Morning Endorsement

October 7, 2020
Group 10 | Subgroup 3

Alkuino, Winkle Jones

Belderol, Jacqueline
Madabushi, Sindhu
Manywa, Christian
Selvakumar, Gowthamram
Solano, Deomicah
General Data
• B.J
• 39 y/o
• Male
• Married
• Construction Worker
• Mambaling, Cebu
Chief complaint
Right Lower Quadrant Abdominal Pain
 History of Present Illness
• 1 day PTA
• Patient had sudden onset of gnawing periumbilical pain, PS of 5/10.
• The pain started two hours after dinner, and radiated to the right
lower quadrant.
• Pain in the RLQ was sharp and jarring in characteristic.
• Walking aggravated the pain, while lying on the patient’s left side
was a relieving factor.
• No fever, anorexia, nausea, vomiting or diarrhea noted.
 Past Medical History
• No known Medical illness
• No Maintenance Medications
• Non asthmatic
• No known food and drug allergies
• No history of previous hospitalizations or surgeries
 Family History
• Father is well with no known medical conditions.
• Mother is a known hypertensive.
• No heredofamilial diseases.
 Personal and Social History

• High school graduate

• Usual diet include rice, meat, and veggies
• Smokes 5-6 sticks/day starting at the age of 16 (23 pack years)
• Drinks alcohol occasionally (1-2 glass of beer/occasion)
• No history of illicit drug use
 Review of Systems

• General: No fever, no changes in weight.

• Skin: No rashes, lumps and sores.
• HEENT: No headache. No hearing problems. No nasal stuffiness.
No sore throat and bleeding gums.
• Respiratory: No difficulty in breathing. No cough.
• Cardiovascular: No chest pain or discomfort.
 Review of Systems
• Gastrointestinal: (+)RLQ pain. (+) Periumbilical pain. No nausea or
vomiting. No constipation or diarrhea.
• Genitourinary: No dysuria, polyuria, and hematuria.
• Musculoskeletal: No muscle or joint pain. No stiffness.
• Psychiatric: No suicidal intentions.
 PHYSICAL EXAMINATION
•General Survey: Awake, conscious, coherent not in respiratory distress
•Vital signs: HR: 88bpm
BP : 100/60 mmHg
RR: 20 cpm
Temp: 36.7 C
O2 sat: 99%
Height: 5 ft 5 in.
Weight: 69 kg
BMI: 25.3 (Overweight)
 PHYSICAL EXAMINATION

• HEENT: Scalp without lesions, normocephalic. Anicteric sclerae,

pink palpebral conjunctiva, pupils are round, equally reactive to
light. No hearing deficits. No nasal discharges. Oral mucosa is
pink and moist. Tongue is midline.
• Neck: Neck is supple. Trachea is midline. No palpable masses.
• Chest and Lungs : Equal chest expansion. Clear breath sounds,
no rales, no wheezes.
• Cardiovascular : Adynamic precordium, Distinct heart sounds,
regular rhythm. No murmurs.
 PHYSICAL EXAMINATION
• Abdomen: Flat abdomen, Normoactive bowel sounds,
Tympanitic on all four quadrants. (+) Dunphy’s sign (+)
McBurney’s sign (+) Rovsing’s sign (+) Psoas sign. (-) Obturator
sign, (-) Rebound tenderness. No hepatomegaly or
splenomegaly noted.
• Extremities: No edema in both upper and lower extremities.
• Musculoskeletal : No joint deformities.
• GUT: (-) Kidney punch test.
• DRE: No perirectal lesions. External sphincter tone intact.
 Working Impression
• Uncomplicated Acute Appendicitis (Alvarado Score: 3)
DIFFERENTIAL DIAGNOSIS
Right-sided Diverticulitis
RULE IN RULE OUT
• RLQ pain No vomiting
• Periumblical gnawing pain No anorexia
• Abdominal tenderness No hematochezia
Mostly asymptomatic
 Ureterolithiasis

Rule in Rule out

Male Colicky flank pain (renal colic)
Age No Hematuria
Lower abdominal pain with No Nausea
sudden onset not related No Vomiting
to any precipitating event
 Acute Mesentric Adenitis

Rule in Rule out

RLQ pain More common in pediatric patients
RLQ tenderness No fever
No diarrhea
No anorexia
No nausea or vomiting
No gaurding
No history of URTI
 LABORATORY
RESULTS
Complete Blood Count
RESULT REFERENCE
White blood cells 9.3 (x109/L) 4.0-10.0 (x109/L)
Red blood cell 4.8(x1012/L) 4.50-5.50
Hemoglobin 152 g/L 140-170
Hematocrit 0.46 0.42-0.60
MCV 96.9 80-100 fL
MCH 32.1 H 27.0 - 31.0 pg
MCHC 33.1 g/dL 31.0-36.0 g/dL
Platelet 152 (x109/L) 150-450 (x109/L)
 Complete Blood Count Cont'd

Differential count
% Reference (%)
Segmenters 0.74 H 0.55-0.65
Lymphocytes 0.18 L 0.25-0.35
Monocytes 0.06 0.03-0.06
Eosinophils 0.02 0.02-0.04
Basophils 0.00 0.00-0.01
 Clinical Chemistry

RESULT REFERENCE
Sodium 138.10 mEq/L 135-148
Potassium 3.67 mEq/L 3.5-5.0
 Blood Typing, Bleeding time and Clotting Time

BLOOD TYPE O Rh (D) Positive

RESULT REFERENCE

Clotting Time 3 min 46s 2-5 min

Bleeding Time 2 min 22s 1-3 min
 Clotting Factors

RESULT REFERENCE
Prothrombin time 14.00 s 10.00-14.00 s
Activity 86% > or = 70%
INR 1.18 0.7- 1.3
 Ultrasonography

Tubular, hypoechoic, blind-ending structure

seen on the right iliac region, measuring 3.7 x
0.46 x 0.77 cm, surrounded by ill-defined
hypoechoic structures. It is non-compressible
and elicits rebound tenderness with probe
manipulation. No abnormal fluid collection
seen.
 Urinalysis
• Physical Properties
• Color: Dark yellow
• Transparency: Hazy

•Clinical Properties
• pH: 5.5
• Specific Gravity: 1.030
• Negative Protein and Glucose

•Flowcytometry
• RBC: 0-1/HPF
• WBC: 2-4/ HPF
• Epithelial cells: FEW
• Bacteria: FEW
• Mucus Threads: MODERATE
 Final Diagnosis
• Uncomplicated Acute Appendicitis (Alvarado Score: 4)
Management
• Open appendectomy – primary approach to the treatment of acute
appendicitis

• Laparoscopic appendectomy
• Longer to perform
• Less post-op pain
• Faster recovery
• Lower incisional surgical site infection rate
Management
• Antibiotic prophylaxis (Uncomplicated appendicitis)
• Recommended for the prevention of surgical site infections and intra-
abdominal abscess
• Cefoxitin 2g IV single dose
• Alternative:
• Ampicillin-sulbactam 1.5-3g IV single dose, or
• Amoxicillin-clavulanate 1.2-2.4g IV single dose
• Patients allergic to beta-lactam antibiotis:
• Gentamicin 80-120 mg IV single dose + Clindamycin 600 mg IV single dose