Chief complaint

Mr S a 46 years  old Malay gentleman presented to the emergency department with chief
complaints of abdominal pain for 2 days.

History of presenting illness 

He experienced the epigastric pain while about to sleep at night. It was dull aching pain
radiating to the right iliac fossa and persistent with severity of 5 out of 10 for pain scale.
There is no aggravating and relieving factor. He tried to tolerate the pain until the next
morning, he vomited. It was fluid content, non bilious and no blood. He was brought up to
the emergency department by his wife. In the Emergency department he had one episode of
loose stool. Otherwise, no history of eating outside food and contact illness. There is no
fever, no left lower quadrant pain, irregular bowel habits and per rectal bleeding. No
intermittent loin to groin pain and hematuria. He normally passess motion once daily and has
normal urinary habits. No loss of weight and appetite. He denies any chest pain, shortness of
breath, cough and trauma.

Past medical and surgical history

There is no recent admission to hospital and no past surgical history

Drug history
He was not on any medication. No over the counter medication or traditional medicine.

Family history 
Patient has three siblings and he is the third. His older brother and sister are well. Both of his
parents are healthy. No family history of peptic ulcer disease and malignancy.

Social history 
He is a chronic smoker who smokes 1 pack per day for the past 20 years. He did not consume
alcoholic drinks. His diet consists of nasi lemak with tea for breakfast, mixed rice for lunch
and dinner. He mentioned that he loves to eat spicy food. He currently lives in Mengkibol
with his wife who is a housewife and is blessed with one child. He works as an automotive
service technician. No recent history of traveling.

Vital sign:
Heart rate: 84 beats per minute Blood pressure: 118/76mmHg (78)
Respiratory rate: 18 breaths per minute SpO2 99% under room air
Temperature: 37.2°C Pain Score: 3/10

Anthropometry:
Weight 52kg

Height 1.7m

Body Mass Index 18.3kg/m2

(BMI)

All vital signs were normal. He is underweight, stable and afebrile.

Examination in Emergency department

The abdomen was flat and normal. No past surgical scar and masses noted. There was mild
tenderness at the epigastric region and noted rebound tenderness at the right iliac fossa and
Mc Burney’s point.

General examination in ward

Patient is thin built, well hydrated and cooperative. He was lying supine on bed and not in
respiratory distress and obvious pain. Patient is well, no pallor, jaundice, and pedal edema
noted.
Abdominal examination

The patient was lying supine with leg extended. The abdomen was flat and normal in shape.
The umbilicus was centrally located and flat. The abdomen moves with respiration. There
were no peristaltic movements, pulsating swelling and obvious masses observed. The skin
was normal and hernial orifices were intact. Abdomen was soft and tenderness was present at
the McBurney’s point upon deep palpation. Rebound tenderness was present and Rovsing
signs were positives. No hepatosplenomegaly. No ascites were noted. Bowel sounds were
present.

The rectal examination was normal. The external genitalia and scrotum were normal.

Cardiorespiratory examination:

There is no chest deformity and the apex beat located at the 5th left intercostal along the
midclavicular line. There was no thrill or parasternal heave. The first and second heart sounds
were appreciated and no additional heart sound or murmur. No pedal oedema.

Respiratory examination:
The trachea was central. The chest rises equally with breathing. Air entry was equal
bilaterally and vesicular breath sounds were heard upon auscultation of the lung. No
crepitations were heard on the base of the lungs.

Musculoskeletal and nervous systems: 

Grossly normal.

1. Full blood count

Justification: To rule out anemia, look for leukocytosis and thrombocytosis as a sign of acute
infection

Parameters Value (29/7/2023) Unit Normal range

White blood cell 16.62 10 /L9
5 – 15.5
Red blood cell  4.94 10 /L 3.8 – 5.8 
12
Haemoglobin 13.5 g/dL 11.5 – 15.5
(Hb)
Haematocrit 39.9 % 35 – 45 
MCV 80.8 fL 80.6 – 95
MCH 27.3 pg 27 – 32 
MCHC 33.8 g/dL 31 – 37
Platelet 287 10 /L
9
150 – 400 
RDW - CV 14.0 % 12 – 14.8
Neutrophil 78.6 % 40 – 80 
Lymphocyte 11.2 % 10 - 50

Interpretation: There is leukocytosis with neutrophils predominantly. Otherwise other blood

parameters were normal.

2. Renal profile

Justification: To rule out possible renal impairments, dehydration and electrolyte imbalance.

(29/7/2023 Unit Normal Range

)
Urea 3.4 mmol/L 3.0 – 9.2 
Sodium 141 mmol/L 136 – 145 
Potassium 4.1 mmol/L 3.5 – 5.1
Chloride 109 mmol/L 98 – 107 
Creatinine 91.0 μmol/l 63.6-110 

Interpretation: There was normal kidney function and no electrolyte imbalance.

3. Urine full examination microscopic examination:

Justification: To rule out urinary tract infection and dehydration

Value Normal

Glucose negative

Protein negative

Blood Trace

Leucocytes negative

Nitrites negative

Ketone ++
Interpretation: Ketone is 2+ meaning blood ketone concentration was 1.6 to 3.0 mmol/L. Patient
is dehydrated.

4. Liver function test

Justification: No justification
Parameters 29/7/2023 Unit Normal Range
Total 10.8 μmol/L 3.4 – 20.5
Bilirubin
ALP 58 u/L 40 - 150 
Total Protein 71 g/L 64 - 83
Albumin 42 g/L 34 - 48
AST 16 u/L 3 - 34
ALT 19 u/L 0 - 55

Interpretation: The liver function tests were normal . There is no clinical significance in
evaluating acute appendicitis.

5. Abdominal x-ray

Justification: To look for air fluid levels and dilated bowel due to obstruction.

Interpretation: Normal abdominal radiograph

6. Erect Chest x-ray 

Justification:t To look for air under the diaphragm as sign of viscus perforation

Interpretation: Normal chest radiograph

7. Random blood glucose

Justification: To rule out diabetes mellitus, stress condition can cause hyperglycemia
Interpretation: Blood glucose was 6.9mmol/L, normal.

8. ECG

Justification: To rule out inferior myocardial infarction

Interpretation: Sinus rhythm with no ST changes.

Working diagnosis
Acute appendicitis

Plan of management on admission 

Management in Emergency Department
1. He was given Magnesium Trisilicate 15 ml
2. For his pain relief, IV Tramadol 50 mg TDS, IV Maxolon 10 mg and IV Pantoprazole
40 mg was given
 3. Blood was taken for FBC, RP, LFT and Urine full examination microscopic
examination
4. Chest and abdominal radiograph was requested
5. Start IV normal saline was given for 1 hour
6. Referral to surgical department was made

Mr S was admitted to ward 8B for further history and management of acute appendicitis.

In the ward, he was lying supine, alert and saturating under room air with stable vital signs.

The in ward management plan is:

1. Nil by mouth at 2 am, allow orally first
2. IVD 4 pints normal saline for 24 hours once patient nil by mouth (2NS, 2DS). 
3. For IV Augmentin 1.2g STAT and TDS
4. For Tab Paracetamol 1g QID STAT
5. Continue IV Tramadol 50 mg TDS and IV Pantoprazole 40 mg OD
6. Watchout hypertensive tachycardia
7. Reassess abdomen the next morning
8. KIV for laparoscopic appendectomy if worsening
9. For OGDS later

The staff nurse noted that his blood pressure was 87/56 mmHg and clinically, the patient
had right iliac fossa pain with a pain score of 2/10. Physical examination noted that upon
deep palpation there is tenderness at the right iliac fossa. 

He was given 1 pint of Gelafusin bolus and to keep Mean Arterial Pressure above 70
mmHg. Then, another branula was inserted and strict input output charting was done.

His antibiotics were changed to Tazocin 4.5g QID and IVI Noradrenaline 0.2mcg/kg/min
was given. He was stabilised after that with blood pressure of 126/65 mmHg prior to his
operation.

Operation: 
Lower midline laparotomy and appendectomy and abdominal washing
Pre and postoperative diagnosis: Perforated appendicitis

Intraoperative findings:

 Pus 3 cc at the right iliac fossa

 Appendix at pelvic position
 Perforated tip, edematous appendix
 Base healthy
 Small bowel no meckels
 Terminal ileum mild distended
 Drain inserted at pelvis
 Estimated blood loss is minimal
Postoperative plan:
1. FBC, RP, ABG in ward
2. Wound inspection day 3(2/8/23)
3. Suture to open day 14 (13/8/23)
4. Drain charting
5. Keep MAP ≥ 75mmHg. Keep IVI Norad
6. Input output charting
7. Nil by mouth with IVD 4 pints normal saline dextrose for 24 hours
8. Keep Ryles tube free flow
9. Continue to IV Tazocin 4.5g QID
10. Continue PCA morphine and Tab Paracetamol 1g QID then oralise to C. Tramadol
50 mg TDS
11. TED stocking and ripple mattress
12. Start subcutaneous Clexane 40 mg OD

He is conscious with vital signs of 97/64mmHg (MAP 70 mmHg) and heart rate 61 beats
per minute, afebrile and saturating under room air. He was on Ryles tube free flow and he
can tolerate pain over the operation site. He was on PCA morphine and IVI Noradrenaline
0.05mcg/kg/min in view of low blood pressure.