LPU – ST.
CABRINI SMALL GROUP DISCUSSION
SCHOOL OF HEALTH SCIENCES, INC. ACUTE APPENDICITIS
COLLEGE OF MEDICINE Dr. Shirard Adiviso
CASE 1
A 8 years old obese male was brought to the ER for 24 hours history of vague abdominal pain which later shifted
to the RLQ . The patient was noted to have missed his dinner and had 3 bouts of vomiting .
The pertinent PE findings are the following :
• Normal vital signs; Temperature = 38’C
• SHEENT: Dry Skin, Dry Mucosa
• Abdomen: Full, (+)Cough Signs, (+)Rovsing’s Sign, (+)Psoas’ Sign, (+)Direct & rebound in all quadrants
(S)UBJECTIVE (O)BJECTIVE (A)SSESSMENT (P)LAN
CC: 24hrs hx of vague abdominal pain and later shifted to RLQ, anorexia, 3x vomiting
Clinical Presentation: History and PE:
Vague abdominal pain and shifted • 8yrs old, obese
to RLQ CBC with differential count
• (+) fever, 38’C Increased in WBC and Neutrophils: Earliest
Anorexia • SHEENT: dry skin, dry mucosa marker of inflammation
Vomiting • Abdominal Exam: full;
(+)fever, 38’C o (+)Cough Sign Urinalysis
o (+)Rovisng’s Sign To rule out urinary tract infections or
(+) Cough sign o (+)Psoas’ Sign bladder infections
(+) Rovsing’s sign o (+)Direct & rebound in all quadrants
CRP
(+) Psoas’ sign To find other causes of inflammation
(+) Direct & rebound in all Suspected Acute Appendicitis
quadrants Ultrasound
Visualization of a thickened, non-
Supportive: IV fluids and NPO preoperative compressible appendix >6mm is diagnostic
Compute Tomography (CT) Scan
Diagnostics: Laboratory Workups To confirm the diagnosis and find it cause.
Used to detect atypically located acute
appendicitis
Pediatric Appendicitis Score (PAS) = 8
PAS = 1 – 3 PAS = 4 – 7 PAS = 8 – 10
Low Suspicion Equivocal High Suspicion
NO IMAGING ULTRASOUND ULTRASOUND
INDICATED
Discharge (-) (+)
Indeterminate results Normal findings
Appendicitis
or appendix not seen or alternative dx
Consider Surgery
other dx Consult
Laparoscopic Supportive care
CT Scan
Appendectomy or treatment
CT SCAN
Medical Management:
• Before Surgery: Antibiotic Prophylaxis
• Non-perforated: Cefoxitin 40mg/kg IV single dose
• Perforated: Ampicillin-Sulbactam 75mg/kg IV single dose
• For px allergy to beta-lactam
o Gentamicin 2.5mg/kg IV single dose + Clindamycin
7.5mg/kg IV single dose
(-) No CBC data given. Score is 8, still High-
suspicion. Need for surgery consultation. • Provide adequate analgesia
ARANILLA, HANAKO – ASILO, JOHN CHRISTOPHER – CALDO, ELLEN JHANE
MARALIT, MARIAN JENICA – TOLENTINO, CHERRY NAI
LPU – ST. CABRINI SMALL GROUP DISCUSSION
SCHOOL OF HEALTH SCIENCES, INC. ACUTE APPENDICITIS
COLLEGE OF MEDICINE Dr. Shirard Adiviso
CASE 2
A 40 years old female with BMI of 20 consulted due to abdominal pain in the lower abdomen of 16 hours duration
with associated anorexia and nausea.
Pertinent PE findings :
• BP + 120/80 HR = 88 RR= 20 T= 39’C
• SHEENT : Dry Skin, Pink palpebral conjunctiva , pink nail beds , dry mucosa
• Abdomen : Full , (+) Dunphy’s sign ,(+) Rovsings’ sign , (+) Obturator Sign , Slight tenderness in RLQ &
Periumbilical area , normoactive bowel sounds
• Pelvic Exam : No Vaginal Discharge , No Wriggling tenderness
CC: abdominal pain in the lower abdomen of 16hrs with anorexia and nausea
Clinical Presentation: History and PE:
Lower abdominal pain • 40 years old
Anorexia • BMI: 20
Nausea • (+) fever, 39’C
• SHEENT: dry skin, pink palpebral
(+)fever, 39’C
conjunctiva, pink nail beds, dry mucosa
(+) Dunphy’s sign • Abdominal Exam: full;
(+) Rovsing’s sign o (+)Dunphy’s Sign
o (+)Rovisng’s Sign CBC with differential count
(+) Obturator sign Increased in WBC and Neutrophils: Earliest
o (+)Obturator Sign
(+) Slight tenderness in RLQ & marker of inflammation
o Slight tenderness in RLQ and
periumbilical area periumbilical area Urinalysis
• Pelvic Exam: To rule out urinary tract infections or
o No vaginal discharge bladder infections
o No wriggling tenderness
CRP
To find other causes of inflammation
Suspected Acute Appendicitis
Ultrasound
Visualization of a thickened, non-
Supportive: IV fluids and NPO preoperative compressible appendix >6mm is diagnostic
Compute Tomography (CT) Scan
Diagnostics: Laboratory Workups To confirm the diagnosis and find it cause.
(-) No CBC data given and (-) for rebound Used to detect atypically located acute
pain. Score is 6, the patient needs to be appendicitis
admitted and observed. Alvarado Score = 6
Low risk: 0 – 3 Moderate risk: 4 – 6 High risk: 7 – 10
NO IMAGING ULTRASOUND ULTRASOUND
Male: RLQ ultrasonography
Female: RLQ & pelvic ultrasonography
Discharge on oral Laparoscopic
antibiotics and follow- Appendectomy
up Normal Negative Positive
Findings Findings Findings
Consider CT SCAN Medical Management:
other dx
• Non-perforated: Cefoxitin 40mg/kg IV single dose
• Perforated: Ampicillin-Sulbactam 75mg/kg IV single dose
Observation/ • For px allergy to beta-lactam
Admission o Gentamicin 2.5mg/kg IV single dose + Clindamycin
7.5mg/kg IV single dose
• Provide adequate analgesia
ARANILLA, HANAKO – ASILO, JOHN CHRISTOPHER – CALDO, ELLEN JHANE
MARALIT, MARIAN JENICA – TOLENTINO, CHERRY NAI
