopic surgery also requiresgeneral anesthesia and it can last up to two hours. The latest methods areNOTESappendectomy pioneered in Coimbatore, India where there is no incision on the external skin and SILS (Single incision laparoscopic Surgery) where a single 2.5cm incision is made to perform the surgery.

Pain : Pain medications (such asmorphine) do not appear to affect the accuracy of the clinical diagnosis of appendicitis and therefore should be given early in the person's care.Historically there were concerns among some general surgeons that analgesics would affect the clinical exam in children and thus some recommended that they not be given until the surgeon in question was able to examine the person for themselves.