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UNIVERSITI KUALA LUMPUR

ROYAL COLLEGE OF MEDICINE PERAK



CASE WRITE UP
SURGERY


NAME: ASLAH NABILAH BT ABDULL SUKOR
MATRIC NO: 57260211090
GROUP: 6
MENTOR: DR. MICHAEL CHONG




HISTORY
Identification data
Name : Muhammad Farhan Ikbal bin Ahmad
Age : 16 years old
Race : Malay
Religion : Islam
Sex : Male
Occupation : Student
Date admission : 12/9/2013
Date of clerking : 13/9/2013

Chief Complaint
Pain at right iliac fossa for 3 days

History of Presenting Ilness
The patient was well until 3 days ago he began to feel pain at the right iliac fossa. It was a
sudden onset. It is characterized by throbbing pain and did not radiate to any parts of the body.
Patient complaint once he did the movement and cough, the pain will increase and to relieve it
patient take a rest and panadol. Patient did not have associated symptom like fever, chills and
rigor, headache, nausea. But patient has cough without sputum and without blood and has vomit
once. Patient vomit once in yesterday morning. It is watery clear fluid. Patient felt bitter and felt
pain at the stomach after vomit.
Patient did not have any abdominal distension, no colicky pain, no constipation and the pain did
not radiate to the back or tip of shoulder, no flank pain, , no hematuria, no cloudy urine, no
burning sensation during micturition, no clay color stool, no yellowish sclera. Patient also did not
have shortness of breath. No loss of weight and loss of appetite


Systemic Review
Respiratory system
-Cough over 3 days without sputum
- No hemoptysis
- No asthma
- No history of pneumonia and tuberculosis
Gastrointestinal system
- No dysphagia
- No diarrhea
- No constipation
- No abdominal pain or distension
- No nausea and no vomiting
Genitourinary system
-No painful micturition
- No incontinence
- No difficulty during passing stool.
Musculoskeletal system
-No joint pain
- No muscle pain
- No limb weakness
- No history of trauma




Central nervous system
-No loss consciousness
- No history of fits
- No memory problem
- No vision loss
Endocrine systems
-No swelling in neck
Hematological system
-No bleeding tendency
- No lumps under the arm
- Neck or groin.


Past Medical History
Last year, he admitted to hospital because of dengue. No history of diabetes and hypertension

Past Surgical History
No history of surgery

Drug History
Patient was not consuming any medications. No any drug history and drug allergy




Family History






Patient is the eldest brother from the three siblings. His parents still alive. No family history of
diabetes and hypertension.

Social History

Patient is a student in Form Four in one of the school in Terengganu. He stayed with his family.
He has no any financial difficulties. He is non-smoker ,non-alcoholic and do not take any
intravenous drug









+


PHYSICAL EXAMINATION

General inspection
The patient was lying comfortably supine position. He does not look ill. He is conscious and alert
to time, place and person. He is not pain and in respiratory distress. There is no muscle wasting,
no gross deformity and no abnormal movement. There is an intravenous cannula attached on his
dorsal part of his left hand.

General Systemic examination
Vital sign

1. Blood Pressure : 110/60 mmHg
2. Pulse Rate : 80 beat per min
3. Respiratory rate : 20 min
4. Temperature : 37
o
C

Hands

1. Palm dry and warm
2. No sign of pallor and peripheral cyanosis
3. No leukonychia and koilonychia
4. No finger clubbing

Forearms and arms

1. No scratch marks
2. No bruising




Face

1. No yellowish sclera
2. No pallor of conjunctiva
3. No fetor hepaticus breath
4. No coated tongue
5. No glossitis
6. No angular stomatis
7. Good oral hygiene
8. Good hydrational status like no sunken eyes, no skin tugor and no dry mouth

Lower limb
1. No pitting edema

Abdominal Examination
Inspection
The shape of the abdomen is flat, symmetrical and move with respiration
the umbilicus is centrally located and inverted
There is no any surgical scars, prominent dilated vein, any skin discolouration, visible
peristalsis and visible pulsation
Palpation
On surface palpation, the abdomen is soft and tender at right iliac fossa.
On deep palpation, it is tender at hypogastrium and umbilical region but maximum
tenderness at Mc Burney's point, which lies two thirds of the way along a line drawn
from the umbilicus to the anterior superior iliac spine. There was no mass palpable
There is positive Rovsings Sign. On deep palpation at left iliac fossa and epigastrium, it
gives tenderness to right iliac fossa
There is also positive rebound tenderness. On deep palpation then suddenly release the
hand from the patient abdomen. The patient complaint more tenderness once the hand is
release from the abdomen.
The liver was not palpable. Liver span was 7 cm
The spleen was not palpable and the kidney not ballotable


Auscultation
The bowel sounds were present and has normal intensity

External genitalia and per rectal examination
1. No abnormal fluid discharge from the genitalia
2. No mass, no tenderness during PR examination

Head And Neck Examination
There was no enlargement of lymph node and no thyroid swellings.

Cardiovascular System Examination
a) Inspection: - Chest is symmetry
- No dilated vein noticed suggesting superior vena cava obstruction.
- No pacemaker attached on his chest.
- No visible palpitation.
b) Palpation: - Apex beat can be felt.
- There was no parasternal, pulmonary, and aortic heave or thrill.
c) Auscultation: - 1
st
and 2
nd
heart sound was heard at all mitral, tricuspid, pulmonary
and aortic area.
- There is no murmur heard.



Respiratory Examination
a) Inspection: - the chest is symmetry
- no scars and nodules
b) Palpation: - Trachea is not deviated.
- Apex beat can be felt
- The chest movement and expansion is symmetry.
- The tactile fremitus equal on both sides.
c) Percussion: - There is resonance upon percussion at both chests.
d) Auscultation: - There was no added sound on both sides of the lungs.

Lymphatic System Examination
No enlargement of lymph node at ingunal area, femoral area and axillary lymph nodes area.

CLINICAL SUMMARY
A 16 years old male with no known comorbidities came to the hospital with painful at the right
iliac fossa. The pain is colicky type of pain and it does not radiate to any parts of the body. The
onset is acute and it progressively worsened. Upon palpations, there is tenderness on right iliac
fossa during superficial palpations. There is positive rebound tenderness and rovsings sign.





INVESTIGATIONS
1) Urinalysis
COMPONENT RESULTS NORMAL RANGE
Urine glucose Normal Normal
Urine bilirubin Negative Negative
Urine ketones Negative Negative
Urine blood Negative Negative
Urine protein Negative Negative
Urobilinogen Negative Negative
Urine nitrites Negative Negative
Urine leukocytes Negative Negative
Urine colour Yellow
Urine clarity Clear
Urine pH 6.0 6.5-7.5
Specific gravity 1.01 1.002-1.025
.
There is no significant abnormality of the urine test result except that she is having a little bit
low level of urine pH which means his urine is acidic. It may be because of the disease or maybe
because of the side effect of any medicines . It may indicate that she was having vomiting.

Basically all findings are negative.









Full Blood Count: high white blood cell count may indicate an infection.
COMPONENT RESULTS NORMAL VALUE
White blood cell 14.4 0-11.0
Haemoglobin 14.5 13.0-18.0
Haematocrit 42.6 40-52
MCV 80.1 76.0-96.0
MCH 27.2 27.0-32.0
MCHC 33.9 30.0-35.0
RDW 13.3L 13.0-14.4
TRBC 5.34 5-6.5
Platelets 390 150-400
Neutrophils 61.3% 40-75
Lymphocytes 20.3% 20-45
Monocytes 2% 2-10
Eosinophils 5.1% 1-6
Basophils 0.2% 0-1
MPV 8.8 7.4-10.4


There was significant abnormality regarding his full blood test result. Only that he is having high
white blood count . An increases percentage of white blood cells may be due bacterial infection.







Urine Feme (Dipstick)
COMPONENTS RESULTS RANGE
Glucose, urine NORMAL NORMAL
Urine Ketone bodies NEGATIVE NEGATIVE
Nitrite NEGATIVE NEGATIVE
Leukocyte NEGATIVE NEGATIVE
Blood in urine NEGATIVE NEGATIVE
Bilirubin, urine NEGATIVE NEGATIVE
Protein, urine NEGATIVE NEGATIVE
Urobilinogen NEGATIVE NEGATIVE
Colour YELLOW
There is no significant abnormality of the urine test. Basically all findings are negative.















DISCUSSION

Differential diagnosis
Diagnosis Points support Points against
Intestinal obstruction Pain at the right iliac fossa
Vomit
no abdominal distension, no
colicky pain, no constipation
and only have
Acute cholecystitis Pain at the right iliac fossa not radiate to the back or tip of
shoulder, no clay color stool,
no yellowish sclera
Perforated peptic ulcer Pain at the right iliac fossa
patient did not have shortness
of breath,The abdomen is not
rigid but patient have tender.

Pancreatitis Pain at the right iliac fossa patient never take alcohol or
has any pain after taking fatty
meal and no pain radiate to the
back
Urinary tract infection Pain at the right iliac fossa no fever, no burning sensation
during micturition, no fever,
no flank pain, no hematuria,
no cloudy urine
Acute appendicitis pain at the right iliac fossa
throbbing pain
pain increase with movement
and cough



Provisional Diagnosis
Acute appendicitis




DAILY PROGRESS OF THE PATIENT
13
th
September 2013
On the second day of admission, the patient was only given IV drip of normal saline. He was
required to fast since he will be going for appendicectomy. He is looking slight ill and cough
many times. The cough make the pain more worse. However, his pain was reduced compared to
the day before. At 7 pm, he went for the surgery and it finished on 10.30 pm.
14
th
September 2013
He was conscious and looking well. He can eat and move but at slower pace. He does not
experience any more pain.
15
th
Septmeber 2013
He is feeling and looking well. He did not complained for any pain from the surgery done. After
being assessed by the surgeon, he was given the permission to discharged from the ward at11
am.

CONCLUSION
Muhammad Farhan came to the hospital with a presentation of severe pain at right iliac
fossa. The onset was sudden and progressively worsened. He was diagnosed to have acute
appendicitis.
Appendix usually is located at right iliac fossa, together with caecum, terminal end of
ileum, right kidney and right ureter. All of the structures are located close to each other.
Therefore, when there is a complaint of pain at right iliac fossa, all of these organs must be at the
back of the head as differential diagnosis. Appendix has few positions in right iliac fossa. It
varies according to individual. Yet, the commonest position of appendix is retroceacal position.
The other positions are paraceacel, preileal, postileal and pelvis type. Appendix usually located
at McBurney point at a line form from umbilicus to right-side ASIS which is a point 2/3 from
medial and 1/3 from lateral. In detail, appendix have four layers which are serosa, muscularis,
submucosa and mucosa which consists of abundants of lymphoid tissue.
The cause of appendicitis is mainly due to the obstruction of lumen by feacolith,
threadworm and any foreign materials. It is also can cause from the stricture of previous
operation or the swollen Peyers Patches. Since it is an inflammation, there are five signs that can
be seen around the appendix area, surely if they have appendicitis, are red, heat, tumor, oedema
and loss of function. This is quite common in young age patient.
In order to investigate more to confirm the diagnosis, the doctors should do amylase test
exclude acute pancreatitis in differential diagnosis. As for the imaging, ultrasound of
hepatobiliary system is easy and cheap. However, it is not very accurate as the surgeon cannot be
too sure. Thus, CT scan can be done to confirmed if any abnormalities in right iliac fossa region.
Management for appendicitis usually is appendicectomy. This is to avoid the reccurent of
appendicitis which may perforated if it is too late to detect it. Perforated appendicitis is very
dangerous as the toxins will be entering the abdominal cavity and cause toxineamia or even
worse, septicaemia. In addition, the scientists still do not know the function of the appendix.
Therefore, they should be no effect on body functions if the appendix is remove.
As conclusions, Muhammad Farhan is a good and cooperative patient. He gives the
permission to do the examination and he still can tolerate well even he was in pain. In getting
into the diagnosis, I did not find any difficulties because patient came with the common sign and
symptom of appendicitis that is the age of the patient, the pain at Mc Burneys point that is at the
right iliac fossa, the positive finding of Rovsigns sign and has rebound tenderness on doing
examination.