Long case

:Personal history
Ahmed el Sayed Abdel Hamid, 20 years old, male
patient, student, he was born in abo Khalifa in Ismailia
and lives in it, he's not married, no special habits of
.medical importance
:Complaint
He came complaining of severe pain in the RT lower
.abdomen for 3 days' duration
:History of present illness
The patient was well till 3 days ago when pain started in
RT iliac fossa with gradual onset and progressive course
for 3 days. It was dull aching in character. it was referred
to hypogastric area. pain continued all over the time
with remission and exacerbation. it increased with food
intake after 30-60 minutes of intake and decreased in
severity by analgesics but not relived completely. pain
was associated with nausea, relative constipation, with
.no vomiting, diarrhea or jaundice
Patient also suffered from dysuria with dark yellow urine
but no hematuria or abnormalities in amount or
frequency. Patient also had headache and blurred
.vision
:Review of other systems
No other GIT symptoms, no other urinary symptoms, no
cardiac symptoms, no neurological symptoms, no
.musculoskeletal symptoms, no endocrinal symptoms
:Past history
No similar attacks before. Patient was known to be
asthmatic since childhood. attacks of asthma were
caused by exposure to fumes and gases and
accompanied by productive cough and wheezes and
relieved by bronchodilator and expectorant
.medications
No other chronic diseases. No previous operations. no
previous blood transfusions. no drug intake no known
.drug allergy
:Family history
.His brother had an appendectomy 2 months ago
:General examination
Patient is alert, conscious, oriented to time, place and
persons, average built, quiet facial expression, normal
.decubitus, average intelligence, he's cooperative
:Airway
.is secure and patent
:Breathing
no respiratory distress, no chest deformity. respiratory
rate is 14 breath/min. symmetrical chest movements.
percussion is resonant. normal breath sounds on
.auscultation
:Circulation
Capillary refill time is less than 2 sec. carotid pulse is felt.
.temperature is 37•c
Pulse: rate is 76 BPM. regular rhythm. Average volume.
vessel wall wasn't felt. Equal on both sides. BP is 110/70
mmHg
:Disability
GCS is 15. pupils are normal in size, reactive to light and
equal on both sides. No loss of sensation or motor
.function
:Exposure
.No head, neck or spine findings
: Local examination (abdominal examination)
:Inspection
Costal margin is acute angle. Umbilicus is midway
between xiphisternum and symphysis pubis. No
epigastric pulsation .no scars, no ulceration, no
.contusions. pubic hair is normal in distribution
:Palpation
Abdomen is slightly rigid. severe tenderness and positive
rebound tenderness in RT iliac fossa and slight
tenderness in hypogastric area. no palpable liver, spleen
.or kidney. No swellings found
:Auscultation
.Audible intestinal sounds around the umbilicus

:Provisional diagnosis
years old male patient with severe RT iliac fossa pain 20
with positive rebound tenderness for 3 days most
.probably due to acute non-complicated appendicitis
 Scientific background
Acute appendicitis is the commonest cause of acute
abdomen in young adults and appendectomy is the
most frequently performed urgent abdominal
.operation
.It's usually caused by E. coli (85%), staph, strept. fecalis
Obstruction is the commonest and most important
predisposing factor. it may be due to hard feces ,
.… ascaris, foreign body, tumors , adhesions
Also appendix has a narrow lumen and this also aid in
.developing the condition
The commonest complications of appendicitis are
persistent obstruction with gangrene and perforation
that lead to acute peritonitis. also, appendicular mass or
.abscess, recurrent subacute appendicitis, fecal fistula
General complications are septicemia, toxemia,
… , bacteremia, pyemia
The patient mostly is presented with acute pain that
shifts, anorexia, nausea, vomiting, constipation. on
. general examination we may find mild fever (≤ 38 •c )
On local examination, we find localized tenderness and
rebound tenderness in RT iliac fossa. Rigidity in
abdominal wall. maybe there are diminished intestinal
.movements on auscultation
There are many atypical forms of appendix such as long
retrocaecal appendix, pelvic appendix, paracaecal
.appendix, postileal appendix, sub hepatic appendix
Acute appendicitis is mainly clinical diagnosis;
investigations are needed mainly to exclude other
causes of acute abdomen. we do CBC, urine analysis,
liver function test, kidney function test, pregnancy test.
.ultrasound, laparoscopy
We start treatment as conservatively by putting Ryle,
urine catheter, 2 large pore IV cannula to supply the
patient with fluids, analgesics, antibiotics, anti –
.inflammatory to prepare him for the operation
Appendectomy is the best method and it shouldn't be
delayed especially in children, elderly, pregnant and
.diabetics