Patient’s profile

Name : Muharmiah Ramli

Gender : Female
Age : 19 years old
Race : Malay
Nationality : Malaysian
Occupation : Student at Segi College
Address : Jengka, Pahang
Marital status : Single
Date of admission : 29 September 2009
Date of clerking : 6 October 2009
Source of clerking : patient

Chief Complaint

Abdominal pain associated with nausea, vomiting and constipation for 7 days.

History of Presenting Complaint

The patient was well until one week before admission when she suddenly developed
epigastric pain, nausea and vomiting when she woke up in the morning. The pain was sudden
in onset, dull in nature, continuous and radiate to both right and left hypochondrium. The pain
aggravated by walking and relieved by bending forward.

Nausea and vomiting started as the pain started. She vomited out food particles each time
after taking meal. No hematemesis.

On the next day, she went to general practitioner because unbearable pain and treated as acute
gastritis. She was given anti-emetic and gastric neutralizing drugs. After taking drugs given,
the pain still not subsided and the nausea and vomiting still persisted.

Then she went to Hospital Jengka on the next day because persisting pain and been treated as
inpatient until the next day which were 4 days before admission. She claimed that she was
only given normal saline and dextrose saline during the hospital stay.

After discharge, the pain still persisted and worsened. 3 days before admission, the pain
moved to right iliac fossa. No more pain at epigastric region. The right iliac fossa pain was
sudden in onset, localized, colicky in nature, aggravated by movement and relieve by bending
forward. No abdominal distension.The pain associated with nausea and vomiting. She
vomited out clear fluid and no hematemesis.

One days before admission, she went to general practitioner again because unbearable and
persisting pain. Then she was referred to Hospital Jengka and the hospital referred her to
Hospital Temerloh.

She also did not pass motion since she got abdominal pain but she could still pass flatus after
abdominal pain started. There were no dysuria, urgency and frequency of urination. There
was no fever.

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Systemic Review

Respiratory system
There was productive cough started few days after abdominal pain started. No hemoptysis, no
rhinitis, sinusitis and no shortness of breath.

Cardiovascular system
No chest pain and palpitation.

Genitourinary system
No alteration in urination habit; urination was about 4-5 times a day. No polydypsia, no
hematuria, no urgency and no urinary incontinence.

Central Nervous System

He had no tremor, loss of sensory, migraine, diplopia, fit, automatism, paralysis, and speech
defect or body incoordination.

Past Medical History

She has no known past medical history

Past Surgical History

She had operation to make a hole to enable her to pass motion and flatus when she was 3
days old at Hospital Kuala Lumpur. She was born with congenital atresia of the anal canal.

Family History

She has no family history of cancer. Her mother has diabetes mellitus for 1 year and her
father has hypertension for 2 years.

Gynaecological history

Patient got her menarche at 13 years old and has regular flow that is once in a month with
interval of 30 days and 7 days flow. Her last menstrual period was 29 September 2009.

Social History

She is a student at Segi Nursing College and doing practical at Hospital Tanjung Karang.
Currently she lives with her friend at a hostel in Tanjung Karang. She is a non-smoker and
not consumes alcohol. She is sexually active.

Allergy and Drug History

She has no known food and drug allergy.

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Physical examination

General inspection
Patient was alert, conscious, propped up 45 degrees on her bed and in pain. The chest moved
with respiration, no respiratory distress. He was mildly dehydrated.

Vital signs:

Blood pressure : 120/60 mmHg

Pulse rate : 112 beats per minute
Respiratory rate : 24 breaths per minute
SpO2 : 97 % under room air
Temperature : 38.5 ᵒC (febrile)

General Examination
Examination of hands showed there were no clubbing, no palmar erythema, no asterixis and
no peripheral cyanosis. Capillary refill time was less than 2 seconds. There were no
conjuctival pallor and no sign of jaundice noted during examining the eyes. No central
cyanosis, dentition was good and the patient was mildly dehydrated noted during inspection
of the mouth. Jugular venous pressure was not raised and no palpable lymph nodes at the
neck region. There were no spider naevi and no loss of axillary hair.

Specific Abdominal Examination

Inspection
The abdomen moved with respiration, scaphoid in shape, the umbilical is centrally located
and inverted, no dilated vein, no swelling and no caput medusa. No visible peristalsis.

Palpation
On light palpation, her abdomen was tender at right and left iliac fossa and suprapubic area.
On deep palpation, no abdominal mass and tenderness at both right and left iliac fossa and
suprapubic region. Her liver, spleen, kidney and inguinal lymph nodes not enlarge. Rebound
tenderness and Rovsing’s sign positive.

Percussion
The abdomen was resonance on percussion. Liver span was measured to be 10cm and
Traube’s space was resonance.

Auscultation
Bowel sound was decrease, no hepatic and renal bruit.

Renal punch was negative.

The patient’s inguinal orifices cannot be examined because of pain. The abdominal
examination should be ended by per rectum examination. However, the examinations was not
done as patient uncomfortable and in pain.

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Systemic examination

Respiratory system
The lungs were clear. No rhonchi and no crepitation. Normal vesicular breath sound were
heard bilaterally. Patient was not tachypnoeic.

Cardiovascular system
Dual rhythm no murmur. No added sound.

Musculoskeletal system
The tone was normal, power 5/5 and reflexes were normal for both upper limb and lower
limb and for both right side and left side. Barbinski sign was negative.

Neurological system
All cranial nerves were intact. Reflexes and sensory component were intact.

Summary

In summary 19 year old girl presented with right iliac fossae pain for three days before
admission associated with nausea, vomiting and constipation for one week. On examination
there was tenderness at both right and left iliac fossa and suprapubic area. Rebound
tenderness and Rovsing’s sign was positive.

Differential Diagnosis

1. Acute appendicitis
2. Intestinal obstruction
3. Ileitis

Provisional diagnosis
Acute appendicitis
Reasons:
The history (right iliac fossa pain, nausea and vomiting) and clinical signs (positive rebound
tenderness and Rovsing’s sign) are very suggestive of acute appendicitis.

Investigation

Full Blood Count (On admission)

level Limits units

WBC 14.2 4.0 -10 103/mm3
RBC 3.63 4.5 -6.5 106
HGB 10.8 13.0 – 17.0 g/dL
HCT 30.5 40.0 – 54.0 %
PLT 235 150 – 500 103/mm3

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Urine Full Examination and Microscopic Examination (On admission)

Blood +++250 RBC/μL

Bilirubin negative
Urobilinogen normal
Ketone negative
Protein negative
Nitrogen negative
Glucose negative
pH 5.5
Specific gravity 1.025
Leukocytes 10 WBC/μL

Blood urea and serum electrolytes

Test result normal range

Urea 3.5 mmol/L (2.5 – 6.7)
Sodium 134 mmol/L (135 – 148)
Pottasium 4.2 mmol/L (3.5 – 5.2)
Chloride 101 mmol/L (95 – 108)

Operative findings

 Abscess 10cc in peritoneum ( localized at right iliac fossa )

 Appendix embedded in subserosal layer
 Bone identified and secured
 Drain inserted at right iliac fossa

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Management

Emergency surgery: Appendicectomy

Pre-operative management

1. Nil by mouth
To prevent complication during anaesthetic induction.

2. Fluid and electrolyte replacement

This patient was dehydrated due to repeated vomiting and fluid sequestration. The
basic abnormalities are sodium and water loss. Thus fluid replacement with normal
saline is appropriate.

3. Antibiotics
To prevent septicaemia. The antibiotics were cefobid and flagyl.

Post-operative management

1. Continue nil by mouth

Intestine is passive post operatively. Thus patient should be keep nil by mouth few
days after operation.

2. Analgesic for post-operative pain

IV Tramal 7.5mL/hour

3. Drainage chart
The intraabdominal drainage should be monitored daily. Drainage should be put to
drain any abscess and serous fluid.

4. Continue antibiotic
IV Cefobid and IV Flagyl

5. Intravenous fluid and electrolytes replacement

Patient is keep nil by mouth. Thus fluid and electrolytes replacement was necessary.

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Discussion

The appendix is a worm shaped blind ending tube that arises from posteromedial wall of the
caecum below the ileocaecal valve. Appendicitis is the most common acute surgical
emergency.

Acute appendicitis has a lot of variation in the clinical picture especially in the infant and
young. In this case, the patient initially presented with gradual onset of epigastric pain. A few
days later the pain moved to right iliac fossa region and associated with nausea and vomiting.
On examination, rebound tenderness and Rovsing’s sign were positive. Thus right iliac fossa
pain associated with nausea and vomiting in addition to positive rebound tenderness and
positive Rovsing’s sign were very suggestive of acute appendicitis.

Even most of cardinal sign of intestinal obstruction could be elicited from this patient such as
nausea and vomiting, constipation and abdominal pain, diagnosis of intestinal obstruction still
unlikely because of positive rebound tenderness and positive Rovsing’s sign. Furthermore she
has no history of previous abdominal surgery.

The causes of appendicitis remain unclear but several different mechanisms have been
proposed. Diet lacking in fibre and a consequent slow transit time and alteration bacterial
flora were the popular causes. Pathogenesis of appendicitis is obstruction of lumen of
appendix causes inflammation. Inflammation of the wall of appendix causes venous
congestion which may comprise arterial inflow leading to ischemia and infarction.

Full blood count had done as baseline investigation. The results showed increase in white cell
count indicating there were infections in the body. Renal profile should be done as baseline
test during the admission to monitor kidney function and hydration state of the body but this
not done during admission. Blood urea and serum electrolytes had done only before discharge
and the results were normal. For urine full examination and microscopic examination, the
results were normal except for red blood cell count cell that showed very high value. This
because she was having her menses during that time.

Complications of appendicitis include perforation, appendix mass and appendix abscess. In

children perforation is common due to diagnostic difficulty. Appendix mass result when an
inflamed appendix becomes covered with omentum. Then appendix mass may result if
appendix mass fails to resolve.

Because of coming late for treatment, this patient had suffered complication of appendicitis
that was perforation. Perforation had detected during the operation. Fortunately perforation
had occurred not for a long time before operation and generalized peritonitis had not
developed yet at that time. However due to perforated appendix, this cause prolong stay at
hospital to monitor general condition of the patient and to infuse appropriate antibiotics
intravenously. Upon discharge, she was clinically well.