Good morning Doctors and Fellow Medical Students.

In behalf of the CPC group 3, I will be

presenting our management to the case.

First of all, we start with the list of problems of our patient. Her chief complaint is abdominal
pain with a pain scale of 6-7/10 intensity, characterized as a dull ache with a direct tenderness localized
to the RLQ, non-radiating and is worsened by sudden movement and palpation. There is also a positive
Obturator and Psoas sign. She also has loss of appetite or anorexia, nausea without vomiting, fever at 38
degrees Celsius, a decreasing haematocrit value from hospital day 1 – 5, a decreasing RBC count from
Hospital day 5 – 9, a significantly increased WBC count on the 4th hospital day with an significantly
increased neutrophil count on the 4th and 5th hospital day and a decreased lymphocyte count on the 4th
– 6th hospital day. With these list of problems identified, our group has decided to assess the ALVARADO
Score of the patient. The Alvarado scoring system is a clinical scoring system used in the diagnosis of
appendicitis. The score has 6 clinical parameters and 2 laboratory parameters with a total of 10 points. A
total score of <3 has a low likelihood of appendicitis, a score of 4-6 considers appendicitis and further
imaging test should be conducted, a score of 7-8 has a high likelihood of appendicitis and a score which
falls in the range of 9-10 is almost certain that the patient has appendicitis. For our patient, there is no
migration of pain, but there is anorexia, there is nausea, there is tenderness in the RLQ, there is rebound
pain, an elevated temperature with leucocytosis and a shift of the WBC count to the left which gives her
a total score of 9. This score implies that our patient most certainly has appendicitis.

With these data gathered from the history taking and the physical examination, we have
decided to admit the patient in the Surgery Department under the service of Dr. Selma. Consent for care
must be secured and the vital signs must be monitored every 4 hours as well as the patient’s input and
output which should be monitored every shift. The patient should be placed on NPO and an IV line
should be started with PLR, 1L at 33gtts/min. Laboratories such as CBC, urinalysis, serum sodium, serum
potassium, creatinine, BUN, SGPT, and Albumin must be requested to further support the diagnosis and
to help rule out the possibility of a ruptured appendix which could possibly turn out to be septic.
Imaging test should also be ordered. In this case, according to the Evidence-based clinical practice
guidelines on the diagnosis and treatment of acute appendicitis, CT Scan should be preferred over
ultrasonography in clinically equivocal appendicitis in adults because of its superior accuracy, however,
for the case of our patient, since her Alvarado score is very high and suggest a high certainty of
appendicitis, an ultrasound of the whole abdomen with the appendix can be done instead because it is
cost-effective and thus is the one commonly ordered in the hospital setting. The patient should also be
started with antibiotic medications. She is to start with Cefuroxime 750mg every 8 hours IVTT after a
negative skin test. Cefuroxime is a second generation Cephalosporin which is bactericidal against many
organisms, including the beta lactamase producing strains. It is highly effective against gram-negative
cocci and gram negative bacilli. Aside from that, the patient should also be given Metronidazole 500mg
every 6 hours IV infusion. Metronidazole is an Amebicide used for the treatment of serious infections
caused by susceptible anaerobic bacteria as well as for prophylaxis against post-op infections in patients
undergoing abdominal surgeries. The patient should also be given Ketorolac 30mg IVTT every 8 hours for
the management of severe acute pain that requires analgesia. In early cases of appendicitis wherein the
diagnosis is not clear, pain relievers should be avoided because they mask the symptoms of pain,
therefore derailing the doctor from arriving on his or her correct diagnosis. However, when the clinical
symptoms are clear enough and a diagnosis has been made, a pain reliever can be given to help alleviate
the patient’s discomfort. The patient should also be given Omeprazole 40mg IVTT which is used to
prevent the patient from developing gastrointestinal ulcer because it decreases the amount of acid the
stomach makes. The patient should also undergo a STAT Open appendectomy. According to the
Evidence-based clinical practice guidelines on the diagnosis and treatment of acute appendicitis, open
appendectomy is the recommended primary approach in the treatment of acute appendicitis in the
Philippine setting, whereas Laparoscopic appendectomy is an alternative in selected cases. The
operating room and the anaesthesiologist should be informed for the STAT Appendectomy and a Foley
Catheter French 16 with a urobag should also be inserted to the patient and AP Prep has to be done
before the surgery as well.

On the second hospital day, and 1st post-operative day, the patient’s vital signs should be
assessed every 4 hours. A post-operative fever occurring on the 1st and 2nd post-operative day is most
likely part of a natural and non-infectious inflammatory process. The patient’s IV medications should be
continued and the patient may have clear liquids once fully awake from the operation.

On the third hospital day, the patient may have general liquids and she can start having soft diet
once she is able to pass flatus already. The Foley Catheter should be removed and the patient is
expected to be able to void within 4-6 hours from the removal of the Foley catheter. If there is no urine
output 6 hours after the removal of the Foley Catheter, the nurse is expected to refer this immediately
to the resident in charge and the wound dressing should be changed care of surgery JI.

On the fourth hospital day, assess if the patient was able to have any bowel movement. Once
with bowel movement, the patient can now have a full diet. Her IV medications can also be shifted to
oral medications. Shift Cefuroxime 750mg q 8 hours IVTT to Cefuroxime axetil 500mg tablet, thrice a day
for 4 days as a continuation from her IV antibiotics. Shift Metronidazole 500mg q 6 hours IV infusion to
Metronidazole 400mg Tablet every 6 hours for 4 days as a continuation of her IV infusion
Metronidazole. Discontinue the patient’s Ketorolac 30mg IVTT and Omeprazole 40mg IVTT. Give the
patient Celecoxib 200mg twice a day for 5 days for pain relief from her post-operative site. Request for a
CBC and Urinalysis.