case presentation

1. Case Presentation

2. Turki Ali Ahmed is a 37 y/o Saudi male
Presented to the ER with Right Iliac Fossa pain for 2 days

3. History of presenting illness:
 37 year old Saudi male, presented to ER complaining of Right iliac fossa pain for
2 days, pain is sharp stabbing in nature, increased in severity today, aggravated
by movement and not relieved by anything, pain doesn’t radiate, pain is 10/10 on
Wong Baker scale
Associated symptoms:
 Nausea, vomiting and loss of appetite.
 No fever

4. Past medical history:
 No DM, HTN, Asthma or kidney failure
 Past medication: non
Past Surgical history:
 Left hand fracture and cut due to RTA 3 years ago
Blood transfusion history: non
Allergies: NO known allergies
Family history:
 His father has DM and HTN
Social history:
 lives in a villa in Riyadh, good socio-economic status, traveled to Dubai 1 year
ago, no history of smoking or alcohol consumption or drug abuse

5. Systemic review: Unremarkable
General: NO weight loss, night sweats, fever
HEENT: NO headache, NO change in vision, hearing or smell and NO difficulty in
swallowing
CVS: NO palpitation or chest pain
Respiratory: NO shortness of breath or cough
Gastroenterology: NO constipation or diarrhea, NO bleeding or change in color
Genitourinary: NO blood or foul smell or burning sensation
Dermatological: NO itching or redness
Musculoskeletal: NO pain/swelling/stiffness in muscle/joints/back
CNS: NO numbness or weakness
Endocrine: NO hot or cold intolerance, NO loss or gain of weight

6. Physical examination
 General appearance:
looks ill, lying uncomfortably, grasping on clothes, afebrile
 Vital signs:
 Temp: 37.0 ᵒC
 PR: 70 beats per minute
 BP: 146/72 mmHg
 RR: 18 breaths per minute
 O2: 98%

7. Hands
 Hands were warm and dry
 No clubbing, koilonychia or leukonychia
 No peripheral cyanosis
 No palmar erythema
 Normal sensation
Head and Neck
 No swelling observed
 No conjunctival pallor
 No jaundice
 No central cyanosis
 No mouth ulcers
Legs
 No pitting edema
 No swelling
 No redness
 Normal sensation

8. Abdominal Examination:
Abdomen was soft and lax, no organomegaly,
right iliac fossa tenderness
 Rebound tenderness positive
 Mcburney’s sign positive
 psoas sign positive
 Flank tenderness negative
 Obturator sign negative
 Dunphy's sign negative
 Rovsing's sign negative
Rectal examination may reveal localised tenderness
as the only sign of an inflamed retrocaecal or pelvic
appendix

10. Chest examination:
 Symmetrical, Normal bilateral air entry,
 Vesicular breathing, no bubbling or cracking sounds
Cardiovascular:
 Normal Heart sound S1, S2 (NO added sound)
 Normal capillary refill

11. Lab Tests:
1-CBC
 Elevated WBCs

12. 2- Biochemistry
3- Liver Function Test
4- Electrolytes Profile
 Findings were normal

13. Differential diagnosis

14. 1- provisional diagnosis
Acute appendicitis:
 History
 physical
 Alvarado score:
Score <4: No imaging required (Appendicitis unlikely)
Score 4-6: CT Abdomen
Score >6: Surgical Consultation
 Patient Score >6
Alvarado score
RIF tenderness +2
Increased WBC +2
Pain that migrates to RIF +1
Rebound tenderness +1
Anorexia +1
Nausea/Vomiting +1
Fever +1
WCC- left shift +1

15. Differential diagnosis:
Testicular torsion:
 Swelling of the scrotum
 Painful urination
 Fever
Urinary tract infection
 A burning feeling when urinating
 Cloudy, dark, bloody, or strange-smelling urine
 Fever or chills
 Urine microscopy and culture confirm presence of bacteria.
Right side ureteric colic
 Hematuria
 Referred pain to the scrotum
Chron’s disease
 Age group
 Fever
 Diarrhea
 History

16. Management:
Admit the patient
1- Stabilize
IVF (D5 1L) + (NS 120ml/h)
2-Monitor
 NPO
 Pre op
 Anesthesia [omeprazole 40mg IV]
 Antibiotics [Cefuroxime 1.5g IV on call to OR]
3-surgery
open appendectomy
4- post surgery
 Antibiotics:
cefuroxime750mg BID IV,
flagyl 500mg BID IV
 Paracetamol
1g Q6hrs IV