Question

An 18-year-old woman presents with a new onset of abdominal pain, nausea, and vomiting over the past 18 hours. She is accompanied by her mother. She is tearful and in distress. This patient is not new to your practice. You have followed the entire family for years.

CC: “The pain is getting worse.”

Physical includes:

• Blood pressure, 100/60; pulse rate, 96 beats/min
• respiration rate24/min
• temperature, 100.6°F
• Pale and in acute distress. Guarding.
• Average height and weight.
• Pain is periumbilical, Some right lower quadrant tenderness with rebound
• Denies pregnancy; denies sexual contact.

Questions:

1. What other data do you need to diagnose this patient?

2. Would you do a GYN ex and why?

3. What laboratory tests are important and why?

4. Would you do any imaging and why?

5. Do you need a surgical consult?

6. How many patients diagnosed with appendicitis in actuality have this condition at the time of surgery when the appendix is directly visualized? What are potential

complications of this problem?

7. What is the plan of care for this patient?

Answer 1

ANSWERS:-

1) Other data includes

* Is nausea and vomiting occur after food,or not related to food?

* Any pain or burning sensation during urination.

* A thorough physical examination to identify classical features of appendicitis like Mc Burney's sign(pain and tenderness at the Mac Burney's point; point lies between umbilicus and anterior superior right iliac spine)

* Rovsing sign- when palpating left lower quadrant of abdomen patient feeka pain on the right lower quadrant,it is seen in appendicitis.

2) Yes,a Gynaecological examination is done in this case, to rule out any underlying reproductive system conditions like ovarian cyst,ectopic pregnancy,infections of vagina, Fallopian tube (salpingitis) ovaries ( oopheritis) ,and also urinary tract infections.The patient is 18years old girl.

3) Laboratory tests like

* complete blood count- increased WBC(leukocytes and neutrophils) indicate infection

* Urine analysis to find out urinary tract infections

* Pregnancy test to rule out pregnancy

4) Yes, Ultrasonography of abdomen ,and CT scan .These studies helps to reveal right lower quadrant density and distended bowel loops in case of appendicitis.These imaging studies also helps to diagnose other causes.

5) Yes, here the patient's complaints are strongly suggestive of possible appendicitis,so surgical consultation is required for further management of appendicitis,which is appendectomy (surgical removal of appendix)

6) Studies have shown that many patient's undergo appendicectomy without appendicitis.The life time risk for appendicitis in men is 8.6% and in women it is 6.7%; but the life time possibilities of having appendectomy in men is 12% and of women it is 25%.This is because of the nature of surgery, patient's with probable signs and symptoms of appendicitis are taken for surgery immediately in order to prevent complications like perforation and peritonitis.

7) The plan of actions include-

* Keep the patient Nil per Oral

* Start IV fluids.

* Confirm diagnosis with further investigations like ultrasound, and Laboratory tests .

* Control of nausea and vomiting by administering antiemetics.

* Antibiotics to control infection process.

* Pain assessment and management.

* Monitor vital signs.

* Antipyretics for fever

* Prepare the patient for surgery ,if appendicitis is confirmed.