GROUP 3 1st CASE

1/15/2017

1. What is happening to NM?

- Pertinent Findings
o + Sudden epigastric pain which became more felt in the RLQ
o 2x vomiting
o + muscle guarding
o + direct and rebound tenderness
o Normal VS
o Ambulatory
o No masses & tight sphincter tone on DRE
2. Impression: Acute complicated Appendicitis
3. DDX
a. Female: PID, Ruptured Ectopic Pregnancy, Ovarian cyst/ Torsion, Mittleschmerz
b. Child: Meckels Diverticulum, Intussuception
c. Male: Indirect Inguinal Hernia
d. Elderly: Colon CA
4. Causes:
a. OBSTRUCTION d/t fecalith
b. Bacterial infection
c. Foreign bodies (eg. Seeds, ascaris)
d. Antibiotic treatment leading to proliferation of endogenous microorganism
5. Abdominal Exam
a. Pls READ BATES.
b. Inspect, Auscultate, percuss, palpate
c. Signs: (Rovsing, obturator)
6. Anatomy:
a. Please read Schwartz and or other books (Fischer, Sabiston, etc.)
b. Take note of embryology and location (retrocecal)
7. Pathophysiology
a. Obstruction (FEcalith) inflammation abdominal distention
infarct ischemia perforation

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8. Stages: FOCAL, SUppurative, Gangrene, Perforation

9. Most important sign of impressiong: RLQ pain
10. Suspect surgical importance presence of acute abdomen as manifested by direct and
rebound tenderness
11. Other signs pointing to impression
a. Rovsings
b. Obturator
c. Psoas
d. + tenderness on area when coughing is done - ________ sign
12. Do you have to elicit all signs?
a. If possible yes but if not _______???
b. LEARNING ISSUE! READ READ READ =D
 c. IS there a pathognomonic sign for AP?
13. Mcburneys Point Lateral 1/3 from asis to umbilicus
14. Rectal Exam = YES and why???
15. READ on ALVARADO & MANTREL SCORING SYSTEM
16. Admitting Order:
1/15/2017
3:58PM
Please admit patient to female surgical ward under DR. ________.
Dx: Acute Uncomplicated Appendicitis
Condition: Conscious, coherent, oriented to time and place
Vital Signs every 4 hours
Activity/ Limitation: No restriction?
Nursing Instruction: Insert Foley Catheter, French 14 and attached to urobag
Diet: NPO
IV: Start IVF with D5LR 1 L and regulate at 30 gtts/min
Meds: ANALGESIC: Paracetamol 300 mg 1 amp IVTT for moderate to severe pain
ANTIBIOTICS: Ampicillin 1 gm IVTT ANST ( )
PPI: Omperazole _____
No food and drug allergies
LABS:
CBC
Urinalysis
Blood Typing
Note if what can be prioritized be patient indigent
17. CBC for infection
U/A rule out urinary problems cystitis
18. DX YES!
19. DX modalities:
a. Lower Abdomen Ultrasound
b. CT Scan if complicated to localized soft tissue involvement
20. Chances of perforation:
a. If very young.
b. Please read Schwartz and or other books (Fischer, Sabiston, etc.)
21. Preparation:
a. PRE OP orders
i. NPO
ii. Pre=op Antibiotics - ______
22. Meal 3 hours ago, what will anesthesiologist do?
WAIT? NPO 6-8 hours normally
a. Please read Schwartz and or other books (Fischer, Sabiston, etc.)
23. Bacterias
GM (+) (-) Anaerobes
a. Pls read on what specific organism
24. Antibiotic Preparation:
a. Ceftriaxonne 1 gm IVTT one dose
b. Cost?
25. Incision you do? What is Mc Burneys Incision ?
a. Do: Rocky Davis and why?
 b. Know what is Mcburneys Incision
c. Please read Schwartz and or other books (Fischer, Sabiston, etc.)
26. What is Gridiron incision? Rocky Davis Incision?
a. Gridiron aka MCbruneys
b. Rocky Davis from umbilical to mmidclavicular
27. Layers of abdominal wall
a. Skin
b. Campers
c. Scarpa
d. External oblique
e. Internal oblique
f. Transverse Abdominis
g. Transversali Fascia
h. Preperitoneal Fat
i. Parietal PEritoneum
j. Visceral Peritoneum
28. Grasp Tinea Coli: guide
29. Turbid fluid Suction and send for culture and sensitivity
30. Abscess Drain and collect then send to lab for C&S
a. If encapsulated remove with capsule
b. Please read Schwartz and or other books (Fischer, Sabiston, etc.) to differentiate
what to do if encapsulated vs. non encapsulated
31. Leave a drain? Yes if with perforation and abscess
32. Impression is normal, do? Remove the appendix and explore other possible causes for the
signs manifested.
33. Close the abdomen? YES!!! Why?
34. Post-op care
a. Please read Schwartz and or other books (Fischer, Sabiston, etc.)
b. Note difference on what to do if ruptured vs unruptured
c. Incision/wound care
d. Drainage
e. Ambulation
35. Complication
a. Sepsis most lethal
b. Peritonitis
36. Feed if pt has normal bowel sound appreciated
a. Please read Schwartz and or other books (Fischer, Sabiston, etc.)
b. Note difference on what to do if ruptured vs unruptured
37. If child with unclear History, do?
a. Please read Schwartz and or other books (Fischer, Sabiston, etc.)
38. Progress Notes
a. Please read Schwartz and or other books (Fischer, Sabiston, etc.)
b. How to make and sample.