TANGPUZ, JOFEN ANN H.

MEDICAL CLERK

Date and Time of History: December 28, 2020, 8 AM

Source of Information: Patient
Reliability: 95%
Referral: None

General Data

N.R., male, 75 years old, born on September 13, 1946, Filipino, Roman Catholic, residing
at Tacloban City, was admitted for the first time in Remedios Trinidad Romualdez Hospital
(RTRH) on December 28, 2020 at around 6:30 am.

Chief Complaint

Loose Bowel Movement and Vomiting

History of Present Illness

2 days prior to admission, patient complained of multiple episodes of vomiting of

previously ingested food approximately 150 cc per episode, characterized as non-projectile &
non-bilious. It was accompanied with generalized colicky abdominal pain with a PRS 7/10, non-
radiating, lasted for 2 minutes and is not relieved by food. Patient was given anti-acid
medication but noted no relief.
A day prior to admission, still with episodes of vomiting and now associated with 4
episodes of loose bowel movement characterized with watery, foul smelling stools accompanied
with anorexia, abdominal pain. There was no fever noted. Persistence of symptoms lead patient
to a private institution for admission.

Past Medical History

Immunizations: Unrecalled immunizations

Childhood Illnesses: No history of mumps, measles and other childhood illnesses.
Adult Illnesses: None
Surgical: 2015- Undergone spinal cord surgery due to an alleged injury.
Allergies: No known allergies to food and drugs

Family History
Patient is married to a 74-year old housewife, diagnosed for having hypertension and
with maintenance medication of Losartan 50 mg OD. He has 6 children, 4 boys and 2 girls, all
living and apparently well. Patient’s father died due to a cardiac arrest at an unrecalled age.
Patient’s mother died from old age but is a known hypertensive. With one sibling in good health
condition. No history of cancer, diabetes mellitus, asthma, TB, and other heredofamilial
diseases.

Psychosocial History
Patient studied until 4th Grade of elementary. He and his wife are currently living with
their 2 children in a 3-bedroom 2-storey house made of semi-concrete materials with a water-
sealed toilet. Their drinking water is from a water refilling station and water for other purposes
is from LMWD. They dispose their garbage in plastic bags and wait for the local garbage truck
to pass by once a week.
Patient usually wakes up at 4 AM and eats breakfast composed of rice and fish with
coffee as his beverage. He is an occasional alcoholic beverage drinker and a non-smoker.

REVIEW of SYTEMS
General: (-) weight loss, (+) body malaise since onset of illness
(-) fever; (+) poor appetite
Skin: no itchiness, no recurrent skin lesions
Eyes: no blurring of vision, does not wear eyeglasses, (-) discharges
Ears: (-) hearing loss, (-) pain, (-) discharges
Nose: (-) cold, (-) loss of smell, (-) pain, (-) epistaxis
Mouth and throat: (-) pain, (-) dysphagia, (-) hoarseness
Neck: (-) mass, no stiffness
Respiratory: (-) wheezing, (-) orthopnea, (-) cough (-) difficulty
Breathing
Heart: (-) palpitations, (-) easy fatigability, (-) paroxysmal
nocturnal dyspnea
Abdomen: (+) abdominal pain, (+) nausea & vomiting, (-) belching, (-) bloating, (-) history of
hematochezia and melena
GUT: (-) dysuria, (-) hematuria, (-) urinary frequency, (-) flank
pains, urinates 5-6x a day of 250 mL per voiding
Extremities: (-) joint pains, (-) swelling or edema,
Endocrine: (-) polyuria, (-) polydipsia, (-) heat and cold
intolerance
Hematologic: no easy bruising, (-) gum bleeding
Peripheral vascular: (-) intermittent claudication, (-) recurrent
pain on extremities, (-) numbness, (-) cramps
Musculosketal: (-) myalgia, (-) bone pains
Neurologic: (-) seizures, (-) recurrent headache, (-) dizziness, (-) loss of consciousness,
(-) head trauma
Psychiatric: (-) sleep disturbance

PHYSICAL EXAMINATION
General Survey
Patient is conscious, coherent, oriented to time, place and person, cooperative, with
intact memory, afebrile, well developed, pale and thin. In pain with facial grimace and
guarding.
Vital signs are as follows:
BP: 110/70mmHg (within normal range)
HR: 75 bpm (within normal range)
RR: 20 cpm (within normal range)
T: 36.0 C (hypothermia)
02 sat: 99% (within normal range)
WT: 61 kg
HT: 175 cms
BMI: 19.9 kg/m2 - Normal
Skin: warm, with senile skin turgor, no swelling, no lesions, no petechiae, no ecchymoses, no
jaundice, no active lesions
Nails: pinkish nail beds with good capillary refill (<2 seconds), without clubbing or cyanosis
Head: skull is normocephalic, hair equally distributed, temples not depressed, no nits, no scalp
lesion, no engorged vein, no tenderness
Eyes: sunken eyeballs, symmetrical eyebrows with equally distributed hair, full EOM with no
field cuts, pupils 2 mm in diameter and briskly reactive to direct and consensual light, no
periorbital edema, no dryness or redness, no nystagmus, no swelling, no tenderness,
Ears: symmetrical, no impacted cerumen, no discharges, hearing not impaired, no tenderness
Nose and Sinuses: pinkish mucous membrane, septum at midline, no discharges, no
congestion, no nasal flaring, no sinus tenderness
Mouth and Throat:
Lips: dry lips, no lesions, no cheilosis, no angular deviation
Buccal mucosa: no lesions, pale, dry mucous membrane
Tonsils: no enlargement, no redness, no abscess
Tongue: dry and at the midline
Neck: flat neck veins, carotid pulse full, no lesions, thyroid not palpable, trachea at midline, no
lumps, (-) supraclavicular lymphadenopathy
Breast: symmetrical, no lesions, no discharges, no
lumps, no palpable lymph nodes, no tenderness
Chest and Lungs:
Inspection: symmetrical lung expansion, no lagging, no subscapular and intercostals retraction
on respiration, breathing not labored
Palpation: confirmed symmetrical chest expansion, unimpaired tactile fremitus, no masses, no
tenderness
Percussion: resonant all over lung fields
Auscultation: bronchovesicular breath sounds, no rales, no wheezing, no pleural friction rub
Abdomen:
Inspection: abdomen is flat, symmetrical, no visible pulsation, no distended veins, no scars, no
signs of inflammation; (-) Murphy sign; (-) Cullen sign, (-) Turner sign
Auscultation: hyperactive bowel sounds at 50 clicks/min, no bruits, no peritoneal friction rubs
Percussion: tympanitic on all quadrants with dullness over liver and spleen, (-) fluid wave, (-)
shifting dullness, Liver span is 7cm along the MCL with upper border at 5 th ICS and lower border
at 7th ICS.
Palpation: soft and direct tenderness on the right lower quadrant, (+) Rovsing sign (+)
Obturator sign, (+) Rebound tenderness. (+) Iliopsoas sign.

Extremities:
Upper limbs: equal in length and size, full range of motion, no rashes, no peripheral edema,
no cyanosis, skin is warm and dry, good skin turgor, pulses faint, no muscle tenderness, no
edema, no joint pain, no swelling of joints, no bruits,
Lower Limbs: equal in length and size, full range of motion, with varicose veins, no peripheral
edema, no rashes, skin is warm and dry, pulses faint, no muscle tenderness, no edema, no joint
pain, no swelling of joints, no bruits
Rectal examination: No perirectal lesions or fissures. External sphincter tone intact. Rectal
vault is empty and without masses. No rectal tenderness, no palpable mass nor hemorrhoids

Neurologic Exam
Mental status exam:
Patient is alert and cooperative. Thought process is coherent. Oriented to person, place,
and time. GCS 15.

Cranial Nerves:
CN I – No anosmia (X.O. coffee candy)
CN II – Pupils are 2 mm in diameter, equally round and reactive to light and
accommodation. Visual acuity intact. Visual fields full.
CN III, IV, and VI – The patient was able to move eyes upward, downward, medially,
laterally.
CN V – Temporal and masseter strength intact, sensory corneal reflexes present
CN VII – Face is symmetric with normal eye closure, can smile, cry and laugh
symmetrically.
CN VIII – Responsive to verbal stimuli and normal communication.
CN IX and X – Gag reflex is intact
CN XI – Able to shrug shoulder with resistance
CN XII – The tongue is at midline upon protrusion

Motor:
 Good muscle bulk and tone. Can flex and extend both upper and lower extremities
without limitations.

Cerebellum:
RAM, finger-to-nose, heel-to-shin intact. (-) Romberg’s sign, (-) pronator drift

Sensory:
On both upper and lower extremities, light touch, pinprick and position sense are intact.

Reflexes:
Biceps triceps brach knee ankle plantar
Right 2+ 2+ 2+ 2+ 2+ ⭣
Left 2+ 2+ 2+ 2+ 2+ ⭣

Primitive Reflexes: Absent primitive reflexes

Pathologic Reflexes: (-) Babinski, (-) Ankle clonus

Meningeal:
(-) nuchal rigidity, (-) Kernig’s sign, (-) Brudzinski’s sign.

Autonomics:
No excessive sweating and no urinary incontinence

Diagnostics

Complete Blood Count (CBC)

● Leukocytosis may represent inflammation or infection
● Lack of hemoconcentration rules out severe disease

Laboratory Result Normal Value Interpretation

Hemoglobin 13 g/dL 13-17g/dL Normal

(males)

Hematocrit 0.42 0.38-0.47 Normal

White cell Count 12 x 10^9/L 4.5-10x10^9/L Increased

Neutrophils 88 0.50-0.70 Increased

Lymphocytes 8 0.20-0.50 Increased

Monocytes 4 0.02-0.09 Normal

 Platelet Count 308 x 10^9/L 150-400 x Normal
10^9/L

Serum Electrolytes
● A complication of pancreatitis is hypocalcemia and hypomagnesemia which is due to the
saponification of fats
● To assess level of dehydration

Sodium 137mmol/L 135-145mmol/L Normal

Potassium 3.83 mmol/L 3.5-5.5mmol/L Normal

Serum Creatinine and BUN

● To monitor kidney function
BUN 12.80 mmol/L 2.5-6.1 mmol/L Increased

Creatinine 100umol/L 61-114.9umol/L Normal

Amylase
Amylase 67 U/L 30-110 U/L Normal

H. pylori test
H. pylori test Negative

Urinalysis
● To rule out infection
Patient’s Test
Values
Color Yellow
Clarity Slightly turbid
Specific Gravity 1.010
pH 6.5
Sugar -
 Albumin +
Ketones -
WBC 4-6 /hpf
RBC 2-4 /hpf
Pus cells 6-8/hpf
Coarse granular, 2-4/lpf
Hyaline Casts
Stool Exam
Stool Exam Yellowish brown soft stools with no Ova or cyst seen
Abdominal Xray

Segmental ileus pattern

HOSPITAL COURSE
1st day
Admitted to IM department
Diagnostics results
IV fluids started with PPI, antidiarrheal and anti-spasmodic
Abdominal X-RAY showed segmental ileus pattern
Quinolone antibiotic was added to the medications.
rd
3 day
No episodes of vomiting or LBM
(+) Abdominal pain and anorexia
Repeat CBC-Elevated WBC with predominance of neutrophils
Antibiotic shifted to Penicillin-beta lactam combination
CT-scan of the whole abdomen with oral and IV contrast was requested
th
4 day
-referred to Surgery department
-Surgery evaluation; Direct tenderness and indirect rebound tenderness on the Right
lower quadrant
 -on NPO
-started with antiprotozoal antibiotic and scheduled for Operation.

Salient Features

Demographics HPI PE Laboratory

Imaging
● 75 years old ● Multiple episodes of Vital signs Abdominal Xray
● Male vomiting BP: 110/70mmHg Segmental Ileus
● Filipino ● Generalized colicky HR: 75 bpm pattern
abdominal pain PRS
RR: 20 cpm
7/10
T: 36.0 C
● Loose bowel
movement 02 sat: 99%
characterized with WT: 61 kg
watery, foul smelling HT: 175 cms
stools BMI: 19.9 kg/m2 – Normal
● anorexia -Sunken eyeballs
-dry lips
-dry tongue
Abdomen: hyperactive bowel sounds
at 50 clicks/min,
tympanitic on all quadrants with
dullness over liver and spleen, soft
and direct tenderness on the right
lower quadrant
(+) Rovsing sign (+) Obturator sign, (+)
Rebound tenderness. (+) Iliopsoas sign.

Pivot

Vomiting
 Differential Diagnosis
Rule In
Acute -75 y.o
Appendicitis -Multiple episodes of
vomiting
-Direct tenderness on the
right lower quadrant
-Leukocytosis
-shift to the left neutrophils
-(+) Rovsing sign (+)
Obturator sign, (+)
Rebound tenderness. (+)
Iliopsoas sign
(Alvarado score: 8
interpreted as high
likelihood)
Rule Out Diagnostics
Cannot completely CBC (WBC & Differential count) –
rule out. Mild leukocytosis - <18,000
cells/mm3 for uncomplicated
appendicitis
o Counts above this level raise the
possibility of a perforated appendix
with or without an abscess.
o If >18,000: then you think of later
stages of the disease (most probably,
gangrenous) „g
o Up to 1/3 have normal leukocyte
count
Plain Film of the Abdomen
-May be of benefit in ruling out other
pathologies
-May show fecalith and fecal loading
in the cecum
o (+) fecalith → high likelihood of
appendicitis
Chest X-ray
Rules out referred pain from a right
lower lobe pneumonic process
Ultrasound
Thickening of the appendiceal wall
and the presence of periappendiceal
fluid are highly suggestive of
appendicitis.
CT Scan
More sensitive and specific than
ultrasonography
• Dilation of > 5mm + thickened wall
= INFLAMED APPENDIX
• Evidence of inflammation often
include the following:
 o periappendiceal fat stranding
o thickened mesoappendix
o periappendiceal phlegmon
o free-fluid
• Fecalith can be often visualized

Urinalysis – Done to rule out urinary

tract infection (UTI)

Mesenteric -Multiple episodes of No history of Blood tests- determine whether

Adenitis vomiting
-Direct tenderness on the
right lower quadrant
-Anorexia
-(+) Rovsing sign (+)
Obturator sign, (+)
Rebound tenderness. (+)
Iliopsoas sign
Systemic Illness your child has an infection and what
Concomitant ARI type of infection it is.
Imaging studies:
 -Abdominal ultrasound is used to
diagnose mesenteric lymphadenitis.
-CT scan

Acute -generalized colicky -No ova or cyst seen Diagnosis is mainly clinical. But
Gastroenteritis abdominal pain in the stool exam several tests can also be performed:
-Anorexia -No history of travel -Stool examination
-Loose bowel movements
-Complete Blood Count
-Weakness
-Electrolytes
-Fatigue
-Kidney function tests

Small bowel -75 y.o -no obstipation CT scan with water soluble contrast-
obstruction -Multiple episodes of -Patient presented may reveal abscess, inflammatory
vomiting with loose bowel processes, extraluminal pathology
-generalized colicky movement
abdominal pain -No abdominal Abdominal X-ray
-Leukocytosis distention
-Hyperactive bowel sounds

FINAL DIAGNOSIS
Acute appendicitis

ANATOMY AND PHYSIOLOGY OF THE APPENDIX

-Average length 6-9 cm (variable from <1 to >30

cm)
-Outer diameter 3-8 mm
-Blood supply from appendicular branch of the
ileocolic artery
PATHOPHYSIOLOGY OF APPENDICITIS

Obstruction of lumen by fecalith or hypertrophy of lymphoid

tissue

Obstruction of proximal appendicial lumen produces:

-closed-loop obstruction
-continuing normal appendiceal mucosal secretion
- luminal distension
-visceral afferent stretch fiber nerve ending stimulation Generalized colicky abdominal
pain

Increasing distension from continued mucosal secretion and reflex nausea and vomiting, and
from rapid multiplication of the resident bacteria increased visceral pain

As pressure in the organ increases, venous pressure is

exceeded. Capillaries and venules are occluded but arterial engorgement and vascular
inflow continues congestion

Inflammatory process soon involves the serosa of the shift in pain to the right lower
appendix and in turn the parietal peritoneum quadrant

STAGES OF APPENDICITIS

1. Acute Focal Appendicitis

2. Acute Suppurative Appendicitis
3. Gangrenous Appendicitis
4. Perforative appendicitis
TREATMENT AND MANAGEMENT

A. UNCOMPLICATED APPENDICITIS
✔ Surgical (operative) treatment has been the standard of care
✔ The concept of non-operative treatment for uncomplicated appendicitis
developed from two lines of observations: o For patients in an environment
where surgical treatment is not available instead antibiotics is given.
✔ Many patients with signs and symptoms consistent with appendicitis who did not
pursue medical treatment would occasionally have spontaneous resolution of
their illness

B. COMPLICATED APPENDICITIS
✔ Refer to perforated appendicitis commonly associated with an abscess or
phlegmon.
✔ Open Appendectomy
✔ Surgery (operative treatment) for patients with sepsis and generalized peritonitis
• Operative treatment of presumed uncomplicated appendicitis remains the standard of
care
• Advise surgery if there is sepsis and generalized peritonitis

OPERATIVE MANAGEMENT

A. Open Appendectomy
-Performed under general anesthesia (GA)
-Patient in supine position
- Entire abdomen is prepped and draped in case a large incision is made
-For early non-perforated appendicitis: McBurrney (oblique), Rocky Davis
(transverse) incision
- If perforated appendicitis is suspected: Lower midline Laparotomy
- Irrigation in complicated appendicitis is not recommended o If there is
an abscess seen, just suction. Irrigating will spread infection further

1. Early non-perforated
-RLQ incision at McBurney’s point is commonly used

• McBurney’s point – 1/3 of the distance from ASIS to umbilicus

• McBurney (oblique) or Rocky-Davis (transverse) RLQ muscle splitting incision is
made

2. Perforated Appendix
• Lower midline laparotomy may be considered

B. Laparoscopic Appendectomy
-Done under general anesthesia
-Patient is supine with left hand tucked away or securely strapped
-10 or 12mm port is placed at the umbilicus, two 5mm ports are placed suprapubic and
LLQ
-Placed in Trendelenburg position and tilted to the left