CASE PRESENTATION ON

APPENDICITIS

I – Introduction
Appendicitis is the most common cause of acute abdomen in the United States, is the most
common reason for emergency abdominal surgery. Although it can occur at any age, it more
commonly occurs between the ages 10 and 30 years.

II - Objectives:
General:

Specific:

III – Definition
It is the inflammation of the vermiform appendix, usually acute, that if undiagnosed leads
rapidly to perforation and peritonitis.

Causes:
- basically idiopathic (unknown)
- a hard mass of feces (fecalith)
- foreign body in a lumen of the appendix
- fibrous disease of the bowel wall
- an adhesion or a parasitic quadrant
- stricture of the bowel lumen
- barium ingestion
- viral infection

IV. Patient’s Profile

A. General Data
Patient name: Pt. C
Address: Jaen, Nueva Ecija
Age: 12 y/o
Weight: 21 kilograms
Gender: Male
Birthday: August 28, 1997
 Nationality: Filipino

B. Chief Complaint
Persistent abdominal pain accompanied by nausea and vomiting (7 times) 2 days PTA

C. History of Present Illness

Two day prior admission, patient experience persistent abdominal pain, generalized during
the first day then becomes localized in the right lower quadrant. Patient wasn’t able to
consume food on the second day due to persistent nausea and vomiting. Emergency
appendectomy was done within the day of admission.

D. Past Health History

1. Past Illnesses: Measles, Influenza (never hospitalize before)
2. Current Medication: Calpol, Neo-kidilets, Ceelin
3. Allergy: no allergies stated

E. Heredo-Familial Illness
Paternal: +DM
Maternal: no illness stated

F. Personal/ Social History

A. Habits: Able to consume meals in less than 5 minutes
B. Caffeine: Never coffee, but drinks Milo or Ovaltine in the morning
C. Smoking: Never smoke
D. Alcohol: Never drinks
E. Drugs: Calpol, Neo-kidilets, Ceelin, Biogesic, Neozep
F. Lifestyle: Active/ Playful
G. Rank in the Family: 3rd of 4 children
H. Educational Attainment: High School Level

G. Environment
The family does not totally belong to the poverty line. They provide developmental
support for their children and they live near the city.
V. I. Physical Assessment
A. General Survey
Patient is awake, alert, verbally responsive and oriented to the environment and still with
the complaint of RUQ pain associated with intermittent nausea and vomiting
B. Admitting vital signs:
T- 37.5°C Height: 49 inches
P-89bpm Weight: 21 kgs
R-24cpm
BP-130/90 mmHg
C. General Assessment
- weak
- pain scale of 7
- conscious but seems confusion
D. Regional Examination
Body Parts Techniques Actual findings Normal Findings Analysis
1. Skin *Inspection (-) Jaundice Skin color varies The skin color is
No abrasion and from light to deep light brown; there
lesion brown, absence is no lesions and
of abrasion and abrasion visible.
lesion

* Palpation No edema No edema There is poor skin

Skin turgor was Good skin turgor turgor due to
slightly altered vomiting that
result in
dehydration.
2. Eyes *Inspection Yellowish sclera White sclera Normal
PERRLA PERRLA

Conjunctiva is Pinkish Paleness of

slightly pale and conjunctiva, conjunctiva due
dry. slightly moist to fluid deficit.
3.Lips *Inspection Slightly dry and Moist and not Dryness of
cracked cracked membranes due
to fluid deficit
4. Abdomen *Inspection Rounded Rounded Normal
abdomen abdomen
No lesion No lesion

* Palpation (+) rebound No tenderness Rebound

tenderness No palpable mass tenderness was
(-) Rovsing sign due to
noted. inflammation of
the appendix.
Rovsing’s sign
was noted to be
negative because
upon palpating
the lower left
quadrant, there is
no pain felt in
right lower
quadrant.

E. Activities of Daily Living

Gordon’s Functional Pattern
Function Pattern Before Hospitalization After Hospitalization Analysis
1. Health perception Patient is not health Listen to the He become aware that
and health conscious. physician’s instruction he is responsible for
management and somehow able to his health.
attain better perception
of his health.

2. Nutrition and Have 3 meals every Eat meal 3x a day Because of

Metabolic day, tend to eat fast Food was regulated hospitalization diet
due to active lifestyle. according to the was modified
 doctor’s order.
3.Elimination Bowel movement was Bowel movement was Constipation prior
not evident for the past also not evident admission was due to
three days. immediately after inflammation of the
surgery. 12 hours prior appendix, surgery
transfer to ward, (+) temporary decrease GI
bowel movement was peristalsis.
noted.
4. Activity-Exercise Active lifestyle Sedentary; needs to lie Patient understands the
down at bed, but limitations and
ambulation was restrictions of
encouraged. activities, and
importance of early
ambulation.
5. Cognitive- Patient has lack of Patient understands Health teaching helps
perceptual knowledge about his the disease and he was the client to
current condition accepting information understand his
from the health care condition
provider for his own
good.
6. Sleep-Rest Patient was able to Usually sleep length Patient sleep pattern is
sleep 6 – 8 hours at was 6 hours, and was disturbed due to the
night. Never had able to take naps operation that he
afternoon naps. throughout the day. undergone.
7. Self-perception and Patient has high self- Patient self-esteem He became anxious
self-concept esteem becomes low due to because he thinks that
belief that he is not he cannot perform his
complete anymore. best in any activities.
8. Role- relationships Patient has a good Patient relationship Hospitalization
relationship with his with his family and brought the family and
family and friends. friends becomes more his friends to him.
intact.
9. Sexuality- Patient is not sexually Patient is not sexually Hospitalization doesn’t
Reproductive active. Puberty was active. change his sexuality
just setting in. and reproduction state.
10. Coping-Stress He was afraid that his Felt secure that he will Hospitalization
tolerance condition will worsen. get healthy soon. improves the coping
 mechanisms of the
patient.
11. Values-Belief Patient is a Roman Patient spiritual belief Patient becomes GOD
catholic. becomes high. He lover because of what
He go to church with always pray and happened to him.
his parents. promise to go to
church every Sunday

VI. Anatomy and Physiology

VII. Pathophysiology

VIII. Management

I. Medical Management

II. Surgical Management

• Operation:
• Surgeon:
• Time/Date:
• Pre-Op Dx:
• Post-Op Dx:
• Specimen:
Complications
• Cholecystitis
• Empyema of the
gallbladder
• Pancreatitis