Clinical Case: Acute Appendicitis

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Presenting Complaints

The patient, 26 yrs old married male, presented to surgery department with presenting complaints of pain in right iliac fossa, loss of appetite and nausea for the last one day.

History of Present Illness

The patient was asymptomatic one day back, when he developed pain in peri umbilical region, which was mild and sudden in onset. Initially the patient ignored it thinking it of indigestion, but after a few hours pain shifted to right iliac fossa and became severe. Pain was continuous and non-radiating, aggravated by movements and not relieved by analgesics. It was associated with nausea and decreased appetite. No urinary or bowel complaints were present.

Past History, Personal History, Family History

His past medical and surgical history was unremarkable. He was a non smoker, non addict. His family history was not contributory and he belonged to low socioeconomic class.

Examination

On general physical examination the patient was a young man of average build, lying in obvious distress on bed, well oriented in time, place and person. His pulse was 99/min, temperature 98.6 F, blood pressure 120/80 mmHg and respiratory rate 16/min.

Jaundice, pallor, cyanosis, clubbing and edema were not present. Lymph nodes were not palpable, JVP was not raised.

Systemic Examination

On inspection the abdomen looked normal, umbilicus was central and no limitation of respiratory movements were present. On palpation there was tenderness in the right iliac fossa, rebound tenderness was present and Rovsing’s sign was present.

Liver, spleen and kidneys were not enlarged, bladder was empty and bowel sounds were audible. On DRE, the rectum was empty and non tender.

Rest of the systemic examination revealed no abnormality.

Provisional Diagnosis

On the basis of history and physical examination the provisional diagnosis of acute appendicitis was made.

Emergency Management

Patient was hospitalized. He was kept nill per oral and given I/V fluids (I/V Ringer Lactate 3000 ml @30 drops/min). Injectable antibiotics were given (Inj. Co-amoxiclav 1.2 g I/V STAT after test dose, then 12 hourly, Inj. Metronidazole 500 mg I/V, then 8 hourly) along with Diclofenac sodium (75 mg I/M 12 hourly).

Investigations

Investigations were performed on urgent basis. Blood complete picture revelaled leukocytosis with increased neutrophils. Serum amylase, LFTs and RFTs were normal.

On the basis of patient’s sign and symptoms, and lab findings Alvarado scoring was done, which came out to be 8/10.

alvarado score

Thus final diagnosis of acute appendicitis was made.

Management

Emergency appendicectomy was planned. Patient was counselled about the possible outcomes of surgery. Informed written consent was taken.

Appendicectomy under general anesthesia was carried out by Gridiron incision.

After surgery patient was kept nil per oral and given I/V fluids, antibiotic support was continued. His vitals were monitored. Input and output charts was maintained. Care of general anesthesia was done.

On first post op day, patient was stable, with all vitals within normal range. Wound was alright. Oral sips were started. On second post op day, patient was stable, he was discharged after being counseled and given sick leave for four weeks. He was advised Tab. Co-amoxiclav 1g BD, Tab. Metronidazole 400 mg TDS and Tab. Diclofenac sodium 50 mg BD.

Patient was asked for follow up in surgical OPD after 7 days. On follow up visit, wound was healing normally, stitches were removed.