SURGERY

General Surgery Case 1

HISTORY

General Data: This is the case of patient P, J 15 Yrs/F, Filipino, single, Roman Catholic,
residing at mangatarem, Pangasinan

Chief Complaint: abdominal pain

History of Present Illness: 3 days PTA patient experienced intermittent abdominal pain
over RLQ of 8/10 with (+) nausea (+) vomiting (-) difficulty in defecation (-) bowel changes. Few
hours PTA due to persistence of symptoms prompted consult to R1MC hence is the admission.

Past Medical History:

Childhood Illnesses. Medical. No history of mumps, asthma, allergies, and
chickenpox.
Surgical procedure: None.
.

Personal and Social History: without any history of hospitalization; no heredofamilial

diseases were noted. No habit of alcohol or smoke, not allergic to any medicine or foods
.

Environmental History:
Patient lives with 6 family members in a bungalow type house, with 2 bedrooms
and 1 bathroom. Garbage is being segregated and collected. Neighborhood is
described as non-congested and generally peaceful.

Review of Systems:
General: (-) Chills (-) Weight loss (-) Fatigue
Skin: (-) Rash (-) Lumps (-) Itching (-) Pruritus (-) Dryness (-) Pigmentation (-) Color
change (-) Nail changes
HEENT:
Hair: (-) Baldness (-) Excess hair
Head: (-) Trauma (-) Syncope
Eyes: (-) Redness (-) Discharge
Ears: (-) Itching (-) Discharge
Nose: (-) Colds (-) Nasal discharge (-) Itchiness (-) Nose bleed
Mouth and Throat: (-) Mouth sores (-) Bleeding gums (-) Dysphagia
 Neck: (-) Pain (-) Lumps (-) Swollen glands
Breast: (-) Lumps (-) Nipple discharge
Respiratory: (-) Cough (-) Dyspnea (-) Sputum (-) Hemoptysis
Cardiovascular: (-) Easy Fatigability (-) Edema (-) Cyanosis (-) Palpitations (-)
Cyanosis (-) Fainting spells (-) Paroxysmal Nocturnal Dyspnea
Gastrointestinal: (+) vomiting (-) Loss of appetite (-) Hematochezia (-) Melena (-)
Jaundice (-) Hematemesis (-) Constipation
Renal: (-) Polyuria (-) Gross hematuria (-) Tea-colored urine
Genitalia: (-) Ulcers (-) Discharge (-) Swelling (-) Itching (-) Masses
Endocrine: (-) Polydipsia (-) Cold/heat intolerance (-) Polyphagia (-) Excessive
sweating
Musculoskeletal: (-) Limitation of movements (-) Stiffness (-) Joint swelling
Neurologic: (-) Paralysis (-) Tremors (-) Seizures (-) Weakness
Hematologic: (-) Easy bruising (-) Bleeding (-) Pallor

PHYSICAL EXAMINATION

General Survey: Awake, alert, coherent, cooperative, well nourished, well hydrated,
and not in cardiopulmonary distress.

Vital Signs:
BP: 110/60 mmHg O2Sat: 98%

HR: 96 bpm Temperature: 36.5° C

RR: 21 cpm
Anthropometric Measurements
Weight: 44

Length: 163

BMI: 21,21 Kg/m2

Skin: No rashes, no hyper/hypopigmentation, no scars, no jaundice, no pallor, no

edema, good skin turgor, warm to touch.

HEENT:
Head. No contour deformities, no scars.
Face. Symmetrical, no unusual facies, no deformities, (-) facial edema.
Eyes. Non sunken eyeballs, pink palpebral conjunctiva, anicteric sclera, 2-3 mm
equilibrious reactive.
Ears. No deformities, auricles in proper alignment, patent canal, no discharge.
Nose. No asymmetry, midline nasal septum, no alar flaring.
Mouth and Throat. Moist lips and mucosa, no cyanosis, no ulceration, no
tonsillopharyngeal congestion.
Neck: No asymmetry, no mass, no scars, no lymphadenopathy.

Chest and Respiratory: No subcostal and intercostal retractions, no chest lag, no

lumps, no mass, resonant, equal and clear breath sound, no adventitious breath
sounds.

Cardiovascular: Adynamic precordium, no thrills, no heaves, regular rhythm, no

murmurs.

Abdomen: abdomen was soft and distended with positive direct and rebound tenderness
in right lower quardant.

Inguinal and Genitalia: No masses, no hernia, no lesions, no lymphadenopathy.

Rectum: unremmarkable

Extremities: No deformities, no lesions, no edema, no limitation of movements, good

pulses, CRT of <2 sec.

Neurological:
GCS. 15/15.
Cerebellum. No dysmetria, no ataxia.
Cranial Nerve. CN I. Intact.
CN II. Pupils are equally reactive to light.
CN III, IV, VI. Pupils are symmetrical and normal size, intact direct
and consensual light reflex, intact EOM.
CN V. Normal jaw movement.
CN VII. Normal facial symmetry.
CN VIII. Intact gross hearing.
CN IX, X. Uvula at midline, can swallow.
CN XI. Able to shrug shoulders against resistance.
CN XII. Tongue at midline.
Motor. 5/5 on all fours.
Sensory. Intact sensation on all fours as to pain and light touch.
Reflexes. Normoreflexive on all fours.

Admitting Diagnosis: Acute appendicitis

PLAN

Hp day 1- Admission to general surgery ward, secure consent for

admission and operation, diagnostics requested and threupatics were
given. Follow up the labs, npo refer
Hp Day2- Patient with fever, no dob. no chest pain, given medication as
paracetamol continue monitoring.
Hp Day3- May go home with home medication, cefuroxime, celecoxib,
follow up on 01/08/2024.

Pre-operative Diagnosis: Acute appendicitis

Procedure Done: Laparoscopic Appendectomy

POST OPERATIVE DIAGNOSIS: Acute Suppurative appendicitis

(Dr. valenzuela / dr. nidoy / dr. rayulada 01/03/2024).