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Kursk State Medical University

Department of Surgery

Head of Department: Dr. Nazarenko P.M.


Teacher: Dr. Kennady ferdoravich
Name of Patient: Sapunov Sergei Nikolavich
Diagnosis:
1) Main Diagnosis:
Acute phelgmonus Appendicitis

2) Complications:
Nil

3) Associated Diseases:
Nil

Name of Student: sivanan thananjay


Group N. 19
th
4 Year 2nd Semester
Medical Faculty
Kursk 2011

PASSPORT DATA

1.Name: Sapunov Sergei Nickolavich


2.Age: 37 years
3.Sex: Male
4.Address: Kursk .
5.Profession: wo
6.Marital Status:Married
7.Nationality: Russian
8.Date and Time of Hospitalization: 05 September 2011

SUBJECTIVE EXAMINATION

COMPLAINTS
The patient complains of pain at the right iliac region. It is felt as a stabbing pain. The
intensity of pain is severe. The pain increases while walking. It is relieved when the
patient is lying down.
He also complains of infrequent vomiting. It contains stomach contents.
Patient complains of fever.
He also complains of a poor appetite.

PRESENT ILLNESS (ANAMNESIS MORBI)


On the night of 12 .11 14, the patient first felt pain. The pain was severe. The patient
does not know what might have caused the pain.
Pain was first felt by the patient at the umbilical region. After a few hours, the pain
shifted to the right iliac region. This is known as the shifting pain of acute appendicitis.
The patient came to the hospital with an ambulance. The pain was so severe that an
ambulance was required to transport the patient to the hospital.

LIFE HISTORY (ANAMNESIS VITAE)


The patient was born on 1977, at Kursk State. He has had a normal childhood. His
family conditions are quite good. They do not have any financial problems
He has good body hygiene. He is dressed according to the season.
He is married and he lives with his wife. His parents are healthy.
No allergies to anything. He has never had a blood transfusion before.
His sleep patterns are normal. He is not exposed to any environmental hazards.

OBJECTIVE EXAMINATION
GENERAL INSPECTION

The patients general condition is satisfactory. There is conformity between the


appearance and the age of the patient. The patient is alert. His posture is active. The
patient is well-nourished. His state of development is normal.
His skin colour is normal, without any flushing. He does not have any rashes,
subcutaneous hemorrhages, ulcerations, desquamation or pigmentation. He does not have
any surgical scars on his body. His skin is of normal moistness. His nails are normal,
without any brittleness. His hair distribution is normal. He does not have any changes in
hair growth.
Development of subcutaneous fat is moderate. The place for the best deposit of fat is on
the abdomen. He does not have oedema or anarsarca. He has normal development of
muscle and his muscular tension is normal. He does not have pain in the muscles,
convulsions or tremors. His muscular strength is normal.
There was no enlargement of the lymph nodes. There was no pain or tenderness during
the palpation. The palpation of bones and joints did not reveal any pathological changes.
He did not have clubbing of the fingers.
The configuration of the head is normal. There were no scars or tremors. The form of the
nose is normal. There was no abnormal septum deviation. The patients eyes were
normal. There was no oedema on the lids and no jaundice or hemorrhages on the sclera.
The conjunctivae and cornea were normal. His pupils and vision were also normal. There
was no coloration, scars or fissures on his lips. The condition of the neck is normal. There
was no enlarged thyroid, no nodules and no bruits. His body temperature is normal.

RESPIRATORY SYSTEM

The form of chest is barrel form. There is symmetry in both sides of the body. There is no
deformation. There are no changes in expansion of chest. State of intercostal region is
normal. He has abdominal type of breathing.
His respiration rate is about 18 breaths per minute.
He does not have any kinds of dyspnoea.
Palpation of the chest revealed normal conditions of the ribs, clavicles and intercostal
spaces. No pain was felt during palpation. The vocal fremitus was normal.
Comparative percussion showed resonant sound at the upper lobes but dull sound at the
lower lobes of both the lungs. The dull sound can be heard at the scapular line, at level of
the 9th intercostal spaces.
Topographic percussion:
Height (altitude) of apex pulmonaris:
i) 3 cm above clavicle
ii) 3 cm laterally to spinous process of 7th cervical vertebra.
Lower border of the lungs:
Percussion point
Right lung
Left lung
Parasternal line
5th intercostals space
th
Midclavicular line
6 rib
Anterior axillary line
7th rib
7th rib
Midaxillary line
8th rib
8th rib
th
Posterior axillary line
9 rib
9th rib
Scapular line
10th rib
10th rib
th
Paraspinal line
Spinous process of 11
Spinous process of 11th
thoracic vertebra
thoracic vertebra
Auscultation revealed normal breath sounds in the upper and lower lobes of the lungs.
There was an absence of any types of rales.

CARDIOVASCULAR SYSTEM

There was no cardiac humpback. The apex beat is strong. There were no abnormal
pulsations. There was no aortic arch pulsation, no carotid artery pulsation, and no
engorgement of jugular veins. There was also no undulation of neck veins. The trachea
was located at the midline. The peripheral arteries pulsation was also strong and quite
easy to find. There were no arrhythmic pulsations. There was no wriggleness of arteries
(worms sign). There was also no epigastric pulsation. Plesh sign was negative. Patient
did not have varicose veins.
Palpation of the apex beat showed the apex beat to be in the 5th intercostal space and was
located 2cm laterally from the midclavicular line, which is normal. The strength and
intensity of the apex beat was normal. There was no presence of thrills. The palpation of
aortic arch showed that the Oliver-Kardarelli symptom was absent. Palpation of the aorta
and pulmonary artery showed no changes. The radial artery pulsation was rhythmic.
There were no extrasystoles.
Percussion revealed normal configuration of the heart. The borders of the heart were
normal. The right border was at the 4th intercostal space, 1.5cm laterally from the
parasternal line. The left border was located at 5th intercostal space, 1.5cm medially from
midclavicular line. The upper border was at the lower border of the 3rd rib.
In auscultation, there were no changes in S1 and S2. Both sounds were perceived as
normal. The patients rhythm is rhythmic. There is an absence of murmurs and extra heart
sounds. Auscultation of vessels was normal.
Blood Pressure is 140/80

GASTROINTESTINAL SYSTEM

The oral cavity was normal. There was no abnormal odour. Inspection of teeth was
normal. Patient did not have any gold tooth. Colour of the gums was normal. There was
no bleeding, ulceration or suppuration. The mucous membrane of the oral cavity was
normal. There was no pigmentation, ulceration, cicatrices, cleft or palate.
The tongue size was normal. It is pink in colour. It is clean and not coated. The tongue is
moist. There was no papilla, ulceration, cracks or scars. The throat was normal. The
colour of the mucous membrane was normal. The tonsils were also normal.
The size of the abdomen was normal for the patients configuration. There was no
diverticulum and the belly was not retracted in the upper region of the abdomen. There
was no visible gastric or intestinal peristalsis. There was no stria and pigmentation. There
are no scars on his body. The umbilicus is normal.
There was tenderness and muscle guarding during surface palpation of the abdomen. The
Schetkin-Blumberg symptom was positive. There was tenderness in the McBurney point.
There were no tumours and no ascites.

The lower border of the stomach is normal, 2cm above the navel. Percussion of the
stomach did not present any pain. There was no succusion sound. Auscultation of the
stomach was normal.
The palpation of the intestine revealed no abnormalities. There was no tenderness and no
splashing sounds.
The percussion of the liver showed normal upper borders. At the right parasternal and
midclavicular line, liver dullness was heard at the 6th rib. It was at the 7th rib at the right
anterior axillary line. Palpation of the lower border of the liver was normal. The patient
did not feel any pain or tenderness.
Palpation of the gallbladder was normal. There was no pain.
Palpation of the spleen also revealed normal borders and was not painful.
Inspection of the lumbar area did not reveal any redness, swelling or oedema. There was
no pain during percussion.
The external examination of the genitals did not reveal any abnormalities.

PROVISIONAL DIAGNOSIS

Acute appendicitis.

PLAN OF SUPPLEMENTARY INVESTIGATION


1. Blood test
2. Urine test
3. Plain abdominal X-ray
4. Abdominal ultrasound

PLAN OF TREATMENT
Operation: Emergency appendicectomy

LABORATORY TESTS
Urine Analysis
Colour: Yellow

Blood Analysis
19 nov 2014
RBC: 4.67
Hemoglobin: 152
Colour Index: 0.98
WBC: 14.4
Segmented: 74
Bent: 5
Basophiles: 1
Lymphocytes: 14
Monocytes: 2
ESR: 5
Blood Screening
Urea: 4.5
Creatinine: 405
Bilirubin:
General Protein:16.3
Glucose: 4.3

INSTRUMENTAL TESTS
Plain abdominal X-ray: absence of any mass in the intestine.
Abdominal ultrasound: NOT DONE

DIFFERENTIAL DIAGNOSIS

1. Right sided ureteric colic: hematuria, severe pain from loin to groin,
absence of cough
tenderness help in excluding acute appendicitis.
2. Amoebic typhilitis is associated with diarrhea, blood in the stools and
tenderness in
left iliac fossa (Manson Barrs amoebic point of tenderness)
3. Torsion of undescended testis: absence of testis in the scrotum clinches
the diagnosis.
4. Meckels diverticulitis.

CLINICAL DIAGNOSIS AND GROUNDS FOR IT


Clinical Diagnosis:
Acute phelgmonus appendicitis.
Grounds for diagnosis:
This diagnosis was given because of the location of pain and signs of
tenderness at the right iliac fossa. Perforation is ruled out after the X-ray
investigation. Gynaecological causes were ruled out with the help of the
ultrasound investigation. There was no hematuria, no diarrhea, no melena,
and there was presence of testis in the scrotum. All these help rule out right
sided ureteric colic, amoebic typhilitis, torsion of the undescended testis and
Meckels diverticulitis.

AETIOLOGY AND PATHOGENESIS (according to literature)


Aetiology
1. Racial and dietary factors

2.

3.
4.

5.

It is common in white races more often than dark coloured persons. Young
males are affected more often.
It may be related to westernization of food a diet rich in meat precipitates
appendicitis and a diet rich in fibers (cellulose) protects the person from
appendicitis.
Familial susceptibility
It is related to having a long retrocaecal appendix in which case the blood
supply is diminished to the distal portion, which may precipitate appendicitis.
Socio-economic status
Appendicitis is common in middle class and rich people. The exact reasons
are not known.
Obstructive theory
Obstruction to the lumen of the appendix due to faecoliths, worms, ova, cysts
of entamoeba causes obstructive appendicitis.
Non-obstructive theory
It is due to bacteria like E.Coli, Enterococci, Proteus, Pseudomonas,
Klebsiella and anaerobes which produce diffuse inflammation of appendix and
cause appendicitis.

Pathogenesis
1. In non-obstructive cases (catarrhal appendicitis)
Process of inflammation is slow and gradual.
A mild attack may completely resolve or mucosal and sub-mucosal oedema
can occur.
Ulceration of the appendix results in slow bacterial invasion of lymphoid
tissue.
Gangrene and perforation are rare.
2. In obstructive cases, symptoms are abrupt, vomiting, pain and tenderness are more.
It is a more dangerous variety. Due to obstruction, the contents get infected
fast and the tension increases. The appendix becomes a closed loop, which
results in septic thrombosis of vessels. Gangrene of appendix, perforation,
peritonitis, followed by a local abscess can occur.
In children, greater omentum is very thin. Hence, it cannot localize the
infection. In adults, omentum is like a fatty apron which localizes the
infection.
In aged patients, because of atherosclerosis, gangrene occurs very fast
resulting in peritonitis. Obstruction is caused by faecoliths, worms and bands
which cause tenting. Other causes are volvulus, carcinoma, hepatic flexture,
etc.
Common bacteria encountered in acute appendicitis are Bacteroides fragilis,
Escherichia coli, Cloustridium perfringens, Streptococcus faecalis,
Pseudomonas aeruginosa, etc.

TREATMENT (according to literature)

Emergency appendicectomy: It is offered when patient comes within 24 to 48 hours of


abdominal pain. It is very important to rule out or detect a mass, especially if a decision is
made to operate around the 2nd or 3rd day. If a mass is palpable, it is better not to operate
now.

DAILY EXAMINATION
The patient was not hospitalized before the operation; therefore there was no daily
examination of the patient.

PREOPERATIVE EPICRISIS
The operation was indicated because the patient came to the hospital within 24 to 48
hours of abdominal pain. There was pain and tenderness at the right iliac fossa. There was
tenderness and muscle guarding during surface palpation of the abdomen. The SchetkinBlumberg symptom was positive. There was tenderness in the McBurney point. The
presence or absence of a mass was detected with the help of the X-ray investigation.
There was no presence of mass.

OPERATION
An emergency appendicectomy was done on 5th September 2011.
Appendix is identified by tracing taenia coli which converges onto the base of the
appendix. Mesoappendix is divided in between ligatures. Purse-string suture is applied all
around the appendix in the cecum. The appendix is divided in between ligatures, the
stump is invaginated and the purse-string is tightened. Abdomen is closed in one layer.
Laparoscopic appendicectomy has become more popular nowadays.

POSTOPERATIVE PERIOD. DAILY EXAMINATION.

After the operation, the patient feels better. He does not complain of anymore pain. He
was not allowed any food per os. Patient was administered glucose drips.

FINAL EPICRISIS. PROGNOSIS OF DISEASE.


On the afternoon of 12 .11. 14 , the patient experienced such a severe pain that an
ambulance was called for the transport of the patient to the hospital. He was then put
through a series of tests and was diagnosed with acute appendicitis. The patient was
scheduled for an emergency appendicectomy. This was done to avoid the dangers of a
perforated appendix. After the operation, the patient was warded for further observation.
The patient has been in a stable condition since the operation and does have any
complains.
The prognosis to life is excellent.
The prognosis to health is good.
The prognosis to working conditions is also good.