PATIENT’S DATA:

Name: Noraini bt. Berahim

I/C No.: 700731- 03-5424
Gender: Female
Race: Malay
Age: 38 years old
Date of Admission: 9 July 2009; 10.30pm
Date of Clerking: 10 July 2009
Source of information: Patient

PRESENTING COMPLAINT:
Right iliac fossa pain since 8 hours ago prior to admission.

HISTORY OF PRESENTING COMPLAINT:

She was previously apparently well until yesterday, 9 July 2009 at 2.30pm when
she had right iliac fossa pain radiated to umbilicus, right lumbar and suprapubic region.
The pain was severe, sudden in onset, sharp in nature. The pain was continuous,
progressively increase intensity and aggravated by movement. The pain can only be
partially relieved by injection at the GP clinic until she was given morphine when she
was emergently admitted to Hospital Ampang last night.
She also had projectile vomiting 7 times preceded by nausea since the abdominal
pain started. The content of the vomitus is undigested food and the amount is about five
cups. However, the vomitus has no blood stain.
She had no altered bowel motion and passed urine normally with day to night
ratio 4:1. She had dark, brownish colour, dandy, cloudy urine two times however no
haematuria and dysuria

SYSTEMIC REVIEW:
Cardiovascular system
There were no chest pain, palpitation, orthopnea and paroxysmal nocturnal dypsnoea.
Respiratory system

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Her lungs are clear, no shortness of breath. No heamoptysis.
Gastrointestinal system
She had abdominal pain at the right iliac fossa, right lumbar, umbilicus and suprapubic
region. No hematemesis.
Genitourinary system
She can pass urine normally and there is no dysuria, polyuria, polydypsia, hematuria,
urgency, swollen ankle or urinary incontinence.
Her menarche when she was 17 years old. Her last menstrual period was 28 June ’09. She
had two miscarriages, first in 1995 and second was 3 years ago in 2006.
Musculoskeletal System
She had no muscle weakness, arthralgia, bony pain and rigor, chills, muscle stiffness and
abnormal gait.
Central Nervous System
She had no headache, tremor, loss of sensory, diplopia, fit, paralysis, and speech defect or
body incoordinations.

PAST MEDICAL HISTORY:

She had a known case of asthma since childhood and she was diagnosed having
hypertension since 3 years ago. She had no other medical illnesses.

PAST SURGICAL HISTORY:

She had no significant past surgical history.

DRUG/MEDICATION HISTORY:
She is on medication Tab Atenolol for hypertension for 3 years and she had
nebulizer Ventolin for asthma. She also had known drug allergy towards Voltaren since
she had generalized itchiness when took the drug.

FAMILY HISTORY:
No known family history of diabetes mellitus, hypertension and cancer. Her father
has asthma and had appendicectomy 1 year ago.

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SOCIAL HISTORY:
She is married with 2 children, both of them are boys. She works as PA sale for
Telekom at MINES. Now, she stayed alone in Langat. She lived separately with her
husband due to different workplace since 4 months ago. Both her sons were under care of
her mother and mother in law in Pahang. She did not smoke and no alcohol intake.

PHYSICAL EXAMINATION:
General Examination
On inspection, the patient is alert, conscious, pink and in pain at that time lying on
her bed using 1 pillow. There is branula on her right hand connected to IV drip. The
patient looks well nourished but lethargic. Her vital signs were
Blood Pressure : 180/95 mmHg
Pulse Rate : 116 beats/ minute, normal volume and regular rhythm
Respiratory Rate: 20 breaths per minute
Temperature : 37 ˚C
She is fairly hydrated. There were no facies abnormalities, muscle wasting, scars
or any other abnormalities. There were also no signs of jaundice and pallor.

Hand
Warm, no excessive sweating, capillary filling time was less than 2 seconds, no finger
clubbing, no nicotine stain, no rashes or petechiae, no palmar erythema.
Eye
There are no signs of pallor on the conjunctiva and no jaundice.
Mouth
No central cyanosis, no gum bleeding and hydration was fair.
Lower limb
No rashes or petechiae, no ankle edema.
Breast
No breast lump detected.
Heart

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Her heart is normal, no heart murmur and no chest pain.
Lungs
Her lungs are clear no shortness of breath.
Lymph nodes
No palpable lymph nodes detected

Specific physical examination

[Abdomen]

Inspection: Abdomen is symmetrical, scaphoid in shape and not distended. Umbilicus is

centrally located an inverted. Abdomen moves equally with respiration. There
are no scratch marks, visible veins, scars and obvious mass. Inguinal orifices
are still intact.
Palpation: On light palpation, the abdomen is soft; tender at the umbilicus, right iliac
fossa, suprapubic and right lumbar region. The most painful at right iliac fossa
region and there is rebound tenderness; positive Rovsing sign but no guarding,
rigidity and mass are founded. On deep palpation, no hepatosplenomegaly
detected.
Percussion: Abdominal resonance is present, no shifting dullness that indicates ascites.
Auscultation: Bowel sound is normal.
During per rectal examination, no irregular mass is detected and no bleeding.

CASE SUMMARY:
38 year old Malay lady with known case of hypertension and asthma presented
with right iliac fossa pain radiating to the umbilicus, right lumbar and suprapubic region,
sudden in onset, sharp in nature, no altered bowel habit since 8 hours ago prior to
admission. On examination, she is in pain and lethargy, the abdomen is soft, tender at the
right iliac fossa, umbilicus, right lumbar and suprabubic region, and no mass and
hepatosplenomegaly detected.

PROVISIONAL DIAGNOSIS:

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 Acute Appendicitis
Reasons for:
- Right iliac fossa pain, presence of rebound tenderness, positive Rovsing
sign, feel nauseated

DIFFERENTIAL DIAGNOSIS:
Crohn’s disease
Gynaecological disorders
Torsion of the ovarian cyst
Genitourinary
Urinary tract infection

INVESTIGATIONS:

The diagnosis of appendicitis begins with a thorough history and physical examination.
Patients often have an elevated temperature, and there usually will be moderate to severe
tenderness in the right lower abdomen when the doctor pushes there. If inflammation has
spread to the peritoneum, there is frequently rebound tenderness. Rebound tenderness is
pain that is worse when the doctor quickly releases his hand after gently pressing on the
abdomen over the area of tenderness. Palpation in the left iliac fossa may reproduce the
pain in the right iliac fossa (Rovsing’s sign)

White Blood Cell Count

The white blood cell count in the blood usually becomes elevated with infection.

Urinalysis
Most patients with appendicitis, however, have a normal urinalysis. Therefore, a normal
urinalysis suggests appendicitis more than a urinary tract problem.

Abdominal X-Ray
An abdominal x-ray may detect the faecalith (the hardened and calcified, pea-sized piece
of stool that blocks the appendiceal opening) that may be the cause of appendicitis.

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Ultrasound
Ultrasound also is helpful in women because it can exclude the presence of conditions
involving the ovaries, fallopian tubes and uterus that can mimic appendicitis.

Barium Enema
This test can, at times, show an impression on the colon in the area of the appendix where
the inflammation from the adjacent inflammation impinges on the colon. Barium enema
also can exclude other intestinal problems that mimic appendicitis, for example Crohn's
disease.

Computerized tomography (CT) Scan

In patients who are not pregnant, a CT scan of the area of the appendix is useful in
diagnosing appendicitis and peri-appendiceal abscesses as well as in excluding other
diseases inside the abdomen and pelvis that can mimic appendicitis.

Laparoscopy
Laparoscopy allows a direct view of the appendix as well as other abdominal and pelvic
organs. If appendicitis is found, the inflamed appendix can be removed with the
laparoscope. The disadvantage of laparoscopy compared to ultrasound and CT is that it
requires a general anesthetic.

MANAGEMENT:
 Surgical removal
 IV fluids and antibiotics

Treatment of acute appendicitis is open or laparoscopic appendectomy. Appendectomy

should be preceded by IV antibiotics. Third-generation cephalosporins are preferred. For
nonperforated appendicitis, no further antibiotics are required. If the appendix is
perforated, antibiotics should be continued until the patient's temperature and WBC count
have normalized or continued for a fixed course, according to the surgeon's preference.
An appendectomy is the surgical removal of the appendix through an incision in your
abdomen that can be several inches long. A laparoscopic appendectomy involves making
several tiny cuts in the abdomen and inserting a miniature camera and surgical

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instruments. The surgeon then removes the appendix through one of the small incisions.
Recovery is usually faster than with traditional surgery, and the scars are smaller.
However, not everyone is a candidate for the laparoscopic procedure.

DISCUSSION:
1. The symptoms and signs of acute appendicitis are influenced by variety of factors such
as age, sex, personality and the position of the appendix.
An inflamed retrocaecal appendix may produce poorly localized abdominal pain,
and an inflamed pelvic appendix lying close to the bladder may produce symptoms of
frequency and dysuria.
As the retrocaecal appendix overlies the ureter, it may irritate the ureter and
produces signs and symptoms of urinary tract infection. An inflamed pelvic appendix
lying near the rectum causes irritation and diarrhea, and is commonly mistaken for
gastroenteritis. A very long appendix extending up to the right upper quadrant might even
mimic acute cholecystitis.
Acute appendicitis is most dangerous in the very young, the very old and pregnant
women. It is uncommon under the age of 2 years which it is often incorrectly diagnosed
as gastroenteritis. In elderly patients, the onset is more insidious. The inflamed area tends
to wall off, with the development of a mass, and symptoms and signs of obstruction may
be present. In the pregnant patient, the appendix is displaced upwards by the enlarged
uterus, and the site of the pain and tenderness is high in the abdomen.

2. Gangrene and perforation are common and dangerous in infants, during pregnancy and
in the elderly. Gangrenous appendicitis and perforation tend to occur after a significantly
more prolonged period of pain than uncomplicated appendicitis.
Generalized peritonitis results in the inflamed area are not walled off by omentum
and loop of bowel. If walling off does occur, either an appendix mass or an abscess will
develop. A perforated pelvic appendix will lead to a pelvic abscess.